| (a) Introduction. This section establishes the Quality
Incentive Payment Program (QIPP) for nursing facilities (NFs) providing
services under Medicaid managed care on or after September 1, 2019.
QIPP is designed to incentivize NFs to improve quality and innovation
in the provision of NF 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 quality strategy.
(b) Definitions. The following definitions apply when
the terms are used in this section. Terms that are used in this and
other sections of this subchapter may be defined in §353.1301
(relating to General Provisions) or §353.1304 (relating to Quality
Metrics for the Quality Incentive Payment Program for Nursing Facilities
on or after September 1, 2019) of this subchapter.
(1) CHOW application--An application filed with HHSC
for a NF change of ownership (CHOW).
(2) Program period--A period of time for which an eligible
and enrolled NF may receive the QIPP amounts described in this section.
Each QIPP program period is equal to a state fiscal year (FY) beginning
September 1 and ending August 31 of the following year.
(3) Network nursing facility--A NF 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.
(4) Non-state government-owned NF--A network nursing
facility where a non-state governmental entity located in the state
of Texas holds the license and is a party to the NF's Medicaid provider
enrollment agreement with the state.
(5) Private NF--A network nursing facility not owned
by a governmental entity located in the state of Texas, and holds
a license.
(6) 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).
(7) Runout Period--A period of 23 months following
the end of the program period during which the MCO may make adjustments
to the MCO member months.
(c) Eligibility for participation in QIPP. A NF is
eligible to participate in QIPP if it complies with the requirements
described in this subsection.
(1) The NF is a non-state government-owned NF.
(A) The non-state governmental entity that owns the
NF must certify the following facts on a form prescribed by HHSC.
(i) That it is a non-state government-owned NF where
a non-state governmental entity holds the license and is party to
the facility's Medicaid contract; and
(ii) That all funds transferred to HHSC via an intergovernmental
transfer (IGT) for use as the state share of payments are public funds.
(B) The NF must be located in the state of Texas in
the same RHP as, or within 150 miles of, the non-state governmental
entity taking ownership of the facility, be owned by the non-state
governmental entity for no less than four years prior to the first
day of the program period, or must be able to certify in connection
with the enrollment application that they can demonstrate an active
partnership between the NF and the non-state governmental entity that
owns the NF. The following criteria demonstrate an active partnership
between the NF and the non-state governmental entity that owns the
NF.
(i) Monthly meetings (in-person or virtual) with NF
administrative staff to review the NF's clinical and quality operations
and identify areas for improvement. Meetings should include patient
observations; regulatory findings; review of CASPER reports, quality
measures, grievances, staffing, risk, incidents, accidents, and infection
control measures; root cause analysis, if applicable; and design of
performance improvement plans.
(ii) Quarterly joint trainings on topics and trends
in nursing home care best practices or on needed areas of improvement.
(iii) Annual, on-site inspections of the NF by a non-state
governmental entity-sponsored Quality Assurance team.
(2) The NF is a private NF. The NF must have a percentage
of Medicaid NF days of service that is greater than or equal to 65
percent. For each private NF, the percentage of Medicaid NF days is
calculated by summing the NF's Medicaid NF fee-for-service and managed
care days of service, including dual-eligible demonstration days of
service, and dividing that sum by the facility's total days of service
in all licensed beds. Medicaid hospice days of service are included
in the denominator but excluded from the numerator.
(A) The days of service will be annualized based on
the NF's latest cost report or accountability report but from a year
in which HHSC required the submission of cost reports.
(B) HHSC will exclude any calendar days that the NF
was closed due to a natural or man-made disaster. In such cases, HHSC
will annualize the days of service based on calendar days when the
NF was open.
(d) Data sources for historical units of service. Historical
units of service are used to determine an individual private NF's
QIPP eligibility status and the distribution of QIPP funds across
eligible and enrolled NFs.
(1) All data sources referred to in this subsection
are subject to validation using HHSC auditing processes or procedures
as described under §355.106 of this title (relating to Basic
Objectives and Criteria for Audit and Desk Review of Cost Reports).
(2) Data sources for the determination of each private
NF's QIPP eligibility status are listed in priority order below. For
each program period, the data source must be from a cost-reporting
year and must align with the NF's fiscal year.
(A) The most recently available Medicaid NF cost report
for the private NF. If no Medicaid NF cost report is available, the
data source in subparagraph (B) of this paragraph must be used.
(B) The most recently available Medicaid Direct Care
Staff Rate Staffing and Compensation Report for the private NF. If
no Medicaid Direct Care Staff Rate Staffing and Compensation Report
is available, the data source in subparagraph (C) of this paragraph
must be used.
(C) The most recently available Medicaid NF cost report
for a prior owner of the private NF. If no Medicaid NF cost report
for a prior owner of the private NF is available, the data source
in subparagraph (D) of this paragraph must be used.
(D) The most recently available Medicaid Direct Care
Staff Rate Staffing and Compensation Report for a prior owner of the
private NF. If no Medicaid Direct Care Staff Rate Staffing and Compensation
Report for a prior owner of the private NF is available, the private
NF is not eligible for participation in QIPP.
(3) Data sources for determination of distribution
of QIPP funds across eligible and enrolled NFs are listed in priority
order below. For each program period, the data source must be from
a cost-reporting year and must align with the NF's fiscal year.
(A) The most recently available Medicaid NF cost report
for the NF. If the cost report covers less than a full year, reported
values are annualized to represent a full year. If no Medicaid NF
cost report is available, the data source in subparagraph (B) of this
paragraph must be used.
(B) The most recently available Medicaid Direct Care
Staff Rate Staffing and Compensation Report for the NF. If the Staffing
and Compensation Report covers less than a full year, reported values
are annualized to represent a full year. If no Staffing and Compensation
Report is available, the data source in subparagraph (C) of this paragraph
must be used.
(C) The most recently available Medicaid NF cost report
for a prior owner of the NF. If the cost report covers less than a
full year, reported values are annualized to represent a full year.
If no Medicaid NF cost report for a prior owner of the NF is available,
the data source in subparagraph (D) of this paragraph must be used.
(D) The most recently available Medicaid Direct Care
Staff Rate Staffing and Compensation Report for a prior owner of the
NF. If the Staffing and Compensation Report covers less than a full
year, reported values are annualized to represent a full year.
(e) Conditions of Participation. As a condition of
participation, all NFs participating in QIPP must do the following.
(1) The NF must submit a properly completed enrollment
application, on a form prescribed by HHSC, by the due date determined
by HHSC. The enrollment period must be no less than 30 calendar days,
and the final date of the enrollment period will be at least nine
days prior to the IGT notification.
(2) The entity that owns the NF must certify, on a
form prescribed by HHSC, that no part of any payment made under the
QIPP will be used to pay a contingent fee; and that the entity's agreement
with the nursing facility does not use a reimbursement methodology
containing any type of incentive, direct or indirect, for inappropriately
inflating, in any way, claims billed to Medicaid, including the NF's
receipt of QIPP 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 the 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.
(4) The NF must ensure that HHSC has access to the
NF records referenced in subsection (c) of this section and the data
for the NF from one of the data sources listed in subsection (d) of
this section. Participating facilities must ensure that these records
and data are accurate and sufficiently detailed to support legal,
financial, and statistical information used to determine a NF's eligibility
during the program period.
(A) The NF must maintain these records and data through
the program period and until at least 90 days following the conclusion
of the runout period.
(B) The NF will have 14 business days from the date
of a request from HHSC to submit to HHSC the records and data.
(C) Failure to provide the records and data could result
in adjustments pursuant to §353.1301(k) of this subchapter.
(5) Report all quality data denoted as required as
a condition of participation in subsection (g) of this section.
(6) Failure to meet any conditions of participation
described in this subsection will result in removal of the provider
from the program and recoupment of all funds previously paid during
the program period.
(f) Non-federal share of QIPP payments. The non-federal
share of all QIPP payments is funded through IGTs from sponsoring
non-state governmental entities. No state general revenue is available
to support QIPP.
(1) HHSC will share suggested IGT responsibilities
for the program period with all QIPP eligible and enrolled non-state
government-owned NFs at least 15 days prior to the IGT declaration
of intent deadline. Suggested IGT responsibilities will be based on
the maximum dollars available under the QIPP program, plus eight percent,
for the program period as determined by HHSC; forecast STAR+PLUS NF
member months for the program period as determined by HHSC; and the
distribution of historical Medicaid days of service across non-state
government-owned NFs enrolled in QIPP for the program period. HHSC
will also share estimated maximum revenues each eligible and enrolled
NF could earn under QIPP for the program period. Estimates are based
on HHSC's suggested IGT responsibilities and an assumption that all
enrolled NFs will meet 100 percent of their quality metrics. The purpose
of sharing this information is to provide non-state government-owned
NFs with information they can use to determine the amount of IGT they
wish to transfer.
(2) Sponsoring governmental entities will determine
the amount of IGT they wish to transfer to HHSC for the entire program
period and provide a declaration of intent to HHSC 15 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 wishes to transfer to HHSC and whether the sponsoring governmental
entity intends to accept Component One payments.
(B) The declaration of intent is certified to the best
knowledge and belief of a person legally authorized to sign for the
sponsoring governmental entity but does not bind the sponsoring governmental
entity to transfer IGT.
(3) Sponsoring governmental entities will transfer
the first half of the IGT amount by a date determined by HHSC. The
second half of the IGT amount will be transferred by a date determined
by HHSC. The IGT deadlines and all associated dates will be published
on the HHSC QIPP webpage by January 15 of each year.
(4) Reconciliation. HHSC will reconcile the actual
amount of the non-federal funds expended under this section during
each program period with the amount of funds transferred to HHSC by
the sponsoring governmental entities for that same period using the
methodology described in §353.1301(g) of this subchapter.
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