| (a) Introduction. This section establishes the Texas
Incentives for Physicians and Professional Services (TIPPS) program.
TIPPS is designed to incentivize physicians and certain medical professionals
to improve quality, access, and innovation in the provision of medical
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 §353.1311 of this subchapter (relating to Quality
Metrics for the Texas Incentives for Physicians and Professional Services
Program).
(1) Health Related Institution (HRI) physician group--A
network physician group owned or operated by an institution named
in Texas Education Code §63.002.
(2) Indirect Medical Education (IME) physician group--A
network physician group contracted with, owned, or operated by a hospital
receiving either a medical education add-on or a teaching medical
education add-on as described in §355.8052 of this title (relating
to Inpatient Hospital Reimbursement) for which the hospital is assigned
or retains billing rights for the physician group.
(3) Intergovernmental Transfer (IGT) Notification--Notice
and directions regarding how and when IGTs should be made in support
of the program.
(4) Network physician group--A physician group located
in the state of Texas that has a contract with a Managed Care Organization
(MCO) for the delivery of Medicaid-covered benefits to the MCO's enrollees.
(5) Network status--A provider's network status with
a contracted MCO, as determined by the national provider identification
(NPI) number and Plan Code combination.
(6) Other physician group--A network physician group
other than those specified under paragraphs (1) and (2) of this subsection.
(7) Plan code--A unique 2-digit alphanumeric code established
by HHSC denoting the individual managed care organization, program,
and service delivery area.
(8) Program period--A period of time for which an eligible
and enrolled physician group may receive the TIPPS amounts described
in this section. Each TIPPS program period is equal to a state fiscal
year beginning September 1 and ending August 31 of the following year.
(9) Suggested IGT responsibility--Notice of potential
amounts that a governmental entity may wish to consider transferring
in support of the program.
(10) Total program value--The maximum amount available
under the TIPPS program for a program period, as determined by HHSC.
(c) Eligibility for participation in TIPPS. A physician
group is eligible to participate in TIPPS if it complies with the
requirements described in this subsection.
(1) Physician group composition. A physician group
must indicate the eligible physicians, clinics, and other locations
to be considered for payment and quality measurement purposes in the
application process.
(2) Minimum volume. For program periods beginning on
or before September 1, 2023, but on or after September 1, 2021, physician
groups must have a minimum denominator volume of 30 Medicaid managed
care patients in at least 50 percent of the quality metrics in each
component to be eligible to participate in the component. For program
periods beginning on or after September 1, 2024, no minimum denominator
volume is required.
(3) The physician group is:
(A) an HRI physician group;
(B) an IME physician group; or
(C) any other physician group that:
(i) can achieve the minimum volume during program periods
beginning on or before September 1, 2023, but on or after September
1, 2021, as described in paragraph (2) of this subsection;
(ii) is located in a service delivery area with at
least one sponsoring governmental entity; and
(iii) for program periods beginning on or before September
1, 2023, but on or after September 1, 2021, served at least 250 unique
Medicaid managed care clients in the prior state fiscal year. For
program periods beginning on or after September 1, 2024, no minimum
volume is required.
(d) Data sources for historical units of service and
clients served. Historical units of service are used to determine
a physician group's eligibility status and the estimated distribution
of TIPPS funds across enrolled physician groups.
(1) HHSC will use encounter data and will identify
encounters based upon the billing provider's NPI number and taxonomy
code combination that are billed as a professional encounter only.
(2) HHSC will use the most recently available Medicaid
encounter data for a complete state fiscal year to determine the eligibility
status of other physician groups for program periods beginning on
or before September 1, 2023, but on or after September 1, 2021.
(3) HHSC will use the most recently available Medicaid
encounter data for a complete state fiscal year to determine distribution
of TIPPS funds across eligible and enrolled physician groups.
(4) In the event of a disaster, HHSC may use data from
a different state fiscal year at HHSC's discretion.
(5) The data used to estimate eligibility and distribution
of funds will align with the data used for purposes of setting the
capitated rates for managed care organizations for the same period.
(6) HHSC will calculate the estimated rate that an
average commercial payor would have paid for the same services using
either data that HHSC obtains independently or data that is collected
from providers through the application process described in subsection
(c) of this section.
(7) If HHSC is unable to compute an actuarially sound
payment rate based on private payor information described in paragraph
(6) of this subsection for any services, then those services will
be removed from consideration from the TIPPS program.
(8) All services billed and delivered at a Federally
Qualified Health Center, dental services, and ambulance services are
excluded from the scope of the TIPPS program.
(9) Encounter data used to calculate payments for this
program must be designated as paid status. Encounters reported as
a paid status, but with zero or negative dollars as a reported paid
amount will not be included in the data used to calculate payments
for the TIPPS program.
(10) If a provider with the same Tax Identification
Number as the payor is being paid more than 200 percent of the Medicaid
reimbursement on average for the same services in a one-year period,
then a related-party-adjustment will be applied to the encounter data
for those encounters. This adjustment will apply a calculated average
payment rate from the rest of the provider pool to the related parties
paid units of service.
(e) Conditions of Participation. As a condition of
participation, all physician groups participating in TIPPS must allow
for the following.
(1) The physician group must submit a properly completed
enrollment application by the due date determined by HHSC. The enrollment
period will be no less than 21 calendar days, and the final date of
the enrollment period will be at least nine days prior to the release
of suggested IGT responsibilities.
(2) Enrollment is conducted annually, and participants
may not join the program after the enrollment period closes. Any updates
to enrollment information must be submitted prior to the publication
of the suggested IGT responsibilities under subsection (f)(1) of this
section. For each program period, a physician group must be located
in a Service Delivery Area (SDA) in which at least one sponsoring
governmental entity that agrees to transfer to HHSC some or all of
the non-federal share under this section is also located. An SDA is
designated by HHSC for each provider, or physician group with multiple
locations, based on the SDA in which the majority of a physician group's
claims are billed. Services that are provided outside of a designated
SDA may be included in the designated SDA.
(3) Network status for providers for the entire program
period will be determined at the time of enrollment based on the submission
of documentation through the enrollment process that shows an MCO
has identified the provider as having a network agreement.
(4) The entity that bills on behalf of the physician
group must certify, on a form prescribed by HHSC, that no part of
any TIPPS payment will be used to pay a contingent fee nor may the
entity's agreement with the physician group 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 physician group's receipt of TIPPS funds. The certification must
be received by HHSC with the enrollment application described in paragraph
(1) of this subsection.
Cont'd... |
