| (a) Introduction. Texas Healthcare Transformation and
Quality Improvement Program §1115(a) Medicaid demonstration waiver
payments are available under this section to help defray the uncompensated
cost of charity care provided by eligible hospitals on or after October
1, 2019. Waiver payments to hospitals for uncompensated care provided
before October 1, 2019, are described in §355.8201 of this division
(relating to Waiver Payments to Hospitals for Uncompensated Care).
Waiver payments to hospitals must be in compliance with the Centers
for Medicare & Medicaid Services approved waiver Program Funding
and Mechanics Protocol, HHSC waiver instructions, and this section.
(b) Definitions.
(1) Affiliation agreement--An agreement, entered into
between one or more privately-operated hospitals and a governmental
entity that does not conflict with federal or state law. HHSC does
not prescribe the form of the agreement.
(2) Allocation amount--The amount of funds approved
by the Centers for Medicare & Medicaid Services for uncompensated-care
payments for the demonstration year that is allocated to each uncompensated-care
provider pool or individual hospital, as described in subsections
(f)(2) and (g)(6) of this section.
(3) Anchor--The governmental entity identified by HHSC
as having primary administrative responsibilities on behalf of a Regional
Healthcare Partnership (RHP).
(4) Centers for Medicare & Medicaid Services (CMS)--The
federal agency within the United States Department of Health and Human
Services responsible for overseeing and directing Medicare and Medicaid,
or its successor.
(5) Charity care--Healthcare services provided without
expectation of reimbursement to uninsured patients who meet the provider's
charity-care policy. The charity-care policy should adhere to the
charity-care principles of the Healthcare Financial Management Association
Principles and Practices Board Statement 15 (December 2012). Charity
care includes full or partial discounts given to uninsured patients
who meet the provider's financial assistance policy. Charity care
does not include bad debt, courtesy allowances, or discounts given
to patients who do not meet the provider's charity-care policy or
financial assistance policy.
(6) Data year--A 12-month period that is described
in §355.8066 of this subchapter (relating to Hospital-Specific
Limit Methodology) and from which HHSC will compile cost and payment
data to determine uncompensated-care payment amounts. This period
corresponds to the Disproportionate Share Hospital data year.
(7) Delivery System Reform Incentive Payments (DSRIP)--Payments
related to the development or implementation of a program of activity
that supports a hospital's efforts to enhance access to health care,
the quality of care, and the health of patients and families it serves.
These payments are not considered patient-care revenue and are not
offset against the hospital's costs when calculating the hospital-specific
limit as described in §355.8066 of this subchapter.
(8) Demonstration year--The 12-month period beginning
October 1 for which the payments calculated under this section are
made. This period corresponds to the Disproportionate Share Hospital
(DSH) program year. Demonstration year one corresponded to the 2012
DSH program year, October 1, 2011, through September 30, 2012.
(9) Disproportionate Share Hospital (DSH)--A hospital
participating in the Texas Medicaid program that serves a disproportionate
share of low-income patients and is eligible for additional reimbursement
from the DSH fund.
(10) Governmental entity--A state agency or a political
subdivision of the state. A governmental entity includes a hospital
authority, hospital district, city, county, or state entity.
(11) HHSC--The Texas Health and Human Services Commission,
or its designee.
(12) Institution for mental diseases (IMD)--A hospital
that is primarily engaged in providing psychiatric diagnosis, treatment,
or care of individuals with mental illness.
(13) Intergovernmental transfer (IGT)--A transfer of
public funds from a governmental entity to HHSC.
(14) Large public hospital--An urban public hospital
- Class one as defined in §355.8065 of this subchapter (relating
to Disproportionate Share Hospital Reimbursement Methodology).
(15) Mid-Level Professional--Medical practitioners
which include the following professions only:
(A) Certified Registered Nurse Anesthetists;
(B) Nurse Practitioners;
(C) Physician Assistants;
(D) Dentists;
(E) Certified Nurse Midwives;
(F) Clinical Social Workers;
(G) Clinical Psychologists; and
(H) Optometrists.
(16) Public funds--Funds derived from taxes, assessments,
levies, investments, and other public revenues within the sole and
unrestricted control of a governmental entity. 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.
(17) 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.
Regional Healthcare Partnerships will support coordinated, efficient
delivery of quality care and a plan for investments in system transformation
that is driven by the needs of local hospitals, communities, and populations.
(18) RHP plan--A multi-year plan within which participants
propose their portion of waiver funding and DSRIP projects.
(19) Rural hospital--A hospital enrolled as a Medicaid
provider that:
(A) is located in a county with 60,000 or fewer persons
according to the 2010 U.S. Census; or
(B) was designated by Medicare as a Critical Access
Hospital (CAH) or a Sole Community Hospital (SCH) before October 1,
2021; or
(C) is designated by Medicare as a CAH, SCH, or Rural
Referral Center (RRC); and is not located in a Metropolitan Statistical
Area (MSA), as defined by the U.S. Office of Management and Budget;
or
(D) meets all of the following:
(i) has 100 or fewer beds;
(ii) is designated by Medicare as a CAH, SCH, or an
RRC; and
(iii) is located in an MSA.
(20) Service Delivery Area (SDA)--The counties included
in any HHSC-defined geographic area as applicable to each Managed
Care Organization (MCO).
(21) Uncompensated-care application--A form prescribed
by HHSC to identify uncompensated costs for Medicaid-enrolled providers.
(22) Uncompensated-care payments--Payments intended
to defray the uncompensated costs of charity care as defined in paragraph
(5) of this subsection.
(23) Uninsured patient--An individual who has no health
insurance or other source of third-party coverage for the services
provided. The term includes an individual enrolled in Medicaid who
received services that do not meet the definition of medical assistance
in section 1905(a) of the Social Security Act (Medicaid services),
if such inclusion is specified in the hospital's charity-care policy
or financial assistance policy and the patient meets the hospital's
policy criteria.
(24) Waiver--The Texas Healthcare Transformation and
Quality Improvement Program Medicaid demonstration waiver under §1115
of the Social Security Act.
(c) Eligibility. A hospital that meets the requirements
described in this subsection may receive payments under this section.
(1) Generally. To be eligible for any payment under
this section:
(A) a hospital must be enrolled as a Medicaid provider
in the State of Texas at the beginning of the demonstration year;
and
(B) if it is a hospital not operated by a governmental
entity, it must have filed with HHSC an affiliation agreement and
the documents described in clauses (i) and (ii) of this subparagraph.
(i) Eligible Hospitals. The hospital must certify on
a form prescribed by HHSC:
(I) that it is a privately-operated hospital;
(II) that no part of any payment to the hospital under
this section will be returned or reimbursed to a governmental entity
with which the hospital affiliates; and
(III) that no part of any payment to the hospital under
this section will be used to pay a contingent fee, consulting fee,
or legal fee associated with the hospital's receipt of the supplemental
funds.
(ii) Governmental Entity Acknowledgments. The governmental
entity that is party to the affiliation agreement must certify on
a form prescribed by HHSC:
(I) that the governmental entity has not received and
has no agreement to receive any portion of the payments made to any
hospital that is party to the agreement;
(II) that the governmental entity has not entered into
a contingent fee arrangement related to the governmental entity's
participation in the waiver program;
(III) that the governmental entity adopted the conditions
described in the certification form prescribed by or otherwise approved
by HHSC pursuant to a vote of the governmental entity's governing
body in a public meeting preceded by public notice published in accordance
with the governmental entity's usual and customary practices or the
Texas Open Meetings Act, as applicable; and
(IV) that all affiliation agreements, consulting agreements,
or legal services agreements executed by the governmental entity related
to its participation in this waiver payment program are available
for public inspection upon request.
(iii) Submission requirements.
(I) Initial submissions. The parties must initially
submit the affiliation agreements and certifications described in
this subsection to the HHSC Provider Finance Department on the earlier
of the following occurrences after the documents are executed:
(-a-) the date the hospital submits the uncompensated-care
application that is further described in paragraph (2) of this subsection;
or
(-b-) the new affiliation cut-off date posted on HHSC
Provider Finance Departments' website for each payment under this
section.
(II) Subsequent submissions. The parties must submit
revised documentation to HHSC as follows.
(-a-) When the nature of the affiliation changes or
parties to the agreement are added or removed, the parties must submit
the revised affiliation agreement and related hospital and governmental
entity certifications.
(-b-) When there are changes in ownership, operation,
or provider identifiers, the hospital must submit a revised hospital
certification.
(-c-) The parties must submit the revised documentation
thirty days before the projected deadline for completing the IGT for
the first payment under the revised affiliation agreement. The projected
deadline for completing the IGT is posted on HHSC Provider Finance
Department's website for each payment under this section.
(III) Notification Requirement. A hospital that submits
new or revised documentation under subclause (I) or (II) of this clause
must notify the Anchor of the RHP in which the hospital participates.
(IV) Request for Modifications. The certification forms
must not be modified except for those changes approved by HHSC prior
to submission.
(-a-) Within 10 business days of HHSC Provider Finance
Department receiving a request for approval of proposed modifications,
HHSC will approve, reject, or suggest changes to the proposed certification
forms.
(-b-) A request for HHSC approval of proposed modifications
to the certification forms will not delay the submission deadlines
established in this clause.
(V) Failure to Submit Required Documentation. A hospital
that fails to submit the required documentation in compliance with
this subparagraph is not eligible to receive a payment under this
section.
(2) Uncompensated-care payments. For a hospital to
be eligible to receive uncompensated-care payments, in addition to
the requirements in paragraph (1) of this subsection, the hospital
must:
(A) submit to HHSC an uncompensated-care application
for the demonstration year, as is more fully described in subsection
(g)(1) of this section, by the deadline specified by HHSC; and
(B) submit to HHSC documentation of:
(i) its participation in an RHP; or
(ii) approval from CMS of its eligibility for uncompensated-care
payments without participation in an RHP.
(3) Changes that may affect eligibility for uncompensated-care
payments.
(A) If a hospital closes, loses its license, loses
its Medicare or Medicaid eligibility, withdraws from participation
in an RHP, or files bankruptcy before receiving all or a portion of
the uncompensated-care payments for a demonstration year, HHSC will
determine the hospital's eligibility to receive payments going forward
on a case-by-case basis. In making the determination, HHSC will consider
multiple factors including whether the hospital was in compliance
with all requirements during the demonstration year and whether it
can satisfy the requirement to cooperate in the reconciliation process
as described in subsection (i) of this section.
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