(a)(No change.)
(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)Program [Eligibility] period--A
period of time for which an eligible and enrolled NF may receive the
QIPP amounts described in this section. Each QIPP program [
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 a Managed Care Organization
(MCO) [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).
(7)Runout Period--A period of 23
months following the end of the program period during which the MCO
may make adjustments to the MCO member months.
(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 program [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 program [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 program [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 do [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.]
(1)[(2)] The NF must submit
a properly completed enrollment application, on a form prescribed
by HHSC, 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.
(2)[(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
; and that the entity's agreement with the nursing facility does not
use a reimbursement methodology containing any type of incentive,
direct or indirect, for inappropriately inflating, in any way, claims
billed to Medicaid, including [, consulting fee, or legal
fee associated with] the NF's receipt of QIPP funds. The [
and the] certification must be received by HHSC with the enrollment
application described in paragraph (1) [(2)]
of this subsection.
(3)[(4)] If a provider
has changed ownership in the past five years in a way that impacts
eligibility for the program, the provider [The entity that
owns the NF] must submit to HHSC, upon demand, copies of contracts
it has with third parties with respect to the transfer of ownership
or the management of the provider, and which reference the administration
of, or payment from, this program [that reference the administration
of, or payments from, QIPP].
(4)The NF must ensure that HHSC has
access to the NF records referenced in subsection (c) of this section
and the data for the NF from one of the data sources listed in subsection
(d) of this section. Participating facilities must ensure that these
records and data are accurate and sufficiently detailed to support
legal, financial, and statistical information used to determine a
NF's eligibility during the program period.
(A)The NF must maintain these records and data through
the program period and until at least 90 days following the conclusion
of the runout period.
(B)The NF will have 14 business days from the date
of a request from HHSC to submit to HHSC the records and data.
(C)Failure to provide the records and data could result
in adjustments pursuant to §353.1301(k) of this subchapter.
(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 program [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, plus eight percent, for
the program [eligibility] period as determined
by HHSC [, plus eight percent]; forecast STAR+PLUS NF member
months for the program [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 program [eligibility] period. HHSC
will also share estimated maximum revenues each eligible and enrolled
NF could earn under QIPP for the program [eligibility]
period. Estimates are [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 program
[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 actual amount
of the non-federal funds [actually] expended under this
section during each program [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 program [
eligibility] period as captured by HHSC's Medicaid contractors
for fee-for-service and managed care 180 days after the last day of
the program [eligibility] period. This reconciliation
will only be performed if the weighted average (weighted by Medicaid
NF days of service during the program [eligibility]
period) of the absolute values of percentage changes between each NF's
[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 a percent of remaining QIPP funds after accounting for the
funding of Component One and Component Four [30 percent
of remaining QIPP funds after accounting for the funding of Component
One and Component Four].
(i)For the program period September
1, 2019, through August 31, 2021, the percent will be equal to 30
percent.
(ii)For the program period beginning
September 1, 2021, the percent will be equal to 40 percent.
(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 a percent of remaining QIPP funds after accounting for the
funding of Component One and Component Four [70 percent
of remaining QIPP funds after accounting for the funding of Component
One and Component Four].
(i)For the program period September
1, 2019, through August 31, 2021, the percent will be equal to 70
percent.
(ii)For the program period beginning
September 1, 2021, the percent will be equal to 60 percent.
(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.
Cont'd...
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