| (a) Introduction. This section establishes the Public
Health Provider - Charity Care Program (PHP-CCP). PHP-CCP is designed
to allow qualified providers to receive reimbursement for the cost
of delivering healthcare services, including behavioral health services,
vaccine services, public health services, and other preventative services,
when those costs are not reimbursed by another source. The program
is authorized under the 1115 waiver.
(b) Definitions. The following words and terms, when
used in this section, have the following meanings, unless the context
clearly indicates otherwise.
(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) Medicaid shortfall--The unreimbursed cost to a
qualifying provider of providing Medicaid services to Medicaid clients.
(3) Preventative services--For clients 21 years of
age or older, services described in Section 9.2.56.3.2, Preventative
Care Visits of the Texas Medicaid Provider Procedures Manual as of
the effective date of this section. For clients birth through 20 years
of age, services covered under the Early and Periodic Screening, Diagnosis,
and Treatment (EPSDT) service.
(4) Program period--A period of time for which eligible
and enrolled providers may receive the PHP-CCP amounts described in
this section. Each PHP-CCP period is equal to a Federal Fiscal Year
(FFY) beginning October 1 and ending September 30 of the following
year.
(5) Public health services--Services designed to protect
and promote the general population's health and to prevent higher
cost interventions such as hospitalizations. These services include,
but are not limited to, tuberculosis identification, diagnosis, and
treatment; sexually transmitted diseases identification, diagnosis,
and treatment; immunization (clinical services and administration);
dental care; and chronic disease screening, monitoring, and self-management.
(6) Qualifying Providers--Publicly-owned and operated
Community Mental Health Clinics (CMHCs), community centers, Local
Behavioral Health Authorities (LBHAs) and Local Mental Health Authorities
(LMHAs) that are established under the Texas Health & Safety Code
Chapter 533 or 534 and are primarily providing behavioral health services,
and publicly-owned and operated Local Health Departments (LHDs) and
Public Health Districts (PHDs) that are established under the Texas
Health and Safety Code Chapter 121.
(7) Total program value--The maximum amount available
under PHP-CCP for a program period, as determined by the Texas Health
and Human Services Commission (HHSC) and CMS.
(8) Uncompensated care costs--The sum of the Medicaid
shortfall and the uninsured costs.
(9) Uncompensated care payments--Payments intended
to defray the uncompensated costs of providing services.
(10) Uncompensated care tool--A form prescribed by
HHSC to identify uncompensated costs for Medicaid-enrolled providers
and used to enroll in the program.
(11) Uninsured costs--The unreimbursed cost to a qualifying
provider of providing services that meet the definition of "medical
assistance" in Social Security Act §1905(a) to uninsured patients
as defined by CMS.
(12) Uninsured patient--An individual who has no health
insurance or other source of third-party coverage for the services
provided. The term includes an individual enrolled in Medicaid who
received services that do not meet the definition of "medical assistance"
in the Social Security Act §1905(a).
(13) Waiver--The Texas Healthcare Transformation and
Quality Improvement Program Medicaid demonstration waiver under Social
Security Act §1115.
(c) Participation requirements.
(1) Qualifying provider. A provider must indicate it
is a qualifying provider as defined in subsection (b) of this section
to be considered for reimbursement in the application process.
(2) PHP-CCP financial training. HHSC provides annual
training to participating qualifying providers.
(A) A PHP-CCP financial contact must attend and receive
credit for training for each program period in which the provider
chooses to participate. Multiple individuals from a qualifying provider
may attend and receive credit for training for each program period.
(B) Training is provided for each program period and
is not retroactive. The qualifying provider must have at least one
financial contact attend the annual training directly prior to the
program period to participate.
(C) A provider that does not have a trained PHP-CCP
financial contact who is an employee of the provider is prohibited
from submitting a PHP-CCP application. Provider-contracted vendors
are permitted to enter a provider's data into the cost report for
any provider as a report preparer.
(3) Cost reports. Qualifying providers must submit
an annual uncompensated care tool for uncompensated care costs. Uncompensated
care tools must be completed for a full year based on the federal
fiscal year.
(A) The uncompensated care tool format will be specified
by HHSC. Qualifying providers certify through the cost report process
their total actual federal and non-federal costs and expenditures
for the program period. Costs must be reported in a manner that is
consistent with the PHP-CCP protocol that is approved under the 1115
Waiver.
(B) The cost report is due on or before November 14
of the year of the program period ending date and must be certified
in a manner specified by HHSC.
(i) If November 14 falls on a federal or state holiday
or weekend, the due date is the first working day after November 14.
(ii) A provider whose cost report is not received by
the due date is ineligible for PHP-CCP payment for the federal fiscal
year.
(C) HHSC reserves the right to request a corrective
action plan (CAP) from providers who submit incorrect cost reports
or bill incorrectly. PHP-CCP payments will be withheld until the CAP
is accepted by the HHSC.
(D) Costs for care delivered to persons who are incarcerated
at the time of the care must be excluded from the cost report.
(E) Costs for care delivered as part of an Institution
of Mental Disease (IMD) must be excluded from the cost report. If
a provider includes costs for Crisis Stabilization Units on their
cost report, and the unit is later determined by CMS to be an IMD,
associated PHP-CCP payments are subject to recoupment.
(4) Certification. The provider must certify, on a
form prescribed by HHSC, that no part of any PHP-CCP payment will
be used to pay a contingent fee and that the entity's agreement with
a billing entity or cost report preparer 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 PHP-CCP funds. The certification
must be received by HHSC with the enrollment application described
in paragraph (3) of this subsection.
(d) Source of funding. The non-federal share of funding
for payments under this section is limited to certified public expenditures
from governmental entities.
(e) Payment frequency. HHSC will distribute uncompensated
care payments on a schedule to be determined by HHSC and posted on
HHSC's website.
(f) Calculation of supplemental payment.
(1) Supplemental payment. A qualifying provider may
be eligible to receive a supplemental payment equal to a percentage
of its Medicaid shortfall and uncompensated care costs for the cost
reporting period.
(2) Funding limitations. Payments made under this section
are limited by the amount of funds allocated to the total program
value for the demonstration year. If payments for uncompensated care
for the provider pool attributable to a demonstration year are expected
to exceed the amount of funds allocated to that pool by HHSC for that
demonstration year, HHSC will reduce payments to providers in the
pool by the same percentage as required to remain within the pool
allocation amount.
(g) Recoupment.
(1) Overpayment or disallowance. In the event of an
overpayment identified by HHSC or a disallowance by CMS of federal
financial participation related to a provider's receipt or use of
payments under this section, HHSC may recoup an amount equivalent
to the amount of the overpayment or disallowance.
(2) Adjustments. 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 Texas
Government Code Chapter 403. HHSC may recoup an amount equivalent
to any such adjustment.
(3) Recoupment method. HHSC may recoup from any current
or future Medicaid payments as follows:
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