| (a) Introduction. This section establishes the Quality
Incentive Payment Program (QIPP) for nursing facilities (NFs) providing
services under Medicaid managed care (MC) before September 1, 2019.
QIPP is designed to incentivize NFs to improve quality and innovation
in the provision of NF services to Medicaid recipients, using the
Centers for Medicare & Medicaid Services (CMS) Five-Star Quality
Rating System as its measure of success.
(b) Definitions. The following definitions apply when
the terms are used in this section. Terms that are used in this and
other sections of this subchapter may be defined in §353.1301
of this subchapter (related to General Provisions).
(1) Baseline--A NF-specific starting measure used as
a comparison against NF performance throughout the eligibility period
to determine progress in the QIPP Quality Measures.
(2) Benchmark--The CMS National Average prior to the
start of the eligibility period by which a NF's progress with the
Quality Measures is determined.
(3) CHOW application--An application filed with the
Department of Aging and Disability Services (DADS) for a NF change
of ownership (CHOW).
(4) DADS--The Texas Department of Aging and Disability
Services or its successor agency.
(5) Eligibility period--A period of time for which
an eligible and enrolled NF may receive the QIPP amounts described
in this section. Each QIPP eligibility period is equal to a state
fiscal year (FY) beginning September 1 and ending August 31 of the
following year. Eligibility Period One is equal to FY 2018, beginning
September 1, 2017, and ending August 31, 2018.
(6) MCO--A Medicaid managed care organization contracted
with HHSC to provide NF services to Medicaid recipients.
(7) Network nursing facility--A NF that has a contract
with an MCO for the delivery of Medicaid covered benefits to the MCO's
enrollees.
(8) Non-state government-owned NF--A network NF where
a non-state governmental entity holds the license and is a party to
the NF's Medicaid provider enrollment agreement with the state.
(9) Private NF--A NF that is not owned by a governmental
entity.
(10) Quality Assurance Performance Improvement (QAPI)
Validation Report--A monthly report submitted by a NF, that is eligible
for and enrolled in QIPP, to an MCO that demonstrates that the NF
has convened a meeting to review the NF's CMS-compliant plan for maintaining
and improving safety and quality in the NF.
(11) 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
as defined and established under Chapter 354, Subchapter D, of this
title (relating to Texas Healthcare Transformation and Quality Improvement
Program).
(c) Eligibility for participation in QIPP. A NF is
eligible to participate in QIPP if it complies with the requirements
described in this subsection for each eligibility period.
(1) Eligibility Period One. A NF is eligible to participate
in QIPP for Eligibility Period One if it meets the following requirements:
(A) The NF is a non-state government-owned NF.
(i) The NF must be a non-state government-owned NF
with a Medicaid contract effective date of April 1, 2017, or earlier.
A NF undergoing a CHOW from privately owned to non-state government
owned will only be eligible under this subparagraph if DADS received
a completed CHOW application by March 2, 2017, and all required documents
pertaining to the CHOW (i.e., DADS must have a complete application
for a change of ownership license as described under 40 TAC §19.201
(relating to Criteria for Licensing), §19.210 (relating to Change
of Ownership License), and §19.2308 (relating to Change of Ownership))
by March 31, 2017.
(ii) The non-state governmental entity that owns the
NF must certify the following facts on a form prescribed by HHSC.
(I) that it is a non-state government-owned NF where
a non-state governmental entity holds the license and is party to
the facility's Medicaid contract; and
(II) that all funds transferred to HHSC via an intergovernmental
transfer (IGT) for use as the state share of payments are public funds.
(iii) The NF must have been a participant in the Minimum
Payment Amounts Program (MPAP) or must be located in the same RHP
as, or within 150 miles of, the non-state governmental entity taking
ownership of the facility. This geographic proximity criterion does
not apply to NFs that can establish good cause for an exception to
this criterion.
(B) Private NFs. The NF must have a percentage of Medicaid
NF days of service that is greater than or equal to the private NF
QIPP eligibility cut-off point. The private NF QIPP eligibility cut-off
point will be equal to the mean percentage of historical Medicaid
NF days of service provided under fee-for-service (FFS) and MC by
all private NFs plus one standard deviation, as determined by HHSC.
For each private NF, the percentage of Medicaid NF days is calculated
by summing the NF's Medicaid NF FFS and MC days of service and dividing
that sum by the facility's total days of service in all licensed beds.
Medicaid hospice days of service are included in the denominator but
excluded from the numerator.
(2) Future eligibility periods. Eligibility requirements
for eligibility periods after Eligibility Period One are the same
as the requirements under paragraph (1) of this subsection except
that the deadlines specified in paragraph (1)(A)(i) of this subsection
will be updated by HHSC. Updated deadlines will be shared with all
NFs by a date to be determined by HHSC.
(d) Data sources for historical units of service. Historical
units of service are used to determine the private NF QIPP eligibility
cut-off point, individual private NF QIPP eligibility status, and
the distribution of QIPP funds across eligible and enrolled NFs.
(1) All data sources referred to in this subsection
are subject to validation using HHSC auditing processes or procedures
as described under §355.106 of this title (relating to Basic
Objectives and Criteria for Audit and Desk Review of Cost Reports).
(2) The data source for the determination of the private
NF QIPP eligibility cut-off point is the most recently available,
audited Texas Medicaid NF cost report database.
(3) Data sources for the determination of each private
NF's QIPP eligibility status are listed in priority order below. For
each eligibility period, the data source must align with the NF's
fiscal year that ends no more recently than in the calendar year four
years prior to the calendar year within which the eligibility period
ends. For example, for the eligibility period ending on August 31,
2018, the data source must align with the NF's 2014 fiscal year or
an earlier fiscal year and for the eligibility period ending on August
31, 2019, the data source must align with the NF's 2015 fiscal year
or an earlier fiscal year.
(A) The most recently available Medicaid NF cost report
for the private NF. If no Medicaid NF cost report is available, the
data source in subparagraph (B) of this paragraph must be used.
(B) The most recently available Medicaid Direct Care
Staff Rate Staffing and Compensation Report for the private NF. If
no Medicaid Direct Care Staff Rate Staffing and Compensation Report
is available, the data source in subparagraph (C) of this paragraph
must be used.
(C) The most recently available Medicaid NF cost report
for a prior owner of the private NF. If no Medicaid NF cost report
for a prior owner of the private NF is available, the data source
in subparagraph (D) of this paragraph must be used.
(D) The most recently available Medicaid Direct Care
Staff Rate Staffing and Compensation Report for a prior owner of the
private NF. If no Medicaid Direct Care Staff Rate Staffing and Compensation
Report for a prior owner of the private NF is available, the private
NF is not eligible for participation in QIPP.
(4) Data sources for determination of distribution
of QIPP funds across eligible and enrolled NFs. For each eligibility
period, the data source must align with the NF's fiscal year that
ends no more recently than in the calendar year four years prior to
the calendar year within which the eligibility period ends. For example,
for the eligibility period ending on August 31, 2018, the data source
must align with the NF's 2014 fiscal year or an earlier fiscal year
and for the eligibility period ending on August 31, 2019, the data
source must align with the NF's 2015 fiscal year or an earlier fiscal
year.
(A) The most recently available Medicaid NF cost report
for the NF. If the cost report covers less than a full year, reported
values are annualized to represent a full year. If no audited Medicaid
NF cost report is available, the data source in subparagraph (B) of
this paragraph must be used.
(B) The most recently available Medicaid Direct Care
Staff Rate Staffing and Compensation Report for the NF. If the Staffing
and Compensation Report covers less than a full year, reported values
are annualized to represent a full year. If no Staffing and Compensation
Report is available, the data source in subparagraph (C) of this paragraph
is must be used.
(C) The most recently available Medicaid NF cost report
for a prior owner of the NF. If the cost report covers less than a
full year, reported values are annualized to represent a full year.
If no Medicaid NF cost report for a prior owner of the NF is available,
the data source in subparagraph (D) of this paragraph must be used.
(D) The most recently available Medicaid Direct Care
Staff Rate Staffing and Compensation Report for a prior owner of the
NF. If the Staffing and Compensation Report covers less than a full
year, reported values are annualized to represent a full year.
(e) Participation requirements. As a condition of participation,
all NFs participating in QIPP must allow for the following:
(1) HHSC must be able to access data for the NF from
one of the data sources listed in subsection (d) of this section.
(2) The NF must submit a properly completed enrollment
application by the due date determined by HHSC.
(3) The entity that owns the NF must certify, on a
form prescribed by HHSC, that no part of any payment made under the
QIPP will be used to pay a contingent fee, consulting fee, or legal
fee associated with the NF's receipt of QIPP funds and the certification
must be received by HHSC with the enrollment application described
in paragraph (2) of this subsection.
(4) The entity that owns the NF must submit to HHSC,
upon demand, copies of contracts it has with third parties that reference
the administration of, or payments from, QIPP.
(f) Non-federal share of QIPP payments. The non-federal
share of all QIPP payments is funded through IGTs from sponsoring
non-state governmental entities. No state general revenue is available
to support QIPP.
(1) HHSC will share suggested IGT responsibilities
for the eligibility period with all QIPP eligible and enrolled non-state
government-owned NFs on or around May 15 of the calendar year that
also contains the first month of the eligibility period. Suggested
IGT responsibilities will be based on the maximum dollars to be available
under the QIPP program for the eligibility period as determined by
HHSC, plus ten percent; forecast STAR+PLUS NF member months for the
eligibility period as determined by HHSC; and the distribution of
historical Medicaid days of service across non-state government-owned
NFs enrolled in QIPP for the eligibility period. HHSC will also share
estimated maximum revenues each eligible and enrolled NF could earn
under QIPP for the eligibility period with those estimates based on
HHSC's suggested IGT responsibilities and an assumption that all enrolled
NFs will meet 100 percent of their quality metrics. The purpose of
sharing this information is to provide non-state government-owned
NFs with information they can use to determine the amount of IGT they
wish to transfer.
(2) Sponsoring governmental entities will determine
the amount of IGT they wish to transfer to HHSC for the entire eligibility
period and will transfer one-half of that amount by May 31 of the
calendar year that also contains the first month of the eligibility
period. The second half of the IGT amount will be transferred by November
30 of the calendar year that also contains the first month of the
eligibility period.
(3) Reconciliation. HHSC will reconcile the amount
of the non-federal funds actually expended under this section during
each eligibility 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) QIPP capitation rate components. QIPP funds will
be paid to MCOs through three new components of the STAR+PLUS NF MC
per member per month (PMPM) capitation rates. The MCOs' distribution
of QIPP funds to the enrolled NFs will be based on each NF's performance
on a set of defined quality metrics.
(1) Component One.
(A) The total value of Component One will be equal
to 110 percent of the non-federal share of the QIPP program.
(B) Interim allocation of funds across qualifying non-state
government-owned NFs will be proportional, based upon historical Medicaid
days of NF service.
(C) Monthly payments to non-state government-owned
NFs will be triggered by the NF's submission to the MCOs of a monthly
QAPI Validation Report.
Cont'd... |
