| (a) Introduction. Notwithstanding other provisions
of this subchapter and subject to the availability of funds, supplemental
payments are available under this section for nursing facility services
provided by eligible non-state government-owned nursing facilities.
(b) Definitions. When used in this section, the following
definitions apply:
(1) Adjudicated claim--A claim for a covered Medicaid
nursing facility service that has been paid by HHSC.
(2) HHSC--The Texas Health and Human Services Commission
or its designee.
(3) Intergovernmental transfer (IGT)--A transfer of
public funds from a non-state governmental entity to HHSC.
(4) Medicaid supplemental payment limit--The maximum
supplemental payment available to a participating non-state government-owned
nursing facility for a specific quarterly calculation period as calculated
in subsection (f) of this section.
(5) Medicaid supplemental payment limit calculation
period--The federal fiscal quarter determined by HHSC for which supplemental
payment amounts are calculated based on adjudicated claims for days
of service provided in the same quarter in the prior federal fiscal
year.
(6) Non-state governmental entity--A hospital authority,
hospital district, healthcare district, city, or county.
(7) Non-state government-owned nursing facility--A
nursing facility where a non-state governmental entity holds the license
and is party to the facility's Medicaid contract.
(8) Public funds--Funds derived from taxes, assessments,
levies, investments, and other public revenues within the sole and
unrestricted control of a non-state governmental entity that holds
the license and is party to the Medicaid contract of the nursing facility
identified in subsection (c) of this section. Public funds do not
include gifts, grants, trusts, or donations, the use of which is conditioned
on supplying a benefit solely to the donor or grantor of the funds.
(9) Upper payment limit--A reasonable estimate of the
amount that would be paid for the services furnished by a non-state
government-owned nursing facility under Medicare payment principles,
as calculated in subsection (f) of this section.
(10) Upper payment limit calculation period--The federal
fiscal quarter one year prior to the Medicaid supplemental payment
limit calculation period. For example, October 1 - December 31, 2011,
is the upper payment limit calculation period for the October 1 -
December 31, 2012, Medicaid supplemental payment limit calculation
period.
(c) Eligible nursing facilities.
(1) Supplemental payments are available under this
section to all non-state government-owned nursing facilities that
comply with the requirements described in subsection (d) of this section.
(2) A nursing facility participating in this supplemental
payment program must notify the HHSC Rate Analysis Department of changes
in ownership that may affect the nursing facility's continued eligibility
within 30 days after such change.
(3) A nursing facility that has not received a payment
under this supplemental payment program for four consecutive quarters
is ineligible for future supplemental payments unless the nursing
facility applies again for the supplemental payment program in accordance
with subsection (d) of this section.
(d) Required application. Before a non-state government-owned
nursing facility may receive supplemental payments under this section,
the appropriate non-state governmental entity must certify certain
facts, representations, and assurances regarding program requirements.
(1) The appropriate non-state governmental entity must
certify the following facts on a form prescribed by HHSC before the
first day of the next scheduled Medicaid supplemental payment limit
calculation period in order for the nursing facility to receive a
supplemental payment for that period:
(A) That it is a non-state government-owned nursing
facility where a non-state governmental entity holds the license and
is party to the facility's Medicaid contract.
(B) That all funds transferred to HHSC via IGT for
use as the state share of supplemental payments are public funds.
(C) That no part of any supplemental payment paid to
the nursing facility under this section will be used to pay a contingent
fee, consulting fee, or legal fee associated with the nursing facility's
receipt of the supplemental funds.
(D) That the person signing the certification on behalf
of the nursing facility is legally authorized to bind the nursing
facility and to certify the matters described in the application.
(2) The nursing facility is eligible for supplemental
payments for Medicaid supplemental payment limit calculation periods
that begin after HHSC receives completed application forms from the
appropriate non-state governmental entity. A non-state governmental
entity that has submitted a change of ownership (CHOW) application
to the Department of Aging and Disability Services (DADS) may submit
a provisional application for participation in the supplemental payment
program. If the CHOW is finalized by DADS within six months of the
submission of the provisional application for participation, the facility
will be eligible for payments beginning on the effective date of the
CHOW. If the CHOW is not finalized by DADS within six months of the
submission of the provisional application for participation, the provisional
application is denied and the facility will not be eligible for payments
until the first day of the Medicaid supplemental payment limit calculation
period that begins after the submission of a new application for participation.
(e) Source of funding.
(1) State funding for supplemental payments authorized
under this section is limited to and obtained through IGTs of public
funds from the non-state governmental entity that holds the license
and is party to the Medicaid contract of the nursing facility identified
in subsection (c) of this section.
(2) An IGT that is not received by the date specified
by HHSC may not be accepted. In such a situation, the IGT will be
returned to the non-state governmental entity and the NF will not
be eligible to receive a supplemental payment.
(f) Medicaid supplemental payment limits. A quarterly
supplemental payment amount for each non-state government owned nursing
facility is calculated using the most recent reliable data available
at the time the calculation is made by taking the difference between
the upper payment limit from paragraph (1) of this subsection and
the Medicaid payment from paragraph (2) of this subsection:
(1) The upper payment limit for each non-state government-owned
nursing facility will be calculated based on Medicare payment principles
and in accordance with the Medicaid upper payment limit provisions
codified at Title 42 Code of Federal Regulations (CFR) §447.272.
A total Medicare-equivalent payment is determined for each non-state
government-owned facility as the sum of the products of Medicaid days
of service by Resource Utilization Group (RUG) for adjudicated Medicaid
days of service provided by the facility during the upper payment
limit calculation period multiplied by the Medicare payment rate for
that RUG that will be in effect during the associated Medicaid supplemental
payment limit calculation period. If the Center for Medicare and Medicaid
Services has not adopted Medicare RUG rates for the Medicaid supplemental
payment limit calculation period at the time the calculation is performed,
the Medicaid days of service by RUG will be multiplied by the Medicare
payment rate for that RUG in effect on the last day of the upper payment
limit calculation period.
(2) The Medicaid payment for each non-state government-owned
nursing facility prior to the supplemental payment will be the sum
of the following components calculated for that nursing facility from
data derived from upper payment limit calculation period:
(A) The sum of Medicaid RUG payments for all adjudicated
Medicaid days of service provided by the facility during the upper
payment limit calculation period adjusted to reflect any changes in
Medicaid RUG rates between the upper payment limit calculation period
and the Medicaid supplemental payment limit calculation period; and
(B) Medicaid payments for pharmacy services as defined
in 40 TAC Chapter 19, Subchapter P (relating to Pharmacy Services),
specialized services as defined in 40 TAC §19.1303 (relating
to Specialized Services in Medicaid-certified Facilities), customized
equipment as defined in 40 TAC §19.2614 (relating to Customized
Power Wheelchairs) and emergency dental services as defined in 40
TAC §19.1402 (relating to Medicaid-certified Nursing Facility
Emergency Dental Services), not included in the Medicaid nursing facility
rate in effect during the upper payment limit calculation period.
(i) Medicaid payments for pharmacy services are based
on Texas specific pharmacy payment and rebate data for Texas Medicaid
nursing facility residents during the upper payment limit calculation
period.
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