| (5) If a provider has changed ownership in the past
five years in a way that impacts eligibility for the TIPPS program,
the provider must submit to HHSC, upon demand, copies of contracts
it has with third parties with respect to the transfer of ownership
or the management of the provider and which reference the administration
of, or payment from, the TIPPS program.
(6) Report all quality data denoted as required as
a condition of participation in §353.1311(d)(1) of this subchapter.
(7) Failure to meet any conditions of participation
described in this subsection will result in the removal of the provider
from the program and recoupment of all funds previously paid during
the program period.
(f) Non-federal share of TIPPS payments. The non-federal
share of all TIPPS payments is funded through IGTs from sponsoring
governmental entities. No state general revenue is available to support
TIPPS.
(1) HHSC will communicate suggested IGT responsibilities
for the program period with all TIPPS eligible and enrolled HRI physician
groups and IME physician groups at least 10 calendar days prior to
the IGT declaration of intent deadline. Suggested IGT responsibilities
will be based on the maximum dollars available under the TIPPS program
for the program period as determined by HHSC, plus eight percent;
forecasted member months for the program period as determined by HHSC;
and the distribution of historical Medicaid utilization across HRI
physician groups and IME physician groups, plus estimated utilization
for eligible and enrolled other physician groups within the same service
delivery area, for the program period. HHSC will also communicate
the estimated maximum revenues each eligible and enrolled physician
group could earn under TIPPS for the program period with those estimates
based on HHSC's suggested IGT responsibilities and an assumption that
all enrolled physician groups will meet 100 percent of their quality
metrics.
(2) Sponsoring governmental entities will determine
the amount of IGT they intend to transfer to HHSC for the entire program
period and provide a declaration of intent to HHSC 21 business days
before the first half of the IGT amount is transferred to HHSC.
(A) The declaration of intent is a form prescribed
by HHSC that includes the total amount of IGT the sponsoring governmental
entity intends to transfer to HHSC.
(B) The declaration of intent is certified to the best
knowledge and belief of a person legally authorized to sign for the
sponsoring governmental entity but does not bind the sponsoring governmental
entity to transfer IGT.
(3) HHSC will issue an IGT notification to specify
the date that IGT is requested to be transferred no fewer than 14
business days before IGT transfers are due. Sponsoring governmental
entities will transfer the first half of the IGT amount by a date
determined by HHSC, but no later than June 1. Sponsoring governmental
entities will transfer the second half of the IGT amount by a date
determined by HHSC, but no later than December 1. HHSC will publish
the IGT deadlines and all associated dates on its Internet website
by March 15 of each year.
(4) 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.
(g) TIPPS capitation rate components. TIPPS funds will
be paid to Managed Care Organizations (MCOs) through three components
of the managed care per member per month (PMPM) capitation rates.
The MCOs' distribution of TIPPS funds to the enrolled physician groups
will be based on each physician group's performance related to the
quality metrics as described in §353.1311 of this subchapter.
The physician group must have provided at least one Medicaid service
to a Medicaid client in each reporting period to be eligible for payments.
(1) Component One.
(A) For program periods beginning on or before September
1, 2023, but on or after September 1, 2021, the total value of Component
One will be equal to 65 percent of the total program value.
(i) Allocation of funds across qualifying HRI and IME
physician groups will be proportional, based on historical Medicaid
clients served.
(ii) Monthly payments to HRI and IME physician groups
will be a uniform rate increase.
(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.
Cont'd... |
