| (iii) Other physician groups are not eligible for payments
from Component One.
(iv) Providers must report quality data as described
in §353.1311 of this subchapter as a condition of participation
in the program.
(v) HHSC will reconcile the interim allocation of funds
across qualifying HRI and IME physician groups to the actual distribution
of Medicaid clients served across these physician groups during the
program period, as captured by Medicaid MCOs contracted with HHSC
for managed care 120 days after the last day of the program period.
(vi) Redistribution resulting from the reconciliation
will be based on the actual utilization of enrolled NPIs.
(vii) If a provider eligible for TIPPS payments was
not included in the monthly scorecards, the provider may be included
in the reconciliation by HHSC.
(B) For the program period beginning on September 1,
2024, the total value of Component One will be equal to 90 percent
of the total program value.
(i) Allocation of funds across qualifying HRI and IME
physician groups will be proportional, based upon historical Medicaid
utilization.
(ii) Payments to physician groups will be a uniform
rate increase paid at the time of claim adjudication.
(iii) Other physician groups are not eligible for payments
from Component One.
(iv) Providers must report quality data as described
in §353.1311 of this subchapter as a condition of participation
in the program.
(C) For program periods beginning on or after September
1, 2025, the total value of component one will be equal to 55 percent
of the total program value.
(i) Allocation of funds across qualifying HRI and IME
physician groups will be proportional, based upon historical Medicaid
utilization.
(ii) Payments to physician groups will be a uniform
rate increase paid at the time of claim adjudication.
(iii) Other physician groups are not eligible for payments
from Component One.
(iv) Providers must report quality data as described
in §353.1311 of this subchapter as a condition of participation
in the program.
(2) Component Two.
(A) For program periods beginning on or before September
1, 2023, but on or after September 1, 2021, the total value of Component
Two will be equal to 25 percent of the total program value.
(i) Allocation of funds across qualifying HRI and IME
physician groups will be proportional, based upon historical Medicaid
utilization.
(ii) Payments to physician groups will be a uniform
rate increase.
(iii) Other physician groups are not eligible for payments
from Component Two.
(iv) Providers must report quality data as described
in §353.1311 of this subchapter as a condition of participation
in the program.
(v) HHSC will reconcile the interim allocation of funds
across qualifying HRI and IME physician groups to the actual distribution
of Medicaid clients served across these physician groups during the
program period as captured by Medicaid MCOs contracted with HHSC for
managed care 120 days after the last day of the program period.
(vi) Redistribution resulting from the reconciliation
will be based on the actual utilization of enrolled NPIs.
(vii) If a provider eligible for TIPPS payments was
not included in the monthly scorecards, the provider may be included
in the reconciliation by HHSC.
(B) For the program period beginning September 1, 2024,
Component Two will be equal to 0 percent of the program.
(C) For program periods beginning on or after September
1, 2025, the total value of Component Two will be equal to 35 percent
of the total program value.
(i) Allocation of funds across qualifying HRI and IME
physician groups will be proportional, based upon historical Medicaid
utilization.
(ii) Payments to physician groups will be made through
a pay-for-performance model based on their achievement of quality
measures and paid through a scorecard.
(iii) Other physician groups are not eligible for payments
from Component Two.
(3) Component Three.
(A) The total value of Component Three will be equal
to 10 percent of the total program value.
(B) Allocation of funds across physician groups will
be proportional, based upon actual Medicaid utilization of specific
procedure codes as identified in the final quality metrics or performance
requirements described in §353.1311 of this subchapter.
(C) Payments to physician groups will be a uniform
rate increase.
(D) Providers must report quality data as described
in §353.1311 of this subchapter as a condition of participation
in the program.
(h) Distribution of TIPPS payments.
(1) Before the beginning of the program period, HHSC
will calculate the portion of each PMPM associated with each TIPPS
enrolled practice group broken down by TIPPS capitation rate component
and payment period. The model for scorecard payments and the reconciliation
calculations will be based on the enrolled NPIs and the MCO network
status at the time of the application under subsection (e)(1) of this
section. For example, for a physician group, HHSC will calculate the
portion of each PMPM associated with that group that would be paid
from the MCO to the physician group as follows.
(A) Payments from Component One.
(i) For program periods beginning on or before September
1, 2023, but on or after September 1, 2021, payments will be monthly
and will be equal to the total value of Component One for the physician
group divided by twelve.
(ii) For program periods beginning on or after September
1, 2024, payments will be made as a uniform percentage increase paid
at the time of claim adjudication.
(B) Payments from Component Two.
(i) For program periods beginning on or before September
1, 2023, but on or after September 1, 2021, payments will be semi-annual
and will be equal to the total value of Component Two for the physician
group divided by 2.
(ii) For the program period beginning on September
1, 2024, no payments will be made for Component Two.
(iii) For program periods beginning on or after September
1, 2025, payment will be made on a scorecard basis at payments based
on the reporting of quality measures and paid through a scorecard
at the time of achievement.
(C) Payments from Component Three will be equal to
the total value of Component Three attributed as a uniform rate increase
based upon historical utilization.
(2) MCOs will distribute payments to enrolled physician
groups as directed by HHSC. Payments will be equal to the portion
of the TIPPS PMPM associated with the achievement for the time period
in question multiplied by the number of member months for which the
MCO received the TIPPS PMPM.
(i) Changes in operation. If an enrolled physician
group closes voluntarily or ceases to provide Medicaid services, the
physician group must notify the HHSC Provider Finance Department by
hand delivery, United States (U.S.) mail, or special mail delivery
within 10 business days of closing or ceasing to provide Medicaid
services. Notification is considered to have occurred when the HHSC
Provider Finance Department receives the notice.
(j) Reconciliation. HHSC will reconcile the amount
of the non-federal funds actually expended under this section during
each program period with the amount of funds transferred to HHSC by
the sponsoring governmental entities for that same period using the
methodology described in §353.1301(g) of this subchapter.
(k) Recoupment. Payments under this section may be
subject to recoupment as described in §353.1301(j) and §353.1301(k)
of this subchapter.
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| Source Note: The provisions of this §353.1309 adopted to be effective March 21, 2021, 46 TexReg 1617; amended to be effective May 31, 2022, 47 TexReg 3113; amended to be effective January 28, 2024, 49 TexReg 413 |
