| (D) the estimated ACR gap for the class or individual
hospitals, as indicated on the application described in subsection
(c) of this section; and
(E) the percentage of Medicaid costs incurred by the
class of hospital in providing care to Medicaid managed care clients
that are reimbursed by Medicaid MCOs prior to any rate increase administered
under this section.
(f) Services subject to rate increase and other payment.
(1) HHSC may direct the MCOs in an SDA to increase
rates for all or a subset of inpatient services, all or a subset of
outpatient services, or all or a subset of both, based on the service
or services that will best advance the goals and objectives of HHSC's
managed care quality strategy.
(2) In addition to the limitations described in paragraph
(1) of this subsection, rate increases for a state-owned IMD or non-state-owned
IMD are limited to inpatient psychiatric hospital services provided
to individuals under the age of 21 and to inpatient hospital services
provided to individuals 65 years or older.
(3) CHIRP rate increases will apply only to the in-network
managed care claims billed under a hospital's primary National Provider
Identifier (NPI) and will not be applicable to NPIs associated with
non-hospital sub-providers owned or operated by a hospital.
(g) CHIRP capitation rate components. For program periods
beginning on or before September 1, 2023, but on or after September
1, 2021, CHIRP funds will be paid to MCOs through two components of
the managed care per member per month (PMPM) capitation rates. For
program periods beginning on or after September 1, 2024, CHIRP funds
will be paid to MCOs through three components of the managed care
per member per month (PMPM) capitation rates. The MCOs' distribution
of CHIRP funds to the enrolled hospitals may be based on each hospital's
performance related to the quality metrics as described in §353.1307
of this subchapter (relating to Quality Metrics for the Comprehensive
Hospital Increase Reimbursement Program). The hospital must have provided
at least one Medicaid service to a Medicaid client for each reporting
period to be eligible for payments.
(1) In determining the percentage increases described
under subsection (h)(1) of this section, HHSC will consider:
(A) information from the participants in the SDA (including
hospitals, managed-care organizations, and sponsoring governmental
entities) on the amount of IGT the sponsoring governmental entities
propose to transfer to HHSC to support the non-federal share of the
increased rates for the first six months of a program period, as indicated
on the applications described in subsection (c) of this section;
(B) the class or classes of hospital determined in
subsection (e)(2) of this section;
(C) the type of service or services determined in subsection
(f) of this section;
(D) actuarial soundness of the capitation payment needed
to support the rate increase;
(E) available budget neutrality room under any applicable
federal waiver programs;
(F) hospital market dynamics within the SDA; and
(G) other HHSC goals and priorities.
(2) The Uniform Hospital Rate Increase Payment (UHRIP)
is the first component.
(A) The total value of UHRIP will be equal to a percentage
of the estimated Medicare gap on a per class basis.
(B) Allocation of funds across hospital classes will
be proportional to the combined Medicare gap of each hospital class
within an SDA to the total Medicare gap of all hospital classes within
the SDA.
(3) The Average Commercial Incentive Award (ACIA) is
the second component.
(A) The total value of ACIA will be equal to a percentage
of the ACR gap less payments received under UHRIP, subject to the
limitations described by subparagraph (B) of this paragraph.
(B) The maximum ACIA payments for each class will be
equal to a percentage of the total estimated ACR UPL for the class,
less what Medicaid paid for the services and any payments received
under UHRIP, including hospitals that are not participating in ACIA.
For program periods beginning on or before September 1, 2023, but
on or after September 1, 2021, the percentage is 90 percent. For program
periods beginning on or after September 1, 2024, the percentage may
not exceed 90 percent.
(C) The ACIA payment for the class will be equal to
the minimum of the sum of the ACIA payment in subparagraph (A) of
this paragraph and the limit in subparagraph (B) of this paragraph.
If the amount calculated under subparagraph (B) of this paragraph
is negative, the maximum, aggregated ACIA payments for that class
will be equal to zero.
(D) The ACIA payment for each provider will be equal
to the amount in subparagraph (A) of this paragraph multiplied by
the amount determined in subparagraph (C) of this paragraph for the
class divided by the sum of the preliminary ACIA payment determined
in subparagraph (A) of this paragraph for the class, rounded down
to the nearest percentage. For example, if two hospitals in a class
in an SDA both have anticipated base payments of $100 and UHRIP payments
of $50, but one hospital has an estimated ACR UPL of $400 and an ACR
gap of $300 between its base payment and ACR UPL, and the other hospital
has an estimated ACR UPL of $600 and an ACR gap of $500, HHSC will
first reduce the gaps by the UHRIP payment of $50 to a gap of $250
and $450, respectively. The preliminary ACIA rates are 250 percent
and 450 percent. These are the amounts available under subparagraph
(A) of this paragraph. HHSC would then sum the ACR UPLs for the two
hospitals to get $1000 available to the class and apply the percentage
in subparagraph (B) of this paragraph (e.g., 50 percent of the gap),
which results in an ACR UPL of $500. Then HHSC will subtract the $200
in base payments and $100 in UHRIP payments from the reduced ACR UPL
for a total of $200 of maximum ACIA payments under subparagraph (B)
of this paragraph. The amount under subparagraph (A) for the class
was $700, and the limit under subparagraph (B) of this paragraph is
$200, so all provider in the SDA will have their ACIA percentage multiplied
by $200 divided by $700 to stay under the $200 cap. The individual
ACIA rates would be 71 percent (e.g., 200/700*250 percent) and 128
percent (e.g., 200/700*450 percent), respectively. The estimated ACIA
payments would be $71 and $128. HHSC will then direct the MCOs to
pay a percentage increase for the first hospital of 71 percent in
addition to the 50 percent increase under UHRIP for the first hospital
for a total increase of 121 percent above the contracted base rate,
and 128 percent in addition to the 50 percent increase under UHRIP
for the second hospital for a total increase of 178 percent.
(4) For program periods beginning on or after September
1, 2024, the Alternate Participating Hospital Reimbursement for Improving
Quality Award (APHRIQA) is the third component.
(A) The total value of APHRIQA will be equal to the
sum of:
(i) a percentage of the Medicare gap, not to exceed
100 percent, on a per class basis less the amount determined in paragraph
(2)(A) of this subsection; and
(ii) a percentage of the total estimated ACR UPL, not
to exceed 90 percent, on a per class basis less what Medicaid paid
for the services and any payments received under UHRIP, including
hospitals that are not participating in ACIA and less any payments
received under ACIA.
(B) Allocation of funds across hospitals will be calculated
by allocating to each hospital the sum of:
(i) the difference in the amount the hospital is estimated
to be paid under paragraph (2)(A) of this subsection and the amount
they would be paid if the percentage described in paragraph (2)(A)
of this subsection were the same percentage cited in subparagraph
(A)(i) of this paragraph; and
(ii) the difference in the amount the hospital is estimated
to be paid under paragraph (3)(C) of this subsection and the amount
they would be paid if the percentage described in paragraph (3)(B)
of this subsection were the same percentage cited in subparagraph
(A)(ii) of this paragraph.
(h) Distribution of CHIRP payments.
(1) CHIRP payments for UHRIP and ACIA components will
be based upon actual utilization and will be paid as a percentage
increase above the contracted rate between the MCO and the hospital.
The determination of percentage of rate increase will be as follows.
(A) HHSC will determine the percentage of rate increase
applicable to one or more classes of hospital by program component.
(B) UHRIP rate increases will be determined by HHSC
to be the percentage that is estimated to result in payments for the
class that are equivalent to the amount described under subsection
(g)(2)(A) of this section.
Cont'd... |
