| (a) Introduction. Texas Healthcare Transformation and
Quality Improvement Program §1115(a) Medicaid demonstration waiver
payments are available under this section for eligible performers
described in subsection (c) of this section. Waiver payments to performers
must be in compliance with the Centers for Medicare and Medicaid Services
approved waiver Program Funding and Mechanics Protocol, HHSC waiver
instructions and this section.
(b) Definitions.
(1) Centers for Medicare and Medicaid Services (CMS)--The
federal agency within the United States Department of Health and Human
Services responsible for overseeing and directing Medicare and Medicaid,
or its successor.
(2) Delivery System Reform Incentive Payments (DSRIP)--Payments
related to the development or implementation of a program of activity
that supports a performer's efforts to enhance access to health care,
the quality of care, and the health of patients and families it serves.
(3) Demonstration year--The 12-month period beginning
October 1 for which the payments calculated under this section are
made.
(4) Governmental entity--A state agency or a political
subdivision of the state. A governmental entity includes a hospital
authority, hospital district, city, county, or state entity.
(5) HHSC--The Texas Health and Human Services Commission
or its designee.
(6) Intergovernmental transfer (IGT)--A transfer of
public funds from a governmental entity to HHSC.
(7) Performer--A Medicaid provider that implements
one or more DSRIP projects.
(8) Public funds--Funds derived from taxes, assessments,
levies, investments, and other public revenues within the sole and
unrestricted control of a governmental entity. 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) Regional Healthcare Partnership (RHP)--A collaboration
of interested participants that work collectively to develop and submit
to the state a regional plan for health care delivery system reform.
Regional Healthcare Partnerships will support coordinated, efficient
delivery of quality care and a plan for investments in system transformation
that is driven by the needs of local hospitals, communities, and populations.
(10) RHP plan--A multi-year plan within which participants
propose their portion of waiver funding and DSRIP projects.
(11) Waiver--The Texas Healthcare Transformation and
Quality Improvement Program Medicaid demonstration waiver under §1115
of the Social Security Act.
(c) Eligibility for DSRIP. For a performer to be eligible
to receive DSRIP, the performer must:
(1) be actively enrolled as a Medicaid provider in
the State of Texas;
(2) submit to HHSC documentation of completion of a
milestone identified in the approved RHP plan; and
(3) for a private performer only, complies with the
eligibility requirements in §355.8201(c)(1)(B) of this title
(relating to Waiver Payments to Hospitals for Uncompensated Care)
or §355.8202(c)(3) of this title (relating to Waiver Payments
to Physician Group Practices for Uncompensated Care), as applicable.
(d) Source of funding. The non-federal share of funding
for payments under this section is limited to timely receipt by HHSC
of public funds from a governmental entity.
(e) Payment frequency. DSRIP payments will be distributed
at least annually, not to exceed two payments per performer per year,
upon achievement of RHP plan milestones as reviewed and approved by
CMS and HHSC. The payment schedule or frequency may be modified as
specified by CMS or HHSC.
(f) Funding limitations. Payments made under this section
are limited by the maximum aggregate amount of funds approved by CMS
for DSRIP for each year that the waiver is in effect.
(g) DSRIP maximum payment amounts. The approved RHP
plan establishes the payment amount associated with a particular milestone.
DSRIP payments cannot exceed the amount reported in the RHP Plan.
(h) Payment methodology.
(1) Notice. Prior to making any DSRIP payments, HHSC
will give notice of the following information:
(A) the maximum payment amount for the payment period;
(B) the maximum IGT amount necessary for a performer
to receive the amount described in subparagraph (A) of this paragraph;
and
(C) the deadline for completing the IGT.
(2) Payment amount. The approved RHP plan establishes
the payment amount associated with a milestone. DSRIP payments cannot
exceed the amount established in the approved RHP plan. The amount
of the payment to a performer will be determined based on the amount
of funds transferred by a governmental entity as follows:
(A) If a governmental entity transfers the maximum
amount referenced in paragraph (1) of this subsection on behalf of
each performer owned by or affiliated with that governmental entity,
each performer owned by or affiliated with that governmental entity
will receive the full payment amount calculated for that payment period.
(B) If a governmental entity does not transfer the
maximum amount referenced in paragraph (1) of this subsection on behalf
of each performer owned by or affiliated with that governmental entity,
each performer owned by or affiliated with that governmental entity
will receive a portion of the value associated with that milestone
or quality measure (as specified in the RHP plan) that is proportionate
to the total value of all milestones that are completed and eligible
for payment for that period by all performers owned by or affiliated
with that governmental entity.
(3) Final payment opportunity. If a performer does
not receive a full DSRIP payment as a result of subparagraph (h)(2)(B)
above, a governmental entity may provide the necessary IGT to make
up the non-federal share of that shortfall until the last reporting
period of the demonstration year following the demonstration year
in which the applicable milestone is listed in the RHP plan. Any shortfall
remains the obligation of the original governmental entity until that
governmental entity informs HHSC that it will no longer agree to fund
that obligation.
(A) If the governmental entity will no longer fund
the obligation, that governmental entity must inform HHSC no later
than the last date of the reporting period for the applicable payment
period.
(B) A performer may utilize any affiliated governmental
entity to fund the shortfall but must inform HHSC of the identity
of this governmental entity no later than the last date of a reporting
period in order for that affiliated entity to fund the shortfall during
the associated payment period.
(i) Recoupment.
(1) In the event of an overpayment identified by HHSC
or a disallowance by CMS of federal financial participation related
to a performer's receipt or use of payments under this section, HHSC
may recoup an amount equivalent to the amount of the overpayment or
disallowance. The non-federal share of any funds recouped from the
performer will be returned to the governmental entity that was the
source of those funds.
(2) Payments under this section may be subject to adjustment
for payments made in error, including, without limitation, adjustments
under §371.1711 of this title (relating to Recoupment of Overpayments
and Debts), 42 CFR Part 455, and Chapter 403, Texas Government Code.
HHSC may recoup an amount equivalent to any such adjustment.
(3) HHSC may recoup from any current or future Medicaid
payments as follows:
(A) HHSC will recoup from the performer against which
any overpayment was made or disallowance was directed.
(B) If, within 30 days of the performer's receipt of
HHSC's written notice of recoupment, the performer has not paid the
full amount of the recoupment or entered into a written agreement
with HHSC to do so, HHSC may withhold any or all future Medicaid payments
from the performer until HHSC has recovered an amount equal to the
amount overpaid or disallowed.
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