| (a) Introduction. This section establishes the Rural
Access to Primary and Preventive Services (RAPPS) program. RAPPS is
designed to incentivize rural health clinics (RHCs) 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. Other terms used in this section
may be defined in §353.1301 of this subchapter (relating to General
Provisions) or §353.1317 of this subchapter (relating to Quality
Metrics for the Rural Access to Primary and Preventive Services Program).
(1) Freestanding rural health clinic (RHC)--A network
RHC that is not affiliated with a hospital.
(2) Hospital-based RHC--A network RHC that is affiliated
with a hospital.
(3) Intergovernmental transfer (IGT) notification--Notice
and directions regarding how and when IGTs should be made in support
of RAPPS.
(4) Network RHC--An RHC located in the state of Texas
that has a contract with a managed care organization (MCO) for the
delivery of Medicaid covered services to the MCO's enrollees.
(5) Program period--A period of time for which the
Texas Health and Human Services Commission (HHSC) contracts with MCOs
to pay increased capitation rates for the purpose of making RHC payments
under this section. Each program period is equal to a state fiscal
year beginning September 1 and ending August 31 of the following year.
(6) Rural health clinic (RHC)--Has the meaning assigned
by 42 U.S.C. Section 1396d(l)(1).
(7) Suggested IGT responsibility--Notice of potential
amounts that a sponsoring governmental entity may wish to consider
transferring in support of RAPPS.
(8) Total program value--The maximum amount available
under the RAPPS program for a program period, as determined by HHSC.
(c) Classes of RHCs.
(1) HHSC may direct an MCO to provide an increased
payment or percentage rate increase for certain services to all RAPPS-enrolled
RHCs in one or more of the following classes of RHCs with which the
MCO contracts for Medicaid services:
(A) hospital-based RHCs; and
(B) freestanding RHCs.
(2) If HHSC directs rate increases or payments to more
than one RHC class in the service delivery area (SDA), the rate increases
or payments may vary by RHC class. HHSC will consider the following
factors in identifying the amount of the rate increase or payment
for each class:
(A) the RHC class's contribution to the goals and objectives
in the HHSC managed care quality strategy, as required in 42 C.F.R.
§438.340, relative to other classes;
(B) the class or classes of RHC the sponsoring governmental
entity wishes to support through IGTs of public funds, as indicated
on the application described in subsection (f) of this section; and
(C) the actuarial soundness of the capitation payment
needed to support the rate increase or payment.
(d) Eligibility. An RHC is eligible to participate
in RAPPS if it meets the requirements described in this subsection.
(1) Location. The RHC must be located in an SDA with
at least one sponsoring governmental entity.
(2) Minimum number of Medicaid managed care encounters.
The RHC must have provided at least 30 Medicaid managed care encounters
in the prior state fiscal year.
(e) Data sources for historical units of service and
clients served. Historical units of service are used to determine
an RHC's eligibility status and the estimated distribution of RAPPS
funds across enrolled RHCs.
(1) HHSC will use encounter data and will identify
encounters based upon the billing provider's national provider identification
(NPI) number and provider type code.
(2) HHSC will use the most recently available Medicaid
encounter data for a complete state fiscal year to determine the eligibility
status of an RHC.
(3) HHSC will use the most recently available Medicaid
encounter data for a complete state fiscal year to determine the distribution
of RAPPS funds across enrolled RHCs.
(4) In the event that the historical data are not deemed
appropriate for use by actuarial standards, HHSC may utilize 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
capitation rates for MCOs for the same period.
(6) To determine total program value, HHSC will calculate
the estimated rate that Medicare would have paid for the same services
using either each RHC's state fiscal year 2019 federal cost report
or last submitted cost report. For RHCs where a filed cost report
was not found, the RHC's Medicare payments will be estimated using
the SDA weighted average ratio of Medicare encounter-based reimbursements
divided by MCO reimbursement data.
(7) Encounter data used to calculate RAPPS payments
must be designated as paid status with a reported paid amount greater
than zero. Encounters reported as paid status, but with a reported
paid amount of zero or negative dollars, will be excluded from the
data used to calculate RAPPS payments.
(8) 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-party's
paid units of service.
(f) Conditions of Participation. As a condition of
participation, all RHCs participating in RAPPS, as well as any entities
billing on their behalf, must meet the following requirements.
(1) The RHC 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 calendar days prior to the release of
suggested IGT responsibilities.
(2) An entity that bills on behalf of the RHC must
certify, on a form prescribed by HHSC, that no part of any RAPPS payment
will be used to pay a contingent fee and that the entity's agreement
with the RHC does not 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 RHC's receipt of RAPPS funds. The certification must be received
by HHSC with the enrollment application described in paragraph (1)
of this subsection.
(3) If an RHC has changed ownership in the past five
years in a way that impacts eligibility for RAPPS, the RHC 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
RHC and which reference the administration of, or payments from, RAPPS.
(4) Report all quality data denoted as required as
a condition of participation in subsection (h) of this section.
(5) 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.
(g) Non-federal share of RAPPS payments. The non-federal
share of all RAPPS payments is funded with IGTs from sponsoring governmental
entities. No state general revenue is available to support RAPPS.
(1) HHSC will communicate the following information
for the program period to all RAPPS-enrolled hospital-based RHCs and
sponsoring governmental entities at least 10 calendar days prior to
the IGT declaration of intent deadline:
(A) suggested IGT responsibilities for the program
period, which will be based on:
(i) the maximum funding amount available under RAPPS
for the program period as determined by HHSC, plus ten percent;
(ii) forecasted member months for the program period
as determined by HHSC; and
(iii) the distribution of historical Medicaid utilization
across RHCs, plus the estimated utilization for enrolled RHCs within
the same SDA, for the program period; and
(B) the estimated maximum revenues each enrolled RHC
could earn under RAPPS for the program period, which will be based
on HHSC's suggested IGT responsibilities and the assumption that all
enrolled RHCs will meet 100 percent of their quality metrics.
(2) The estimated maximum revenues each enrolled RHC
could earn under RAPPS for the program period, which will be based
on HHSC's suggested IGT responsibilities and the assumption that all
enrolled RHCs will meet 100 percent of their quality metrics.
(3) HHSC will issue an IGT notification to specify
the date that IGT is requested to be transferred, no fewer than 14
business days before IGT transfers are due. The IGT notification will
instruct sponsoring governmental entities as to the required IGT amounts.
Required IGT amounts will include all costs associated with RHC payments
and rate increases, including costs associated with MCO premium taxes,
risk margin, and administration, plus ten percent.
(4) Sponsoring governmental entities will transfer
the first half of the IGT amount by a date determined by HHSC, but
no later than June 1. Sponsoring governmental entities will transfer
the second half of the IGT amount by a date determined by HHSC, but
no later than December 1. HHSC will publish the IGT deadlines and
all associated dates on the HHSC website by March 15 of each year.
(h) RAPPS capitation rate components. RAPPS funds will
be paid to MCOs through two components of the managed care per member
per month (PMPM) capitation rates. The MCOs' distribution of RAPPS
funds to the enrolled RHCs will be based on each RHC's performance
related to the quality metrics as described in §353.1317 of this
subchapter. The RHC must have had provided at least one Medicaid service
to a Medicaid client for each reporting period to be eligible for
payments.
(1) Component One.
(A) The total value of Component One will be equal
to 75 percent of total program value.
(B) Allocation of funds across qualifying RHCs will
be based upon historical Medicaid utilization and RHC class.
(C) Monthly payments to RHCs will be paid prospectively.
(D) HHSC will reconcile the interim allocation of funds
across RAPPS-enrolled RHCs to the actual Medicaid utilization across
these RHCs during the program period as captured by Medicaid MCOs
contracted with HHSC for managed care 120 days after the last day
of the program period.
(E) Providers must report quality data as described
in §353.1317 of this subchapter as a condition of participation
in the program.
(2) Component Two.
(A) The total value of Component Two will be equal
to 25 percent of total program value.
(B) Allocation of funds across qualifying RHCs will
be based upon actual Medicaid utilization of specific procedure codes
as identified in the final quality metrics and performance requirements
described in §353.1317 of this subchapter.
(C) A percent increase on all applicable services will
begin when an RHC demonstrates achievement of performance requirements
as described in §353.1317 of this subchapter during the reporting
period.
(D) Providers must report quality data as described
in §353.1317 of this subchapter as a condition of participation
in the program.
(i) Distribution of RAPPS payments.
(1) Prior to the beginning of the program period, HHSC
will calculate the portion of each monthly prospective payment associated
with each RAPPS-enrolled RHC broken down by RAPPS capitation rate
component and payment period. For example, for an RHC, HHSC will calculate
the portion of each monthly prospective payment associated with that
RHC that would be paid from the MCO to the RHC as follows.
(A) Monthly payments from Component One will be equal
to the total value of Component One for the RHC divided by twelve.
(B) Payments from Component Two will be equal to the
total value of Component Two attributed as a rate increase for specific
services based upon historical utilization.
(C) For purposes of the calculation described in subparagraph
(B) of this paragraph, an RHC must achieve quality metrics to be eligible
for full payment as determined by performance requirements described
in §353.1317(d) of this subchapter.
(2) An MCO will distribute payments to an enrolled
RHC based on criteria established under subsection (i) of this section.
(j) Changes in operation. If a RAPPS-enrolled RHC closes
voluntarily or ceases to provide Medicaid services, the RHC must notify
the HHSC Provider Finance Department by electronic mail to an address
designated by HHSC, by hand delivery, United States (U.S.) mail, or
by special mail delivery within 10 business days of closing or ceasing
to provide Medicaid services. Notification is considered to have occurred
when the HHSC Provider Finance Department receives the notice.
(k) Reconciliation. HHSC will reconcile the amount
of the non-federal funds actually 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.
(l) Recoupment. Payments under this section may be
subject to recoupment as described in §353.1301(j) and §353.1301(k)
of this subchapter.
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