| (a) Basis for payment for the RHP plan update submission.
A performer will receive 20 percent of its total DY7 valuation if
the anchor of the performer's RHP submits an RHP plan update and HHSC
approves the submitted RHP plan update.
(b) Category A and DSRIP payments. If a performer fails
to fulfill all of the Category A requirements described in §354.1709
of this division (relating to Category A Requirements for Performers)
for a demonstration year (DY), any DSRIP payments the performer received
for the DY will be recouped, and prospective DSRIP payments to the
performer will be withheld.
(1) DSRIP payments for DY7 include payments for the
RHP plan update submission, as well as any payments for DY7 Category
B, Category C, or Category D milestones.
(2) DSRIP payments for DY8 include any payments for
DY8 Category B, Category C, or Category D milestones.
(c) Basis for payment of Category B. A performer's
payment for its MLIU PPP milestone for a DY is calculated as follows.
(1) If the performer's MLIU PPP goal achievement is
greater than or equal to 100 percent minus its allowable MLIU PPP
goal variation, the performer's MLIU PPP milestone payment is equal
to 100 percent of its MLIU PPP milestone valuation.
(2) If the performer's MLIU PPP goal achievement is
greater than or equal to 90 percent, and less than 100 percent minus
its allowable MLIU PPP goal variation, the performer's MLIU PPP milestone
payment is equal to 90 percent of its MLIU PPP milestone valuation.
(3) If the performer's MLIU PPP goal achievement is
greater than or equal to 75 percent, and less than 90 percent, the
performer's MLIU PPP milestone payment is equal to 75 percent of its
MLIU PPP milestone valuation.
(4) If the performer's MLIU PPP goal achievement is
greater than or equal to 50 percent, and less than 75 percent, the
performer's MLIU PPP milestone payment is equal to 50 percent of its
MLIU PPP milestone valuation.
(5) If the performer's MLIU PPP goal achievement is
less than 50 percent, the performer does not receive a MLIU PPP milestone
payment.
(d) Basis for payment of Category C.
(1) Reporting milestones. A performer must fully achieve
a reporting milestone to be eligible for payment related to the milestone.
(2) P4P measure goal achievement milestones. A P4P
measure has a goal achievement milestone for each DY. With the exception
of P4P measure goal achievement milestones described in subparagraph
(B) of this paragraph, partial payment for P4P measure goal achievement
milestones is available in quartiles for partial achievement measured
over baseline in Performance Year (PY) 1, PY2, and PY3.
(A) To calculate the payment for a P4P measure goal
achievement milestone, multiply the milestone valuation by the achievement
value calculated in clause (ii) of this subparagraph.
(i) The percent of the milestone's goal achieved by
the performer is determined as follows.
(I) Measures with a positive directionality where higher
scores indicate improvement:
(-a-) DY7 achievement = (PY1 Achieved - Baseline/ (DY
Goal - Baseline).
(-b-) Carryforward of DY7 achievement = (PY2 Achieved
- Baseline)/ (DY7 Goal - Baseline).
(-c-) DY8 achievement = (PY2 Achieved - Baseline)/
(DY8 Goal - Baseline).
(-d-) Carryforward of DY8 achievement = (PY3 Achieved
- Baseline)/ (DY8 Goal - Baseline).
(II) Measures with a negative directionality where
lower scores indicate improvement:
(-a-) DY7 achievement = (Baseline - PY1 Achieved)/
(Baseline - DY7 Goal).
(-b-) Carryforward of DY7 achievement = (Baseline -
PY2 Achieved)/ (Baseline - DY7 Goal).
(-c-) DY8 achievement = (Baseline - PY2 Achieved)/
(Baseline - DY8 Goal).
(-d-) Carryforward of DY8 achievement = (Baseline -
PY3 Achieved)/ (Baseline - DY8 Goal).
(ii) The achievement value is determined as follows.
(I) If 100 percent of the goal is achieved, the achievement
value is 1.0.
(II) If less than 100 percent but at least 75 percent
of the goal is achieved, the achievement value is 0.75.
(III) If less than 75 percent but at least 50 percent
of the goal is achieved, the achievement value is 0.5.
(IV) If less than 50 percent but at least 25 percent
of the goal is achieved, the achievement value is 0.25.
(V) If less than 25 percent of the goal is achieved,
the achievement value is 0.
(B) If a P4P measure designated as Quality Improvement
System for Managed Care has a baseline above the High Performance
Level, the performer must achieve 100 percent of the goal achievement
milestone to be eligible for payment of the milestone; there is no
payment for partial achievement.
(e) Basis for payment of Category D. A performer must
report on a measure in the Category D - Statewide Reporting Measure
Bundle for its provider type for a DY in accordance with §354.1715(d)
of this division (relating to Category D Requirements for Performers)
to be eligible for payment of the measure for that DY.
(f) At no point may a performer receive a DSRIP payment
for a milestone more than two years after the end of the DY in which
the milestone is to be completed.
(g) If a performer does not complete the remaining
milestones as described in §354.1711of this division (relating
to Category B Requirements for Performers) or §354.1713 of this
division (relating to Category C Requirements for Performers), or
the Category D - Statewide Reporting Measure Bundle measures as described
in subsection (e) of this section, the associated DSRIP funding is
forfeited by the performer.
(h) Once the action associated with a milestone is
reported by the performer as complete, that milestone may not be counted
again toward DSRIP payment calculations.
|
| Source Note: The provisions of this §354.1719 adopted to be effective December 1, 2017, 42 TexReg 6609; amended to be effective April 26, 2018, 43 TexReg 2393; amended to be effective September 1, 2108, 43 TexReg 5497 |
