| (a) Introduction. Beginning October 1, 2019, payments
are available under this section to help defray the uncompensated
charity-care costs incurred by eligible physician group practices
described in subsection (c) of this section. Waiver payments to physician
group practices for uncompensated care provided before October 1,
2019, are described in §355.8202 of this division (relating to
Waiver Payments to Physician Group Practices for Uncompensated Care).
Waiver payments to an eligible physician group practice 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 the physician
group practice uncompensated-care pool, as described in §355.8212
of this division (relating to Waiver Payments to Hospitals for Uncompensated
Charity Care). Starting in demonstration year eleven, the physician
group practice uncompensated-care pool will be further divided into
a state-owned physician group practice pool and a non-state-owned
physician group practice pool.
(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) Demonstration year--The 12-month period beginning
October 1 for which the payments calculated under this section are
made. Demonstration year one was October 1, 2011, through September
30, 2012.
(5) 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.
(6) HHSC--The Texas Health and Human Services Commission
or its designee.
(7) Intergovernmental transfer (IGT)--A transfer of
public funds from a governmental entity to HHSC.
(8) 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.
(9) Non-state-owned physician group--Any physician
group not included in the definition of state-owned physician group
that qualifies for uncompensated care payments.
(10) 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.
(11) 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.
(12) Service Delivery Area (SDA)--The counties included
in any HHSC-defined geographic area as applicable to each Managed
Care Organization.
(13) State-owned physician group--An eligible physician
group practice that is state-owned or state-operated. Physicians under
contract with such a physician group practice are not included. Eligible
state-owned or state-operated physician group practices consist of
those affiliated with:
(A) University of Texas--Southwestern;
(B) University of Texas--San Antonio;
(C) University of Texas--Tyler;
(D) University of Texas--Houston;
(E) University of Texas Medical Branch--Galveston;
(F) University of Texas--MD Anderson Cancer Center;
(G) University of North Texas;
(H) Texas Tech University--Amarillo;
(I) Texas Tech University--El Paso;
(J) Texas Tech University--Lubbock;
(K) Texas Tech University--Odessa; or
(L) Texas A&M Health Science Center.
(14) Uncompensated-care payments--Payments intended
to defray the uncompensated costs of charity care as defined in paragraph
(3) of this subsection.
(15) Uncompensated-care physician application--A form
prescribed by HHSC to identify uncompensated costs for Medicaid-enrolled
providers.
(16) Uninsured patient--An individual who has no health
insurance or other source of third-party coverage for services, as
defined by CMS. 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.
(17) Waiver--The Texas Healthcare Transformation and
Quality Improvement Program Medicaid demonstration waiver under §1115
of the Social Security Act.
(c) Eligibility.
(1) A physician group practice is eligible to receive
payments under this section if:
(A) it is enrolled as a Medicaid provider in the State
of Texas at the beginning of the demonstration year;
(B) for a private physician group practice only, it
has met the submission requirements set forth in §355.8212(c)(1)(B)(iii)
of this division, only insofar as that clause relates to certifications,
and it files documents with HHSC by the date specified by HHSC, certifying
that:
(i) all funds transferred to HHSC as the non-federal
share of the waiver payments are public funds; and
(ii) no part of any payment received by the physician
group practice under this section will be returned to the governmental
entity that transferred to HHSC the non-federal share of the waiver
payments;
(C) it has submitted to HHSC an acceptable uncompensated-care
physician application for the demonstration year by the deadline specified
by HHSC; and
(D) it either:
(i) received a supplemental payment under the Texas
Medicaid State Plan for claims adjudicated in one or more months between
October 1, 2010, and September 30, 2011; or
(ii) is the successor in a contract to a physician
group practice that received a supplemental payment under the Texas
Medicaid State Plan for claims adjudicated in one or more months between
October 1, 2010, and September 30, 2011.
(2) A physician group practice that fails to submit
the required documentation in compliance with this subsection will
not receive a payment under this section.
(d) Source of funding.
(1) The non-federal share of funding for payments under
this section is limited to and obtained through IGTs from the governmental
entities that own or are affiliated with the providers in the physician
group practice uncompensated-care pool. Governmental entities that
choose to support payments under this section affirm that funds transferred
to HHSC meet federal requirements related to the non-federal share
of such payments, including §1903(w) of the Social Security Act.
Prior to processing uncompensated-care payments for any payment period
within a waiver demonstration year, HHSC will survey the governmental
entities that provide public funds for the physician group practices
pool to determine the amount of funding available to support payments
from that pool.
(2) An IGT that is not received by the date specified
by HHSC may not be accepted.
(e) Payment frequency. HHSC will distribute waiver
payments on a schedule to be determined by HHSC and posted on HHSC's
website.
(f) Funding limitations.
(1) For demonstration years nine and ten, payments
made under this section are limited by the maximum amount of funds
allocated to the physician group practice uncompensated-care pool
for the demonstration year as described in §355.8212 of this
division. If payments for uncompensated care for the physician group
practice uncompensated-care pool attributable to a demonstration year
are expected to exceed the amount of funds allocated to that pool
by HHSC for that demonstration year, HHSC will reduce payments to
providers in the pool as described in subsection (g)(4) of this section.
Payments made under this section are limited by the availability of
funds identified in subsection (d) of this section. If sufficient
funds are not available for all payments for which all physician group
practices are eligible, HHSC will reduce payments as described in
subsection (h)(2) of this section.
(2) Beginning in demonstration year eleven, payments
made under this section are limited by the maximum amount of funds
allocated to the non-state-owned physician group practice uncompensated-care
pool for the demonstration year as described in §355.8212 of
this division. Non-state-owned physicians as defined in subsection
(b) of this section, are reimbursed through the non-state-owned physician
group practice uncompensated-care pool. If payments for uncompensated
care for the non-state-owned physician group practice uncompensated-care
pool attributable to a demonstration year are expected to exceed the
amount of funds allocated to that pool by HHSC for that demonstration
year, HHSC will reduce payments to providers in the non-state-owned
pool as described in subsection (g)(4) of this section. Payments made
under this section are limited by the availability of funds identified
in subsection (d) of this section. If sufficient funds are not available
for all payments for which all physician group practices are eligible,
HHSC will reduce payments as described in subsection (h)(2) of this
section.
(g) Uncompensated-care payment amount.
(1) Uncompensated-care physician application. Payments
to eligible physician group practices are based on cost and payment
data reported by the physician group practice on an application form
prescribed by HHSC.
(A) Cost and payment data reported by the physician
group practice in the uncompensated-care physician application is
used to:
(i) calculate the annual maximum uncompensated-care
payment amount for the applicable demonstration year, as described
in paragraph (2) of this subsection; and
(ii) reconcile the actual uncompensated-care costs
reported by the physician group practice for a prior period with uncompensated-care
waiver payments, if any, made to the practice for the same period.
The reconciliation process is more fully described in subsection (j)
of this section.
(B) Unless otherwise instructed in the uncompensated-care
physician application:
(i) the cost and payment data reported in the uncompensated-care
physician application must be consistent with Medicare cost-reporting
principles and must comply with the application instructions or other
guidance issued by HHSC, and the physician group practice must maintain
sufficient documentation to support the reported data or information;
and
(ii) the costs associated with an episode of care where
a physician group practice is paid under contract must be reduced
by any revenues associated with that episode of care prior to inclusion
in the uncompensated-care physician application.
(C) If a physician group practice withdraws from participation
in the waiver, the practice must submit an uncompensated-care application
reporting its actual costs and payments for any period during which
the practice received uncompensated-care payments. The uncompensated-care
physician application will be used for the purpose described in subparagraph
(A)(ii) of this paragraph. If a practice fails to submit the application
reporting its actual costs, HHSC will recoup the full amount of uncompensated-care
payments to the practice for the period at issue.
(2) Calculation. A physician group practice's annual
maximum uncompensated-care payment amount is the sum of the following
components:
(A) its unreimbursed charity-care costs, as reported
on the uncompensated-care physician application; and
Cont'd... |
