| (a) Introduction. This section establishes minimum
payment amounts for certain non-state government-owned nursing facility
providers participating in the STAR+PLUS Program, or other Medicaid
managed care programs offering nursing facility services, and the
conditions for receipt of these amounts.
(b) Definitions.
(1) Calculation Period--A month used to calculate the
Minimum Payment Amount. There are six calculation periods in Eligibility
Period One, twelve calculation periods in Eligibility Period Two,
nine calculation periods in Eligibility Period Two-A, and five calculation
periods in Eligibility Period Three.
(2) CHOW Application--An application filed with the
Department of Aging and Disability Services for a nursing facility
change of ownership.
(3) Clean Claim--A claim submitted by a provider for
health care services rendered to an enrollee with the data necessary
for the managed care organization to adjudicate and accurately report
the claim. Claims for Nursing Facility Unit Rate services that meet
the Department of Aging and Disability Services' criteria for clean
claims submission are considered Clean Claims. Additional information
regarding Department of Aging and Disability Services' criteria for
clean claims submission is included in HHSC's Uniform Managed Care
Manual, which is available on HHSC's website.
(4) DADS--The Texas Department of Aging and Disability
Services, or its successor agency.
(5) Eligibility Period--A period of time for which
a Qualified Nursing Facility may receive the Minimum Payment Amounts
described in this section.
(6) Eligibility Period One--The first period of time
for which a Qualified Nursing Facility may receive the Minimum Payment
Amounts described in this section, covering dates of service from
the later of March 1, 2015, or the date on which nursing facility
services become managed care services, to August 31, 2015.
(7) Eligibility Period Two--The second period of time
for which a Qualified Nursing Facility may receive the Minimum Payment
Amounts described in this section, covering dates of service from
September 1, 2015, to August 31, 2016.
(8) Eligibility Period Two-A--The third period of time
for which a Qualified Nursing Facility may receive the Minimum Payment
Amounts described in this section, covering dates of service from
December 1, 2015, to August 31, 2016.
(9) Eligibility Period Three--The fourth period of
time for which a Qualified Nursing Facility may receive the Minimum
Payment Amounts described in this section, covering dates of service
from April 1, 2017, to August 31, 2017. Centers for Medicare &
Medicaid Services (CMS) approval is required for any payments to be
made under this section for Eligibility Period Three.
(10) First Payment--The payment made in the ordinary
course of business by MCOs to Qualified Nursing Facilities for the
provision of covered services to Medicaid recipients.
(11) HHSC--The Texas Health and Human Services Commission
or its designee.
(12) Intergovernmental transfer (IGT)--A transfer of
public funds from a non-state governmental entity to HHSC.
(13) IGT Responsibility--The IGT owed by a non-state
governmental entity, as determined by HHSC, for funding the non-federal
share of the increase in the payments to the MCOs due to the Minimum
Payment Amount program.
(14) MCO--A Medicaid managed care organization contracted
with HHSC to provide nursing facility services to Medicaid recipients.
(15) Minimum Payment Amount--The minimum payment amount
for a Qualified Nursing Facility, as calculated under subsection (d)
of this section.
(16) Network Nursing Facility--A nursing facility that
has a contract with an MCO for the delivery of Medicaid covered benefits
to the MCO's enrollees.
(17) Non-state Governmental Entity--A hospital authority,
hospital district, health district, city or county.
(18) Non-state Government-owned Nursing Facility--A
network nursing facility where a non-state governmental entity holds
the license and is a party to the nursing facility's Medicaid provider
enrollment agreement with the state.
(19) Nursing Facility Add-on Services--The types of
services that are provided in the nursing facility setting by a provider,
but are not included in the Nursing Facility Unit Rate, including
but not limited to emergency dental services, physician-ordered rehabilitative
services, customized power wheel chairs, and augmentative communication
devices.
(20) Nursing Facility Unit Rate--The types of services
included in the DADS daily rate for nursing facility providers, such
as room and board, medical supplies and equipment, personal needs
items, social services, and over-the-counter drugs. The Nursing Facility
Unit Rate also includes applicable nursing facility rate enhancements
as described in §355.308 of this title (relating to Direct Care
Staff Rate Component), and professional and general liability insurance.
Nursing Facility Unit Rates exclude Nursing Facility Add-on Services.
(21) Qualified Nursing Facility--A Non-state Government-Owned
Network Nursing Facility that meets the eligibility requirements described
in subsection (e) of this section.
(22) Public Funds--Funds derived from taxes, assessments,
levies, investments, and other public revenues within the sole and
unrestricted control of a non-state governmental entity that holds
the license and is party to the Medicaid provider enrollment agreement
with the state. 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.
(23) 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).
(24) RUG--For the purpose of calculations described
in subsection (d)(1) of this section, a resource utilization group
under Medicare Part A as established by the Centers for Medicare &
Medicaid Services (CMS). For the purpose of calculations described
in subsection (d)(2) of this section, a resource utilization group
under the RUG-III 34 group classification system, Version 5.20, index
maximizing, as established by the state and CMS.
(25) Second Payment--The amount a Qualified Nursing
Facility can receive that is equal to the Minimum Payment Amount less
adjustments to that amount, as described in subsection (d) of this
section.
(c) Payment of Minimum Payment Amount to Qualified
Nursing Facilities.
(1) An MCO must pay a Qualified Nursing Facility at
or above the Minimum Payment Amount in two installment payments for
a Calculation Period, using the calculation methodology described
in subsection (d) of this section.
(A) The MCO must make the First Payment no later than
ten calendar days after a Qualified Nursing Facility or its agent
submits a Clean Claim for a Nursing Facility Unit Rate to the HHSC-designated
portal or the MCO's portal, whichever occurs first. The MCO will make
the First Payment for the Nursing Facility Unit Rate at or above the
prevailing rate established by HHSC for the date of service. HHSC's
website includes information concerning HHSC's prevailing rates. The
MCO must make the Second Payment no later than 10 calendar days after
being notified of the Second Payment amount by HHSC. The Second Payment
will be the difference between the Minimum Payment Amount and the
adjustment to the Minimum Payment Amount, as calculated by HHSC and
described in subsection (d) of this section.
(B) For purposes of illustration only, if a Qualified
Nursing Facility provider files a Clean Claim for a Nursing Facility
Unit Rate on March 6, 2015, the MCO must make the First Payment no
later than March 16, 2015, and the Second Payment no later than 10
calendar days after being notified of the Second Payment amount by
HHSC.
(2) HHSC will provide each MCO with a list of its Qualified
Nursing Facilities for each Calculation Period as well as the Second
Payment amount, as calculated by HHSC and described in subsection
(d) of this section, associated with the MCO's members for each of
its Qualified Nursing Facilities.
(d) Calculation of the Second Payment. HHSC will calculate
the Second Payment for each Qualified Nursing Facility using the methodology
detailed in this subsection. If a Qualified Nursing Facility is contracted
with more than one MCO, HHSC will calculate a separate Second Payment
for each MCO with which the Qualified Nursing Facility is contracted.
(1) Calculate the Minimum Payment Amount. The Minimum
Payment Amount is made up of multiple subsidiary amounts. There is
a subsidiary amount for each RUG.
(A) To determine the subsidiary amount for a particular
RUG, use the formula: Subsidiary Amount = Days of Service x Medicare
Rate, where:
Cont'd... |
