(a)Purpose. The purpose of this subchapter is to describe
the circumstances and programs under which the Texas Health and Human
Services Commission may direct expenditures for delivery system and
provider payment initiatives through its contracts with Medicaid managed
care organizations. Federal authority for such directed expenditures
is codified at 42 C.F.R. §438.6(c).
(b)Definitions. The following definitions apply when
the terms are used in this subchapter. Terms that are used in only
one program described in this subchapter may be defined in the section
of this subchapter describing that program.
(1) - (10)(No change.)
(11)Service delivery area (SDA)--The counties
included in any HHSC-defined geographic area as applicable to each
MCO.
(12)Sponsoring governmental entity--A state or non-state
governmental entity that agrees to transfer to HHSC some or all of
the non-federal share of program expenditures under this subchapter.
(c) - (i)(No change.)
(j)Disallowance of federal funds.
[(1)If an arrangement associated
with the funding of payments under this subchapter is determined by
CMS to constitute an impermissible provider donation, resulting in
a disallowance of federal matching funds, the governmental entities
responsible for the non-federal share of such payments must transfer
funds to HHSC in the amount of the disallowed federal funds. HHSC
notifies the governmental entities of the amount and timing of the
required transfers.]
[(2)]If payments under this subchapter
are disallowed by CMS [on grounds other than those described
in paragraph (1) of this subsection, to the extent allowed by federal
and state law and contract], HHSC may recoup the amount of the
disallowance from MCOs, providers, or governmental entities that participated
in the program associated with the disallowance. If the recoupment
from an MCO, provider, or governmental entity for such a disallowance
results in a subsequent disallowance, HHSC will recoup the amount
of that subsequent disallowance from the same entity.
(k)Overpayment. [Recoupment.]
(1)If payments under this subchapter result in an
overpayment to an MCO, HHSC may recoup the amount of the overpayment
from the MCO, pursuant to the terms of the contract between them.
(2)If payments under this subchapter result in an
overpayment to a provider, the MCO may recoup an amount equivalent
to the overpayment.
(3)Payments made under this subchapter may be subject
to any adjustments for payments made in error or due to fraud, including
without limitation adjustments made under the Texas Administrative
Code, the Code of Federal Regulations, and state and federal statutes.
The MCOs may recoup an amount equal to any such adjustments from the
providers in question. Nothing in this section may be construed to
limit the independent authority of another federal or state agency
or organization to recover from the provider for a payment made due
to fraud.
(l)State's cost of administering programs. To the
extent authorized under state and federal law, HHSC will collect the
state's cost of administering a program authorized under this subchapter
from participants in the program generating the costs.
The agency certifies that legal counsel
has reviewed the proposal and found it to be within the state agency's
legal authority to adopt.
Filed with the Office
of the Secretary of State on August 7, 2017
TRD-201702954 Karen Ray
Chief Counsel
Texas Health and Human Services Commission
Earliest possible date of adoption: September 17, 2017
For further information, please call: (512) 730-7450
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