(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 (related to General Provisions).
(1) - (9)(No change.)
(10)Quality Assurance Performance Improvement (QAPI)
Validation Report--A monthly report submitted by a NF, that is eligible
for and enrolled in QIPP, to HHSC [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) - (ii)(No change.)
(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:
(A)the private NF QIPP eligibility
cut-off point will be equal to the mean percentage of historical Medicaid
NF days of service provided under FFS and MC by all private NFs plus
one-quarter of one standard deviation, as determined by HHSC;
(B)a private NF that was eligible
to participate in QIPP during Eligibility Period One is eligible to
participate in the eligibility period for state fiscal year 2019 regardless
of its Medicaid NF days of service for that eligibility period; and
(C)the deadlines specified in paragraph
(1)(A)(i) 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) - (3)(No change.)
(4)Data sources for determination of distribution
of QIPP funds across eligible and enrolled NFs. For each eligibility
period, the data source must align with the NF's fiscal year that
ends no more recently than in the calendar year four years prior to
the calendar year within which the eligibility period ends. For example,
for the eligibility period ending on August 31, 2018, the data source
must align with the NF's 2014 fiscal year or an earlier fiscal year
and for the eligibility period ending on August 31, 2019, the data
source must align with the NF's 2015 fiscal year or an earlier fiscal
year.
(A)The most recently available 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) - (D)(No change.)
(e) - (f)(No change.)
(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) - (B)(No change.)
(C)Monthly payments to non-state government-owned
NFs will be triggered by the NF's submission to HHSC [the
MCOs] of a monthly QAPI Validation Report.
(D) - (E)(No change.)
(2) - (4)(No change.)
(h) - (k)(No change.)
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 April 23, 2018
TRD-201801776 Karen Ray
Chief Counsel
Texas Health and Human Services Commission
Earliest possible date of adoption: June 3, 2018
For further information, please call: (512) 707-6066
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