| (a) Introduction. This section establishes the Hospital
Augmented Reimbursement (HARP) Program, wherein the Texas Health and
Human Services Commission (HHSC) directs payments to certain providers
that serve Texas Medicaid fee-for-service patients, including eligible
non-state government owned hospitals, private hospitals, state-owned
hospitals, state government-owned Institutions for Mental Diseases
(IMDs), and private IMDs. This section also describes the methodology
used by HHSC to calculate and administer such payments. A provider
is eligible for a payment under this section only if HHSC has submitted
and CMS has approved a state plan amendment permitting HHSC to make
payments under this section to the hospital class to which the provider
belongs.
(b) Definitions. The following definitions apply when
the terms are used in this section.
(1) Fee-for-Service (FFS)--A system of the health insurance
payment in which a health care provider is paid a fee by HHSC through
the contracted Medicaid claims administrator directly, for each service
rendered. For Texas Medicaid purposes, fee-for-service excludes any
service rendered under a managed care program through a managed care
organization.
(2) Inpatient hospital services--Services ordinarily
furnished in a hospital for the care and treatment of inpatients under
the direction of a physician or dentist, or a subset of these services
identified by HHSC. Inpatient hospital services do not include services
furnished in a skilled nursing facility, intermediate care facility
services furnished by a hospital with swing-bed approval, or any other
services that HHSC determines should not be subject to payment.
(3) Intergovernmental transfer (IGT)--A transfer of
public funds from another state agency or a non-state governmental
entity to HHSC.
(4) Medicare payment gap--The difference between what
Medicare is estimated to pay for the services and what Medicaid actually
paid for the same services from the most recent FFS upper payment
limit (UPL) demonstration.
(5) Non-state government-owned and operated hospital--A
hospital that is owned and operated by a local government entity,
including but not limited to a city, county, or hospital district.
(6) Outpatient hospital services--Preventive, diagnostic,
therapeutic, rehabilitative, or palliative services that are furnished
to outpatients of a hospital under the direction of a physician or
dentist, or a subset of these services identified by HHSC.
(7) Private hospital--Any hospital that is not government-owned
and operated.
(8) Private Institution for Mental Diseases (IMD)--A
hospital that is primarily engaged in providing psychiatric diagnosis,
treatment or care of individuals with mental illness and that is not
government-owned and operated.
(9) Program period--Each program period is equal to
a federal fiscal year beginning October 1 and ending September 30
of the following year.
(10) Prospective Payment System--A method of reimbursement
in which payment is made based on a predetermined, fixed amount.
(11) Sponsoring governmental entity--A state or non-state
governmental entity that agrees to transfer to HHSC some or all of
the non-federal share of program expenditures under this subchapter.
(12) State government-owned hospital--Any hospital
owned by the state of Texas that is not considered an IMD.
(13) State government-owned IMD--A hospital that is
primarily engaged in providing psychiatric diagnosis, treatment or
care of individuals with mental illness and that is owned by the state
of Texas that is considered an IMD.
(c) Participation requirements. As a condition of participation,
all hospitals participating in the program must allow for the following.
(1) The hospital must submit a properly completed enrollment
application by the due date determined by HHSC. The enrollment period
must be no less than 15 business days, and the final date of the enrollment
period will be at least nine days prior to the intergovernmental transfer
(IGT) notification.
(2) If a provider has changed ownership in the past
five years in a way that impacts eligibility for this program, 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, this program.
(d) Payments for non-state government-owned and operated
hospitals.
(1) Eligible hospitals. Payments under this subsection
will be limited to hospitals defined as "non-state government owned
and operated hospital" that are enrolled in Medicare and participate
in Texas Medicaid fee-for-service.
(2) Non-federal share of program payments. The non-federal
share of the payments is funded through IGTs from sponsoring governmental
entities. No state general revenue is available to support the program.
(A) HHSC will communicate suggested IGT responsibilities.
Suggested IGT responsibilities will be based on the maximum dollars
to be available under the program for the program period as determined
by HHSC. HHSC will also communicate estimated revenues each enrolled
hospital could earn under the program for the program period with
those estimates based on HHSC's suggested IGT responsibilities.
(B) HHSC will issue an IGT notification to specify
the date that IGT is requested to be transferred not fewer than 14
business days before IGT transfers are due. HHSC may post the IGT
deadlines and other associated information on HHSC's website, send
the information through the established Medicaid notification procedures
used by HHSC's fiscal intermediary, send through other direct mailing,
send through GovDelivery, or provide the information to the hospital
associations to disseminate to their member hospitals.
(3) Payment Methodology. To determine each participating
non-state government-owned and operated hospital's payment under this
section, HHSC will sum the hospital's inpatient FFS Medicare payment
gap and the hospital's outpatient FFS Medicare payment gap.
(e) Payments for private hospitals.
(1) Eligible hospitals. Payments under this subsection
will be limited to hospitals defined as "private hospital" in subsection
(b) of this section that are enrolled in Medicare and participate
in Texas Medicaid fee-for-service.
(2) Non-federal share of program payments. The non-federal
share of the payments is funded through IGTs from sponsoring governmental
entities. No state general revenue is available to support the program.
(A) HHSC must receive the non-federal portion of reimbursement
for HARP through a method approved by HHSC and Centers for Medicare
& Medicaid Services (CMS) for reimbursement through this program.
(B) A hospital under this subsection must designate
a single local governmental entity to provide the non-federal share
of the payment through a method determined by HHSC. If the single
local governmental entity transfers less than the full non-federal
share of a hospital's payment amount calculated in any paragraph under
this subchapter, HHSC will recalculate that specific hospital's payment
based on the amount of the non-federal share actually transferred.
(C) HHSC will communicate suggested IGT responsibilities.
Suggested IGT responsibilities will be based on the maximum dollars
to be available under the program for the program period as determined
by HHSC. HHSC will also communicate estimated revenues each enrolled
hospital could earn under the program for the program period with
those estimates based on HHSC's suggested IGT responsibilities.
(D) HHSC will issue an IGT notification to specify
the date that IGT is requested to be transferred not fewer than 14
business days before IGT transfers are due. HHSC may post the IGT
deadlines and other associated information on HHSC's website, send
the information through the established Medicaid notification procedures
used by HHSC's fiscal intermediary, send through other direct mailing,
send through GovDelivery, or provide the information to the hospital
associations to disseminate to their member hospitals.
(3) Payment Methodology. To determine each participating
private hospital's payment under this section, HHSC will sum the hospital's
inpatient FFS Medicare payment gap and the hospital's outpatient FFS
Medicare payment gap.
(f) Payments for state government-owned hospitals.
(1) Eligible hospitals. Payments under this subsection
will be limited to hospitals defined as "state government-owned hospital"
in subsection (b) of this section that are enrolled in Medicare and
participate in Texas Medicaid fee-for-service.
(2) Non-federal share of program payments. The non-federal
share of the payments is funded through IGTs from sponsoring governmental
entities. No state general revenue is available to support the program.
Cont'd... |
