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(a)Introduction. This section establishes the Quality
Incentive Payment Program (QIPP) for nursing facilities (NFs) providing
services under Medicaid managed care on or after September 1, 2019.
QIPP is designed to incentivize NFs to improve quality and innovation
in the provision of NF services to Medicaid recipients through the
use of metrics that are expected to advance at least one of the goals
and objectives of the state's quality strategy.
(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
(relating to General Provisions) or §353.1304 (relating to Quality
Metrics for the Quality Incentive Payment Program for Nursing Facilities
on or after September 1, 2019) of this subchapter.
(1)CHOW application--An application filed with HHSC
for a NF change of ownership (CHOW).
(2)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.
(3)Network nursing facility--A NF located in the state
of Texas that has a contract with an MCO for the delivery of Medicaid
covered benefits to the MCO's enrollees.
(4)Non-state government-owned NF--A network nursing
facility where a non-state governmental entity located in the state
of Texas holds the license and is a party to the NF's Medicaid provider
enrollment agreement with the state.
(5)Private NF-- A network nursing facility not owned
by a governmental entity located in the state of Texas, and holds
a license.
(6)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.
(1)The NF is a non-state government-owned NF.
(A)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.
(B)The NF must be located in the state of Texas in
the same RHP as, or within 150 miles of, the non-state governmental
entity taking ownership of the facility, be owned by the non-state
governmental entity for no less than four years prior to the first
day of the eligibility period, or must be able to certify in connection
with the enrollment application that they can demonstrate an active
partnership between the NF and the non-state governmental entity that
owns the NF. The following criteria demonstrate an active partnership
between the NF and the non-state governmental entity that owns the
NF.
(i)Monthly meetings (in-person or virtual) with NF
administrative staff to review the NF's clinical and quality operations
and identify areas for improvement. Meetings should include patient
observations; regulatory findings; review of CASPER reports, quality
measures, grievances, staffing, risk, incidents, accidents, and infection
control measures; root cause analysis, if applicable; and design of
performance improvement plans.
(ii)Quarterly joint trainings on topics and trends
in nursing home care best practices or on needed areas of improvement.
(iii)Annual, on-site inspections of the NF by a non-state
governmental entity-sponsored Quality Assurance team.
(2)The NF is a private NF. The NF must have a percentage
of Medicaid NF days of service that is greater than or equal to 65
percent. For each private NF, the percentage of Medicaid NF days is
calculated by summing the NF's Medicaid NF fee-for-service and managed
care days of service, including dual-eligible demonstration 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.
(A)The days of service will be annualized based on
the NF's latest cost report or accountability report but from a year
in which HHSC required the submission of cost reports.
(B)HHSC will exclude any calendar days that the NF
was closed due to a natural or man-made disaster. In such cases, HHSC
will annualize the days of service based on calendar days when the
NF was open.
(d)Data sources for historical units of service. Historical
units of service are used to determine an individual private NF's
QIPP eligibility status and the distribution of QIPP funds across
eligible and enrolled NFs.
(1)All data sources referred to in this subsection
are subject to validation using HHSC auditing processes or procedures
as described under §355.106 of this title (relating to Basic
Objectives and Criteria for Audit and Desk Review of Cost Reports).
(2)Data sources for the determination of each private
NF's QIPP eligibility status are listed in priority order below. For
each eligibility period, the data source must be from a cost-reporting
year and must align with the NF's fiscal year.
(A)The most recently available Medicaid NF cost report
for the private NF. If no Medicaid NF cost report is available, the
data source in subparagraph (B) of this paragraph must be used.
(B)The most recently available Medicaid Direct Care
Staff Rate Staffing and Compensation Report for the private NF. If
no 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 Medicaid NF cost report
for a prior owner of the private NF. If no Medicaid NF cost report
for a 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 Medicaid Direct Care
Staff Rate Staffing and Compensation Report for a prior owner of the
private NF. If no Medicaid Direct Care Staff Rate Staffing and Compensation
Report for a prior owner of the private NF is available, the private
NF is not eligible for participation in QIPP.
(3)Data sources for determination of distribution
of QIPP funds across eligible and enrolled NFs are listed in priority
order below. For each eligibility period, the data source must be
from a cost-reporting year and must align with the NF's 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 Medicaid NF
cost report is available, the data source in subparagraph (B) of this
paragraph must be used.
(B)The most recently available 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 Staffing and Compensation
Report is available, the data source in subparagraph (C) of this paragraph
must be used.
(C)The most recently available Medicaid NF cost report
for a 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 Medicaid NF cost report for a prior owner of the NF is available,
the data source in subparagraph (D) of this paragraph must be used.
(D)The most recently available Medicaid Direct Care
Staff Rate Staffing and Compensation Report for a 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. The enrollment period
must be no less than 30 calendar days, and the final date of the enrollment
period will be at least nine days prior to the IGT notification.
(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 at least 15 days prior to the IGT declaration
of intent deadline. 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 eight 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 provide a declaration of intent to HHSC 15 business days
before the first half of the IGT amount is transferred to HHSC.
(A)The declaration of intent is a form prescribed
by HHSC that includes the total amount of IGT the sponsoring governmental
entity wishes to transfer to HHSC and whether the sponsoring governmental
entity intends to accept Component One payments.
(B)The declaration of intent is certified to the best
knowledge and belief of a person legally authorized to sign for the
sponsoring governmental entity but does not bind the sponsoring governmental
entity to transfer IGT.
(3)Sponsoring governmental entities will transfer
the first half of the IGT amount by a date determined by HHSC. The
second half of the IGT amount will be transferred by a date determined
by HHSC. The IGT deadlines and all associated dates will be published
on the HHSC QIPP webpage by January 15 of each year.
(4)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 four components of the STAR+PLUS NF managed
care 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
related to the quality metrics as described in §353.1304 of this
subchapter. The NF must have had at least one Medicaid client in the
care of that NF for each reporting period to be eligible for payments.
(1)Component One.
(A)The total value of Component One will be equal
to 110 percent of the non-federal share of the QIPP.
(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 achievement of performance requirements as
described in §353.1304 of this subchapter.
(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 18 percent.
(2)Component Two.
(A)The total value of Component Two will be equal
to 30 percent of remaining QIPP funds after accounting for the funding
of Component One and Component Four.
(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)Monthly payments to NFs will be triggered by achievement
of performance requirements as described in §353.1304 of this
subchapter.
(3)Component Three.
(A)The total value of Component Three will be equal
to 70 percent of remaining QIPP funds after accounting for the funding
of Component One and Component Four.
(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 §353.1304
of this subchapter.
(4)Component Four.
(A)The total value of Component Four will be equal
to 16 percent of the funds of the QIPP.
(B)Allocation of funds across qualifying non-state
government-owned NFs will be proportional, based upon historical Medicaid
days of NF service.
(C)Quarterly payments to non-state government-owned
NFs will be triggered by achievement of performance requirements as
described in §353.1304 of this subchapter.
(D)Private NFs are not eligible for payments from
Component Four.
(5)Funds that are non-disbursed due to failure of
one or more NFs to meet performance requirements will be distributed
across all QIPP NFs based on each NF's proportion of total earned
QIPP funds from Components One, Two, Three, and Four 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 a NF, 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 performance
requirements are met will be equal to the total value of Component
One for the NF divided by twelve.
(B)Monthly 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 twelve.
(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)Quarterly payments from Component Four associated
with each quality metric will be equal to the total value of Component
Four associated with the quality metric divided by four.
(E)For purposes of the calculations described in subparagraphs
(B), (C), and (D) of this paragraph, each quality metric will be allocated
an equal portion of the total dollars included in the component.
(F)In situations where a NF does not have enough data
for a quality metric to be calculated, the funding associated with
that metric will be evenly distributed across all remaining metrics
within 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. In the
event of a CHOW, the MCO will distribute the payment to the owner
of the NF at the time of the payment.
(i)Changes of ownership.
Cont'd...
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