| (a) Introduction. This section establishes the Directed
Payment Program for Behavioral Health Services (DPP BHS). DPP BHS
is designed to incentivize behavioral health providers to improve
quality, access, and innovation in the provision of medical and behavioral
health services to Medicaid recipients through the use of metrics
that are expected to advance at least one of the goals and objectives
of the state's managed care quality strategy.
(b) Definitions. The following definitions apply when
the terms are used in this section. Terms that are used in this section
may be defined in §353.1301 of this subchapter (relating to General
Provisions) or §353.1322 of this subchapter (relating to Quality
Metrics for the Directed Payment Program for Behavioral Health Services).
(1) Average Commercial Reimbursement (ACR) gap--The
difference between what an average commercial payor is estimated to
pay for the services and what Medicaid actually paid for the same
services.
(2) Certified community behavioral health clinic (CCBHC)--A
clinic certified by the state in accordance with federal criteria
and with the requirements of the Protecting Access to Medicare Act
of 2014 (PAMA).
(3) CCBHC cost-reporting gap--The difference between
what Medicaid pays for services and what the reimbursement would be
based on the CCBHC cost-reporting methodology.
(4) Community mental health center (CMHC)--An entity
that is established under Texas Health and Safety Code §534.0015
and that:
(A) Provides outpatient services, including specialized
outpatient services for children, the elderly, individuals with serious
mental illness, and residents of its mental health service area who
have been discharged from inpatient treatment at a mental health facility.
(B) Provides 24-hour-a-day emergency care services.
(C) Provides day treatment or other partial hospitalization
services, or psychosocial rehabilitation services.
(D) Provides screening for patients being considered
for admission to state mental health facilities to determine the appropriateness
of such admission.
(5) Intergovernmental transfer (IGT) notification--Notice
and directions regarding how and when IGTs should be made in support
of DPP BHS.
(6) Local behavioral health authority (LBHA)--An entity
that is designated under Texas Health and Safety Code §533.0356.
(7) Program period--A period of time for which the
Texas Health and Human Services (HHSC) contracts with participating
managed care organizations (MCOs) to pay increased capitation rates
for the purpose of provider payments under this section. Each program
period is equal to a state fiscal year beginning September 1 and ending
August 31 of the following year.
(8) Providers--For program periods on or before August
31, 2022, an entity described in paragraph (4) of this subsection.
For program periods on or after September 1, 2022, an entity described
in paragraph (4) or (6) of this subsection.
(9) Suggested IGT responsibility--Notice of potential
amounts that a sponsoring governmental entity may wish to consider
transferring in support of DPP BHS.
(10) Total program value--The maximum amount available
under the Directed Payment Program for Behavioral Health Services
for a program period, as determined by HHSC.
(c) Classes of participating providers.
(1) HHSC may direct the MCOs to provide a uniform percentage
rate increase or a uniform dollar increase to all providers within
one or more of the following classes of providers with which the MCO
contracts for services:
(A) Providers that are certified CCBHCs; and
(B) Providers that are not certified CCBHCs.
(2) If HHSC directs rate or dollar increases to more
than one class of providers within the service delivery area (SDA),
the rate or dollar increases directed by HHSC may vary between classes.
(d) Data sources for historical units of service. Historical
units of service are used to determine a provider's eligibility status
to receive the estimated distribution of program funds across enrolled
providers.
(1) HHSC will use encounter data and will identify
encounters based upon the billing provider's national provider identification
(NPI) number.
(2) The most recently available Medicaid encounter
data for a complete state fiscal year will be used to determine the
distribution of program funds across eligible and enrolled providers.
(3) In the event that the historical data are not deemed
appropriate for use by actuarial standards, HHSC may use data from
a different state fiscal year at the discretion of the HHSC actuaries.
(4) The data used to estimate distribution of funds
will align to the extent possible with the data used for purposes
of setting the capitation rates for MCOs for the same period.
(5) HHSC will calculate the estimated rate that an
average commercial payor or Medicare would have paid for similar services
or based on the CMS approved CCBHC cost report rate methodology using
either data from Medicare cost reports or collected from providers.
(6) Encounter data used to calculate DPP BHS payments
must be designated as paid status with a reported paid amount greater
than zero. Encounters reported as paid status, but with a reported
paid amount of zero or negative dollars, will be excluded from the
data used to calculate DPP BHS payments.
(e) Conditions of Participation. As a condition of
participation, all providers participating in the program must allow
for the following.
(1) The provider must submit a properly completed enrollment
application by the due date determined by HHSC. The enrollment period
must be no less than 21 calendar days, and the final date of the enrollment
period will be at least nine calendar days prior to the release of
suggested IGT responsibilities.
(2) The entity that bills on behalf of the provider
must certify, on a form prescribed by HHSC, that no part of any payment
made under the program will be used to pay a contingent fee and that
the entity's agreement with the provider does not use a reimbursement
methodology that contains any type of incentive, directly or indirectly,
for inappropriately inflating, in any way, claims billed to the Medicaid
program, including the provider's receipt of program funds. The certification
must be received by HHSC with the enrollment application described
in paragraph (1) of this subsection.
(3) If a provider has changed ownership in the past
five years in a way that impacts eligibility for DPP BHS, the provider
must submit to HHSC, upon demand, copies of contracts it has with
third parties with respect to the transfer of ownership or the management
of the provider and which reference the administration of, or payment
from, DPP BHS.
(4) Report all quality data denoted as required as
a condition of participation in subsection (h) of this section.
(5) Failure to meet any conditions of participation
described in this section will result in removal of the provider from
the program and recoupment of all funds previously paid during the
program period.
(f) Determination of percentage of rate and dollar
increase.
(1) HHSC will determine the percentage of rate or dollar
increase applicable to providers by program component.
(2) HHSC will consider the following factors when determining
the rate increase:
(A) the estimated Medicare gap for providers, based
upon the upper payment limit demonstration most recently submitted
by HHSC to the Centers for Medicare and Medicaid Services (CMS);
(B) the estimated Average Commercial Reimbursement
(ACR) gap for the class or individual providers, as indicated in data
collected from providers;
(C) the estimated gap for providers, based on the CCBHC
cost-reporting methodology that is consistent with the CMS guidelines;
(D) the percentage of Medicaid costs incurred by providers
in providing care to Medicaid managed care clients that are reimbursed
by Medicaid MCOs prior to any rate increase administered under this
section; and
(E) the actuarial soundness of the capitation payment
needed to support the rate increase.
(g) Services subject to rate and dollar increase. HHSC
may direct the MCOs to increase rates or dollar amounts for all or
a subset of provider services.
(h) Program capitation rate components. Program funds
will be paid to MCOs through two components of the managed care per
member per month (PMPM) capitation rates. The MCOs' distribution of
program funds to the enrolled providers will be based on each provider's
performance related to the quality metrics as described in §353.1322
of this subchapter. The provider must have provided at least one Medicaid
service to a Medicaid managed care client for each reporting period
to be eligible for payments.
(1) Component One.
(A) The total value of Component One will be equal
to 65 percent of total program value.
(B) Allocation of funds across all qualifying CMHCs
will be proportional, based upon historical Medicaid utilization.
(C) Monthly payments to providers will be a uniform
rate increase.
(D) The interim allocation of funds across qualifying
providers will be reconciled to the actual Medicaid utilization across
these providers during the program period, as captured by Medicaid
MCOs contracted with HHSC for managed care 120 days after the last
day of the program period.
(E) Providers must report quality data as described
in §353.1322 of this subchapter as a condition of participation
in the program.
(2) Component Two.
(A) The total value of Component Two will be equal
to 35 percent of total program value.
(B) Allocation of funds across all qualifying providers
will be based upon historical Medicaid utilization.
(C) Payments to providers will be a uniform rate increase.
(D) Providers must report quality data as described
in §353.1322 of this subchapter as a condition of participation
in the program.
(i) Distribution of the Directed Payment Program for
Behavioral Health Services payments.
(1) Prior to the beginning of the program period, HHSC
will calculate the portion of each payment associated with each enrolled
provider broken down by program capitation rate component and payment
period. For example, for a provider, HHSC will calculate the portion
of each payment associated with that provider that would be paid from
the MCO to the provider as follows.
(A) Monthly payments in the form of a uniform dollar
increase for Component One will be equal to the total value of Component
One attributed based upon historical utilization of the provider divided
by twelve. An annual reconciliation will be performed for each provider
based on actual utilization.
(B) Ongoing rate increases from Component Two will
be a uniform percentage rate increase on applicable services calculated
based on the total value of Component Two for the providers divided
by historical utilization of the respective services.
(C) For purposes of the calculation described in subparagraph
(B) of this paragraph, a provider must achieve a minimum number of
measures as identified in §353.1322 of this subchapter to be
eligible for full payment.
(2) MCOs will distribute payments to enrolled providers
based on criteria established under paragraph (1) of this subsection.
(j) Non-federal share of DPP BHS payments. The non-federal
share of all DPP BHS payments is funded through IGTs from sponsoring
governmental entities. No state general revenue that is not otherwise
available to providers is available to support DPP BHS.
(1) HHSC will communicate suggested IGT responsibilities
for the program period with all DPP BHS eligible and enrolled providers
at least 10 calendar days prior to the IGT declaration of intent deadline.
Suggested IGT responsibilities will be based on the maximum dollars
available under DPP BHS for the program period as determined by HHSC,
plus 10 percent; forecasted member months for the program period as
determined by HHSC; and the distribution of historical Medicaid utilization
across providers, for the program period. HHSC will also communicate
estimated maximum revenues each eligible and enrolled provider could
earn under DPP BHS for the program period with those estimates based
on HHSC's suggested IGT responsibilities and an assumption that all
enrolled providers will meet 100 percent of their quality metrics.
(2) Sponsoring governmental entities will determine
the amount of IGT they intend to transfer to HHSC for the entire program
period and provide a declaration of intent to HHSC 21 business days
before the first half of the IGT amount is transferred to HHSC.
(A) The declaration of intent is a form prescribed
by HHSC that includes the total amount of IGT the sponsoring governmental
entity intends to transfer to HHSC.
Cont'd... |
