| (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) 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.
(2) 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.
(3) 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.
(4) Data year--A 12-month period that is described
in §355.8066 of this subchapter (relating to State Payment Cap
and 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.
(5) 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.
(6) Disproportionate Share Hospital (DSH)--A hospital
participating in the Texas Medicaid program as defined in §355.8065
of this subchapter (relating to Disproportionate Share Hospital Reimbursement
Methodology).
(7) 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.
(8) HHSC--The Texas Health and Human Services Commission,
or its designee.
(9) Impecunious charge ratio--A ratio used to determine
if a hospital is eligible to receive payment from the HICH (High Impecunious
Charge Hospital) pool as described in subsection (f)(2)(C)(ii) of
this section.
(10) Institution for mental diseases (IMD)--A hospital
that is primarily engaged in providing psychiatric diagnosis, treatment,
or care of individuals with mental illness, defined in §1905(i)
of the Social Security Act. IMD hospitals are reimbursed as freestanding
psychiatric facilities under §355.8060 of this subchapter (relating
to Reimbursement Methodology for Freestanding Psychiatric Facilities)
and §355.761 of this chapter (relating to Reimbursement Methodology
for Institutions for Mental Diseases (IMD)).
(11) Intergovernmental transfer (IGT)--A transfer of
public funds from a governmental entity to HHSC.
(12) Medicaid cost report--Hospital and Hospital Health
Care Complex Cost Report (Form CMS 2552), also known as the Medicare
cost report.
(13) 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.
(14) Non-public hospital--A hospital that meets the
definition of non-public provider as defined in §355.8200 of
this subchapter (relating to Retained Funds for the Uncompensated
Care Program).
(15) 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.
(16) Public Health Hospital (PHH)--The Texas Center
for Infectious Disease or any successor facility operated by the Department
of State Health Services.
(17) Rural hospital--A hospital enrolled as a Medicaid
provider that:
(A) is located in a county with 68,750 or fewer persons
according to most recent decennial census 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.
(18) Service Delivery Area (SDA)--The counties included
in any HHSC-defined geographic area as applicable to each Managed
Care Organization (MCO).
(19) State institution for mental diseases (State IMD)--A
hospital that is primarily engaged in providing psychiatric diagnosis,
treatment, or care of individuals with mental illness defined in §1905(i)
of the Social Security Act and that is owned and operated by a state
university or other state agency. State IMD hospitals are reimbursed
as freestanding psychiatric facilities under §355.761 of this
chapter (relating to Reimbursement Methodology for Institutions for
Mental Disease (IMD)).
(20) State-owned hospital--A hospital that is defined
as a state IMD, state-owned teaching hospital, or a Public Health
Hospital (PHH) in this section.
(21) State-owned teaching hospital--A hospital that
is a state-owned teaching hospital as defined in §355.8052 of
this subchapter (relating to Inpatient Hospital Reimbursement).
(22) State Payment Cap--The maximum payment amount,
as applied to payments that will be made for the program year, that
a hospital may receive in reimbursement for the cost of providing
Medicaid-allowable services to individuals who are Medicaid-eligible
or uninsured. The state payment cap is calculated using the methodology
described in §355.8066 of this subchapter.
(23) Transferring public hospital--A hospital that
is a transferring public hospital as defined in §355.8065 of
this subchapter.
(24) Uncompensated-care application--A form prescribed
by HHSC to identify uncompensated costs for Medicaid-enrolled providers.
(25) Uncompensated-care payments--Payments intended
to defray the uncompensated costs of charity care as defined in this
subsection.
(26) 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.
(27) 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.
(B) A hospital must meet any criteria described by
the waiver as a condition of eligibility to receive an uncompensated-care
payment.
Cont'd... |
