(a)Introduction. This section establishes the Quality
Incentive Payment Program (QIPP) for nursing facilities (NFs) providing
services under Medicaid managed care (MC). QIPP is designed to incentivize
NFs to improve quality and innovation in the provision of NF services
to Medicaid recipients, using the Centers for Medicare & Medicaid
Services (CMS) Five-Star Quality Rating System as its measure of success.
(b)Definitions. The following definitions apply when
the terms are used in this section. Terms that are used in this and
other sections of this subchapter may be defined in §353.1301
of this subchapter (relating to General Provisions).
(1)Baseline--A NF-specific starting measure used as
a comparison against NF performance throughout the eligibility period
to determine progress in the QIPP Quality Measures.
(2)Benchmark--The CMS National Average prior to the
start of the eligibility period by which a NF's progress with the
Quality Measures is determined.
(3)CHOW application--An application filed with the
Department of Aging and Disability Services (DADS) for a NF change
of ownership (CHOW).
(4)DADS--The Texas Department of Aging and Disability
Services or its successor agency.
(5)Eligibility period--A period of time for which
an eligible and enrolled NF may receive the QIPP amounts described
in this section. Each QIPP eligibility period is equal to a state
fiscal year (FY) beginning September 1 and ending August 31 of the
following year. Eligibility Period One is equal to FY 2018, beginning
September 1, 2017, and ending August 31, 2018.
(6)MCO--A Medicaid managed care organization contracted
with HHSC to provide NF services to Medicaid recipients.
(7)Network nursing facility--A NF that has a contract
with an MCO for the delivery of Medicaid covered benefits to the MCO's
enrollees.
(8)Non-state government-owned NF--A network NF where
a non-state governmental entity holds the license and is a party to
the NF's Medicaid provider enrollment agreement with the state.
(9)Private NF--A NF that is not owned by a governmental
entity.
(10)Quality Assurance Performance Improvement (QAPI)
Validation Report--A monthly report submitted by a NF, that is eligible
for and enrolled in QIPP, to an MCO that demonstrates that the NF
has convened a meeting to review the NF's CMS-compliant plan for maintaining
and improving safety and quality in the NF.
(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
as defined and established under Chapter 354, Subchapter D, of this
title (relating to Texas Healthcare Transformation and Quality Improvement
Program).
(c)Eligibility for participation in QIPP. A NF is
eligible to participate in QIPP if it complies with the requirements
described in this subsection for each eligibility period.
(1)Eligibility Period One. A NF is eligible to participate
in QIPP for Eligibility Period One if it meets the following requirements:
(A)The NF is a non-state government-owned NF.
(i)The NF must be a non-state government-owned NF
with a Medicaid contract effective date of April 1, 2017, or earlier.
A NF undergoing a CHOW from privately owned to publically owned will
only be eligible under this subparagraph if DADS received a completed
CHOW application by March 2, 2017, and all required documents pertaining
to the CHOW (i.e., DADS must have a complete application for a change
of ownership license as described under 40 TAC §19.201 (relating
to Criteria for Licensing), §19.210 (relating to Change of Ownership
License), and §19.2308 (relating to Change of Ownership)) by
March 31, 2017.
(ii)The non-state governmental entity that owns the
NF must certify the following facts on a form prescribed by HHSC.
(I)that it is a non-state government-owned NF where
a non-state governmental entity holds the license and is party to
the facility's Medicaid contract; and
(II)that all funds transferred to HHSC via an intergovernmental
transfer (IGT) for use as the state share of payments are public funds.
(iii)The NF must have been a participant in the Minimum
Payment Amounts Program (MPAP) or must be located in the same RHP
as, or within 150 miles of, the non-state governmental entity taking
ownership of the facility. This geographic proximity criterion does
not apply to NFs that can establish good cause for an exception to
this criterion.
(B)Private NFs. The NF must have a percentage of Medicaid
NF days of service that is greater than or equal to the private NF
QIPP eligibility cut-off point. The private NF QIPP eligibility cut-off
point will be equal to the mean percentage of historical Medicaid
NF days of service provided under fee-for-service (FFS) and MC by
all private NFs plus one standard deviation, as determined by HHSC.
For each private NF, the percentage of Medicaid NF days is calculated
by summing the NF's Medicaid NF FFS and MC days of service and dividing
that sum by the facility's total days of service in all licensed beds.
Medicaid hospice days of service are included in the denominator but
excluded from the numerator.
(2)Future eligibility periods. Eligibility requirements
for eligibility periods after Eligibility Period One are the same
as the requirements under paragraph (1) of this subsection except
that the deadlines specified in paragraph (1)(A)(i) of this subsection
will be updated by HHSC. Updated deadlines will be shared with all
NFs by a date to be determined by HHSC.
(d)Data sources for historical units of service. Historical
units of service are used to determine the private NF QIPP eligibility
cut-off point, individual private NF QIPP eligibility status, and
the distribution of QIPP funds across eligible and enrolled NFs.
(1)All audits referred to in this subsection are performed
by HHSC under the guidance of §355.106 of this title (relating
to Basic Objectives and Criteria for Audit and Desk Review of Cost
Reports).
(2)The data source for the determination of the private
NF QIPP eligibility cut-off point is the most recently available,
audited Texas Medicaid NF cost report database.
(3)Data sources for the determination of each private
NF's QIPP eligibility status are listed in priority order below:
(A)The most recently available, audited Medicaid NF
cost report for the private NF. If no audited Medicaid NF cost report
is available, the data source in subparagraph (B) of this paragraph
must be used.
(B)The most recently available, audited Medicaid Direct
Care Staff Rate Staffing and Compensation Report for the private NF.
If no audited Medicaid Direct Care Staff Rate Staffing and Compensation
Report is available, the data source in subparagraph (C) of this paragraph
must be used.
(C)The most recently available, audited Medicaid NF
cost report for the immediately prior owner of the private NF. If
no audited Medicaid NF cost report for the immediately prior owner
of the private NF is available, the data source in subparagraph (D)
of this paragraph must be used.
(D)The most recently available, audited Medicaid Direct
Care Staff Rate Staffing and Compensation Report for the immediately
prior owner of the private NF. If no audited Medicaid Direct Care
Staff Rate Staffing and Compensation Report for the immediately prior
owner of the private NF is available, the private NF is not eligible
for participation in QIPP.
(4)Data sources for determination of distribution
of QIPP funds across eligible and enrolled NFs.
(A)The most recently available, audited Medicaid NF
cost report for the NF. If the cost report covers less than a full
year, reported values are annualized to represent a full year. If
no audited Medicaid NF cost report is available, the data source in
subparagraph (B) of this paragraph must be used.
(B)The most recently available, audited Medicaid Direct
Care Staff Rate Staffing and Compensation Report for the NF. If the
Staffing and Compensation Report covers less than a full year, reported
values are annualized to represent a full year. If no audited Staffing
and Compensation Report is available, the data source in subparagraph
(C) of this paragraph is must be used.
(C)The most recently available, audited Medicaid NF
cost report for the immediately prior owner of the NF. If the cost
report covers less than a full year, reported values are annualized
to represent a full year. If no audited Medicaid NF cost report for
the immediately prior owner of the NF is available, the data source
in subparagraph (D) of this paragraph must be used.
(D)The most recently available, audited Medicaid Direct
Care Staff Rate Staffing and Compensation Report for the immediately
prior owner of the NF. If the Staffing and Compensation Report covers
less than a full year, reported values are annualized to represent
a full year.
(e)Participation requirements. As a condition of participation,
all NFs participating in QIPP must allow for the following:
(1)HHSC must be able to access data for the NF from
one of the data sources listed in subsection (d) of this section.
(2)The NF must submit a properly completed enrollment
application by the due date determined by HHSC.
(3)The entity that owns the NF must certify, on a
form prescribed by HHSC, that no part of any payment made under the
QIPP will be used to pay a contingent fee, consulting fee, or legal
fee associated with the NF's receipt of QIPP funds and the certification
must be received by HHSC with the enrollment application described
in paragraph (2) of this subsection.
(4)The entity that owns the NF must submit to HHSC,
upon demand, copies of contracts it has with third parties that reference
the administration of, or payments from, QIPP.
(f)Non-federal share of QIPP payments. The non-federal
share of all QIPP payments is funded through IGTs from sponsoring
non-state governmental entities. No state general revenue is available
to support QIPP.
(1)HHSC will share suggested IGT responsibilities
for the eligibility period with all QIPP eligible and enrolled non-state
government-owned NFs on or around May 15 of the calendar year that
also contains the first month of the eligibility period. Suggested
IGT responsibilities will be based on the maximum dollars to be available
under the QIPP program for the eligibility period as determined by
HHSC, plus ten percent; forecast STAR+PLUS NF member months for the
eligibility period as determined by HHSC; and the distribution of
historical Medicaid days of service across non-state government-owned
NFs enrolled in QIPP for the eligibility period. HHSC will also share
estimated maximum revenues each eligible and enrolled NF could earn
under QIPP for the eligibility period with those estimates based on
HHSC's suggested IGT responsibilities and an assumption that all enrolled
NFs will meet 100 percent of their quality metrics. The purpose of
sharing this information is to provide non-state government-owned
NFs with information they can use to determine the amount of IGT they
wish to transfer.
(2)Sponsoring governmental entities will determine
the amount of IGT they wish to transfer to HHSC for the entire eligibility
period and will transfer one-half of that amount by May 31 of the
calendar year that also contains the first month of the eligibility
period. The second half of the IGT amount will be transferred by November
30 of the calendar year that also contains the first month of the
eligibility period.
(3)Reconciliation. HHSC will reconcile the amount
of the non-federal funds actually expended under this section during
each eligibility 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.
(g)QIPP capitation rate components. QIPP funds will
be paid to MCOs through three new components of the STAR+PLUS NF MC
per member per month (PMPM) capitation rates. The MCOs' distribution
of QIPP funds to the enrolled NFs will be based on each NF's performance
on a set of defined quality metrics.
(1)Component One.
(A)The total value of Component One will be equal
to 110 percent of the non-federal share of the QIPP program.
(B)Interim allocation of funds across qualifying non-state
government-owned NFs will be proportional, based upon historical Medicaid
days of NF service.
(C)Monthly payments to non-state government-owned
NFs will be triggered by the NF's submission to the MCOs of a monthly
QAPI Validation Report.
(D)Private NFs are not eligible for payments from
Component One.
(E)The interim allocation of funds across qualifying
non-state government-owned NFs will be reconciled to the actual distribution
of Medicaid NF days of service across these NFs during the eligibility
period as captured by HHSC's Medicaid contractors for fee-for-service
and managed care 180 days after the last day of the eligibility period.
This reconciliation will only be performed if the weighted average
(weighted by Medicaid NF days of service during the eligibility period)
of the absolute values of percentage changes between each NFs proportion
of historical Medicaid days of NF service and actual Medicaid days
of NF service is greater than 20 percent.
(2)Component Two.
(A)The total value of Component Two will be equal
to 35 percent of remaining QIPP funds after accounting for the funding
of Component One.
(B)Allocation of funds across qualifying non-state
government-owned and private NFs will be proportional, based upon
historical Medicaid days of NF service.
(C)Quarterly payments to NFs will be triggered by
achievement of performance requirements as described in subsection
(h) of this section.
(3)Component Three.
(A)The total value of Component Three will be equal
to 65 percent of remaining QIPP funds after accounting for the funding
of Component One.
(B)Allocation of funds across qualifying non-state
government-owned and private NFs will be proportional, based upon
historical Medicaid days of NF service.
(C)Quarterly payments to NFs will be triggered by
achievement of performance requirements as described in subsection
(h) of this section. Payments made to NFs meeting the standards of
Component Three will include both the 35 percent allocated for Component
Two and the remaining 65 percent allocated for Component Three.
(4)Funds that would lapse due to failure of one or
more NFs to meet quality metrics will be distributed across all QIPP
NFs based on each NF's proportion of total earned QIPP funds from
Components One, Two, and Three combined.
(h)Distribution of QIPP payments.
(1)Prior to the beginning of the eligibility period,
HHSC will calculate the portion of each PMPM associated with each
QIPP-enrolled NF broken down by QIPP capitation rate component, quality
metric, and payment period. For example, for NF A, HHSC will calculate
the portion of each PMPM associated with that NF that would be paid
from the MCO to the NF as follows:
(A)Monthly payments from Component One as QAPI reporting
requirements are met will be equal to the total value of Component
One for the NF divided by twelve.
(B)Quarterly payments from Component Two associated
with each quality metric will be equal to the total value of Component
Two associated with the quality metric divided by four.
(C)Quarterly payments from Component Three associated
with each quality metric will be equal to the total value of Component
Three associated with the quality metric divided by four.
(D)For purposes of the calculations described in subparagraphs
(B) and (C) of this paragraph, each metric will be allocated an equal
portion of the total dollars included in the component.
(2)MCOs will distribute payments to enrolled NFs as
they meet their reporting and quality metric requirements. Payments
will be equal to the portion of the QIPP PMPM associated with the
achievement for the time period in question multiplied by the number
of member months for which the MCO received the QIPP PMPM.
(i)Performance requirements.
(1)Quality metrics.
(A)There will be a minimum of three quality metrics
for an eligibility period.
(B)Quality metrics may change from eligibility period
to eligibility period. Information regarding specific quality metrics
for an eligibility period will be provided annually through the QIPP
webpage on the HHSC website on or before February 1 of the calendar
year that also contains the first month of the eligibility period.
(C)Quality metric baselines will be based on each
individual NF's average performance on the metric as reported by CMS
for the federal quarter that ends prior to the first day of the eligibility
period and the three prior federal quarters, or as determined by HHSC.
(D)Quality metric benchmarks will be based on the
national average for the metric as reported by CMS for the federal
quarter that ends prior to the first day of the eligibility period,
or as determined by HHSC.
(2)Achievement requirements. In order to receive payments
from Components Two and Three for a quality metric, a NF must show
improvement over the baseline or exceed the benchmark for the metric.
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