(a) Introduction. Texas Healthcare Transformation and
Quality Improvement Program §1115(a) Medicaid demonstration waiver
Delivery System Reform Incentive Payment (DSRIP) program payments
for demonstration year (DY) 9-10 are available under this section
for eligible performers described in subsection (c) of this section.
DSRIP payments to performers must be in compliance with the Centers
for Medicare & Medicaid Services (CMS) approved Program Funding
and Mechanics Protocol, Health and Human Services Commission (HHSC)
instructions, and this section.
(b) Definitions.
(1) Demonstration Year (DY) 7--Federal fiscal year
2018 (October 1, 2017 - September 30, 2018).
(2) Demonstration Year (DY) 8--Federal fiscal year
2019 (October 1, 2018 - September 30, 2019).
(3) Demonstration Year (DY) 9--Federal fiscal year
2020 (October 1, 2019 - September 30, 2020).
(4) Demonstration Year (DY) 10--Federal fiscal year
2021 (October 1, 2020 - September 30, 2021).
(5) Performer--A provider enrolled in Texas Medicaid
that participates in DSRIP and receives DSRIP payments.
(6) Regional Healthcare Partnership (RHP) Plan Update--An
RHP plan for DY7-8 that is updated for DY9-10, as further described
in §354.1737 of this title (relating to RHP Plan Update for DY9-10).
(c) Eligibility for DSRIP. For a performer to be eligible
to receive DSRIP, the performer must:
(1) be a provider enrolled in Texas Medicaid;
(2) submit documentation of completion of a milestone
identified in the approved RHP plan update to HHSC; and
(3) for a private performer only, comply with the eligibility
requirements in §355.8201(c)(1)(B) of this division (relating
to Waiver Payments to Hospitals for Uncompensated Care) or §355.8202(c)(3)
of this division (relating to Waiver Payments to Physician Group Practices
for Uncompensated Care), as applicable.
(d) Source of funding. The non-federal share of funding
for payments under this section is limited to timely receipt by HHSC
of public funds from a governmental entity.
(e) Payment frequency. DSRIP payments will be distributed
at least annually, not to exceed two payments per performer per year,
upon achievement of RHP plan update milestones as reviewed and approved
by HHSC. The payment schedule or frequency may be modified as specified
by CMS or HHSC.
(f) Funding limitations. Payments made under this section
are limited by the maximum aggregate amount of funds approved by CMS
for DSRIP for each year that the waiver is in effect.
(g) DSRIP maximum payment amounts. The approved RHP
plan update establishes the payment amount associated with a particular
milestone. DSRIP payments cannot exceed the amount in the RHP plan
update.
(h) Payment methodology.
(1) Notice. Prior to making any DSRIP payments, HHSC
will give notice of the following information:
(A) the maximum payment amount for the payment period;
(B) the maximum intergovernmental transfer (IGT) amount
necessary for a performer to receive the amount described in subparagraph
(A) of this paragraph; and
(C) the deadline for completing the IGT.
(2) Payment amount. The approved RHP plan update establishes
the payment amount associated with a milestone. DSRIP payments cannot
exceed the amount established in the approved RHP plan update. The
amount of the payment to a performer will be determined based on the
amount of funds transferred by a governmental entity as follows.
(A) If a governmental entity transfers the maximum
amount referenced in paragraph (1) of this subsection on behalf of
each performer owned by or affiliated with that governmental entity,
each performer owned by or affiliated with that governmental entity
will receive the full payment amount calculated for that payment period.
(B) If a governmental entity does not transfer the
maximum amount referenced in paragraph (1) of this subsection on behalf
of each performer owned by or affiliated with that governmental entity,
each performer owned by or affiliated with that governmental entity
will receive a portion of the value associated with that milestone
(as specified in the RHP plan update) that is proportionate to the
total value of all milestones that are completed and eligible for
payment for that period by all performers owned by or affiliated with
that governmental entity.
(3) Final payment opportunity. If a performer does
not receive a full DSRIP payment as a result of paragraph (2)(B) of
this subsection, a governmental entity may provide the necessary IGT
to make up the non-federal share of that shortfall until the last
reporting period of the DY following the DY in which the applicable
milestone is listed in the RHP plan update. Any shortfall remains
the obligation of the original governmental entity until that governmental
entity informs HHSC that it will no longer agree to fund that obligation.
(A) If the governmental entity will no longer fund
the obligation or a proportion of the obligation, that governmental
entity must inform HHSC no later than the last date of the reporting
period for the applicable payment period.
(B) A performer may utilize any affiliated governmental
entity to fund the shortfall but must inform HHSC of the identity
of this governmental entity no later than the last date of a reporting
period in order for that affiliated entity to fund the shortfall during
the associated payment period.
(i) Recoupment.
(1) In the event of an overpayment identified by HHSC
or a disallowance by CMS of federal financial participation related
to a performer's receipt or use of payments under this section, HHSC
may recoup an amount equivalent to the amount of the overpayment or
disallowance. The non-federal share of any funds recouped from the
performer will be returned to the governmental entity that was the
source of those funds.
(2) 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 Chapter 403, Texas Government Code.
HHSC may recoup an amount equivalent to any such adjustment.
(3) HHSC may recoup from any current or future Medicaid
payments as follows.
(A) HHSC will recoup from the performer against which
any overpayment was made or disallowance was directed.
(B) If, within 30 days of the performer's receipt of
HHSC's written notice of recoupment, the performer has not paid the
full amount of the recoupment or entered into a written agreement
with HHSC to do so, HHSC may withhold any or all future Medicaid payments
from the performer until HHSC has recovered an amount equal to the
amount overpaid or disallowed.
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