The following words and terms, when used in this division,
have the following meanings unless the context clearly indicates otherwise.
(1) Core activity--An activity implemented by a performer
to improve patient health or quality of care. It may be part of a
DSRIP project implemented by a performer during the initial demonstration
period that the performer continues in DY7-8, or a new activity implemented
by a performer in DY7-8. It may be implemented by a performer to achieve
the performer's Category C measure goals or it may be connected to
the mission of the performer's organization.
(2) Demonstration Year (DY) 6--Federal fiscal year
2017 (October 1, 2016 - September 30, 2017).
(3) Demonstration Year (DY) 7--Federal fiscal year
2018 (October 1, 2017 - September 30, 2018).
(4) Demonstration Year (DY) 8--Federal fiscal year
2019 (October 1, 2018 - September 30, 2019).
(5) Demonstration Year (DY) 9--Federal fiscal year
2020 (October 1, 2019 - September 30, 2020).
(6) Denominator--As it relates to a Category C measure's
volume:
(A) the number of Medicaid and low-income or uninsured
(MLIU) cases; or
(B) one of the following, which the performer receives
approval from HHSC to use for the measure:
(i) the number of all-payer cases;
(ii) the number of Medicaid cases; or
(iii) the number of low-income or uninsured (LIU) cases.
(7) DSRIP pool--Funds available to DSRIP performers
under the waiver for their efforts to enhance access to health care,
the quality of care, and the health of patients and families they
serve.
(8) Encounter--An encounter, for the purposes of Medicaid
and Low-income Uninsured (MLIU) Patient Population by Provider (PPP)
and total PPP, is any physical or virtual contact between a performer
and a patient during which an assessment or clinical activity is performed,
with exceptions including those in subparagraph (B) of this definition.
(A) An encounter must be documented by the performer.
(B) A phone call or text message is not considered
an encounter.
(9) Federal poverty level (FPL)--The household income
guidelines issued annually and published in the Federal Register by
the United States Department of Health and Human Services.
(10) Initial demonstration period--The first five demonstration
years (DYs) of the waiver, or December 12, 2011, through September
30, 2016.
(11) Innovative measure--A new measure developed for
use in Category C. Innovative measures are pay-for-reporting (P4R)
in DY7-8.
(12) Insignificant volume--For most Category C measures,
the denominator is considered to have insignificant volume if its
volume is greater than zero but less than 30.
(13) Measure--A mechanism to assign a quantity to an
attribute by comparison to a criterion. As it relates to Category
C, a measure is a standardized tool to measure or quantify healthcare
processes, outcomes, patient perceptions, organizational structure,
and/or systems that are associated with the ability to provide high-quality
health care.
(14) Measure Bundle--A grouping of measures under Category
C that share a unified theme, apply to a similar population, and are
impacted by similar activities. Measure Bundles are selected by hospitals
and physician practices. All Measure Bundles include required measures,
and some Measure Bundles also include optional measures.
(15) Measure Bundle Protocol--A master list of potential
Category C Measure Bundles and measures, as well as Category D Statewide
Reporting Measure Bundles and measures.
(16) Medicaid and Low-income or Uninsured (MLIU) Patient
Population by Provider (PPP)--The number of MLIU individuals in a
performer's system for which there was an encounter during the applicable
DY.
(A) To qualify as a Medicaid individual served, the
individual must be enrolled in Medicaid at the time of at least one
encounter during the applicable DY.
(B) To qualify as a low-income or uninsured individual
served, the individual must either be at or below 200 percent of the
FPL or must not have health insurance at the time of at least one
encounter during the applicable DY.
(C) If an individual was enrolled in Medicaid at the
time of one encounter during the applicable DY, and was low-income
or uninsured at the time of a separate encounter during the applicable
DY, that individual is classified as a Medicaid individual served
for purposes of MLIU PPP.
(17) Medicaid and Low-income or Uninsured (MLIU) Patient
Population by Provider (PPP) Goal--The target number of MLIU individuals
in a performer's system for which there will be an encounter during
the applicable DY.
(18) Milestone--An objective of DSRIP performance on
which DSRIP payments are based.
(19) Minimum point threshold (MPT)--The minimum number
of points that a performer must meet in selecting its Category C Measure
Bundles or measures, as described in §354.1713 of this division
(relating to Category C Requirements for Performers).
(20) No volume--For Category C measures, the denominator
is considered to have no volume if its volume is equal to zero. For
a Category C population-based clinical outcome measure, the numerator
is considered to have no volume if the volume is equal to zero.
(21) Quality improvement collaborative activity--An
activity related to participating in a learning collaborative to improve
targeted health outcomes. As included in Category C, a quality improvement
collaborative activity is pay-for-reporting (P4R) in DY7-8.
(22) Performer--A provider enrolled in Texas Medicaid
that participates in DSRIP and receives DSRIP payments.
(23) Population-based clinical outcome measure--A Category
C clinical outcome measure that measures emergency department utilization
or admissions for select conditions for all individuals in the Measure
Bundle's target population. It may be required as pay-for-performance
(P4P) or pay-for-reporting (P4R) based on the Measure Bundle and the
hospital's or physician practice's MPT as specified in the Measure
Bundle Protocol.
(24) RHP plan update--An RHP plan for the initial demonstration
period and DY6 that is updated for DY7-8, as further described in
§354.1697 of this division (relating to RHP Plan Update).
(25) Significant volume--For most Category C measures,
the denominator is considered to have significant volume if its volume
is greater than or equal to 30.
(26) Statewide hospital factor (SHF)--A factor used
to determine the MPT that takes into account a hospital's MLIU inpatient
days and MLIU outpatient costs compared to all hospitals, as described
in §354.1713 of this division.
(27) Statewide hospital ratio (SHR)--A factor used
to determine the MPT that takes into account whether a hospital's
DY7 DSRIP valuation is higher or lower than would be expected based
on the hospital's MLIU inpatient days and MLIU outpatient costs compared
to other hospitals, as described in §354.1713 of this division.
(28) System--A performer's patient care landscape,
as defined by the performer, in accordance with the Program Funding
and Mechanics Protocol and Measure Bundle Protocol. Essential functions
or departments of a performer's provider type are required components
that must be included in a performer's system definition.
(29) Target population--For a Category C Measure Bundle,
the pool of individuals to be included in a measure denominator for
which a hospital or physician practice is accountable for improvement.
(30) Total Patient Population by Provider (total PPP)--The
total number of individuals in a performer's system for which there
was an encounter during the applicable DY.
(31) Volume--For Category C measure denominators, the
total number of measured units in the denominator. Volume is used
to determine the size of the population for which improvement is being
measured.
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