Current through Reg. 49, No. 38; September 20, 2024
(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
RSA
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)
Capitation rate--A fixed, predetermined fee paid by HHSC to the managed care
organization each month, in accordance with the contract, for each enrolled
member. In exchange for this, the managed care organization arranges for or
provides a defined set of covered services to the enrolled member, regardless
of the amount of covered services used by the enrolled member.
(2) Centers for Medicare & Medicaid
Services (CMS)--The federal agency within the United States Department of
Health and Human Services responsible for overseeing and directing Medicare and
Medicaid.
(3) HHSC--The Texas
Health and Human Services Commission or its designee.
(4) Intergovernmental transfer (IGT)--A
transfer of public funds from another state agency or a non-state governmental
entity to HHSC.
(5) Managed care
organization (MCO)--A Medicaid managed care organization contracted with HHSC
to provide health care services to Medicaid recipients.
(6) Non-federal share--The portion of program
expenditures that is not federal funds. The non-federal share is equal to 100
percent minus the federal medical assistance percentage (FMAP) for Texas for
the state fiscal year corresponding to the program year and for the population
served.
(7) Non-state governmental
entity--A hospital authority, hospital district, health district, city, or
county.
(8) Program rate
component--The fixed percentage of the capitation rate that is attributable to
the delivery system or provider payment initiative.
(9) Provider--A credentialed and licensed
individual, facility, agency, institution, organization, or other entity that
has a contract with the MCO for the delivery of covered services to the MCO's
members.
(10) Public funds--Funds
derived from taxes, assessments, levies, and investments. Public funds also
include other public revenues within the sole and unrestricted control of a
governmental entity. Public funds do not include gifts, grants, trusts, or
donations, the use of which is conditioned on supplying a benefit solely to the
donor or grantor of the funds.
(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) CMS approval. Implementation
of each of the programs described in this subchapter is contingent upon HHSC
receiving written approval from CMS of the contract provisions directing the
MCO expenditures. Federal requirements for CMS approval of directed MCO
expenditures are codified in
RSA
438.6(c)(2).
(d) Program specifications, provider
eligibility, and payment calculations. Descriptions of program specifications,
provider eligibility, and payment calculations are contained in the sections of
this subchapter that describe each delivery system or provider payment
initiative program.
(e) Source of
the non-federal share. The non-federal share of expenditures under this
subchapter is limited to timely receipt by HHSC of public funds from sponsoring
governmental entities.
(1) State-owned
providers. A state-owned provider may transfer to HHSC any non-federal funds
within the control of the provider, including appropriated state general
revenue funds, as the non-federal share of program expenditures associated with
that provider.
(2) All other
providers. For all other providers, the non-federal share of program
expenditures is funded through IGTs. No state general revenue appropriated to
HHSC is available to support program expenditures to non-state providers under
this subchapter.
(f)
Amount and timing of transfer of the non-federal share. The amount of the
non-federal share that governmental entities transfer to HHSC for expenditures
under this subchapter and the timing of such transfers are specific to each
delivery system or provider payment initiative and are described in the section
of this subchapter governing each such program.
(g) Reconciliation of the non-federal share.
(1) Purpose. The amount of HHSC's
expenditures under this subchapter is dependent on member enrollment in each
participating MCO, which may fluctuate from month to month. HHSC's actual
expenditures cannot be determined until final member enrollment data is
available, which may not occur for up to two years following the end of the
program period. The purpose of the reconciliation process is to ensure that
HHSC's actual total expenditures for each program are determined based on
accurate and final member enrollment data for each program period, and that the
non-federal share of HHSC's actual expenditures are borne by the appropriate
governmental entity or entities.
(2) Methodology. For each program described
in this subchapter, HHSC reconciles the amount of the non-federal funds
actually expended during the program period with the amount of funds
transferred to HHSC by the sponsoring governmental entities. For programs with
multiple provider classes, HHSC reconciles expenditures for each provider
class. HHSC completes each reconciliation in multiple parts.
(A) The first reconciliation occurs no later
than 120 days after the end of the program period.
(i) Using the best-available member
enrollment data at the time of the first reconciliation, HHSC:
(I) calculates the amount expended for the
program period by multiplying the program rate component by the total member
months included in the program period;
(II) calculates the non-federal share of the
amount determined in subclause (I) of this clause; and
(III) compares the amount determined in
subclause (II) of this clause to the amount previously transferred to HHSC by
the participating governmental entities for the program period.
(ii) If the amount previously
transferred is less than 102 percent of the amount determined in clause (i)(II)
of this subparagraph:
(I) the participating
governmental entities must transfer additional funds to HHSC such that total
transferred funds equals 102 percent of the amount determined in clause (i)(II)
of this subparagraph;
(II) if more
than one governmental entity is responsible for the non-federal share of
payments under the program, the additional required funds are allocated
proportional to each governmental entity's initial contribution to funding the
program; and
(III) HHSC notifies
the governmental entities of the amount and timing of the required
transfers.
(iii) If the
amount previously transferred is more than 102 percent of the amount determined
in clause (i)(II) of this subparagraph, HHSC refunds the excess amount to the
governmental entities in proportion to each entity's initial contribution to
funding the program.
(B)
Interim reconciliations may occur as updated member enrollment data for the
program period becomes available. HHSC follows the process described in
subparagraph (A) of this paragraph for such interim reconciliations.
(C) The final reconciliation occurs no later
than 25 months after the end of the program period.
(i) Using the final member enrollment data
for the program period, HHSC:
(I) calculates
the amount expended for the program period by multiplying the program rate
component by the total member months included in the program period;
(II) calculates the non-federal share of the
amount determined in subclause (I) of this clause; and
(III) compares the amount determined in
subclause (II) of this clause to the amount previously transferred to HHSC by
the sponsoring governmental entities for the program period, including any
amounts transferred pursuant to subparagraphs (A)(ii) or (B) of this
paragraph.
(ii) If the
amount previously transferred is less than the non-federal share of the amount
expended:
(I) the participating governmental
entities must transfer additional funds to HHSC such that total transferred
funds equals the amount determined in clause (i)(II) of this
subparagraph;
(II) if more than one
governmental entity is responsible for the non-federal share of payments under
the program, the additional required funds are allocated proportional to each
governmental entity's initial contribution to funding the program;
and
(III) HHSC notifies the
governmental entities of the amount and timing of the required
transfers.
(iii) If the
amount previously transferred is more than the amount determined in clause
(i)(II) of this subparagraph, HHSC refunds the excess amount to the
governmental entities in proportion to each entity's initial contribution to
funding the program.
(h) Failure of a governmental entity to
transfer funds. If a governmental entity does not timely complete the transfer
of funds described in this section, HHSC withholds Medicaid payments from any
provider operated by the governmental entity until HHSC has recovered an amount
equal to the amount of the funding shortfall.
(i) Failure of an MCO to comply with contract
provisions. HHSC may review MCO payments to network providers or other
documentation to verify that the MCO is in compliance with contract provisions
directing expenditures for delivery system and provider payment initiatives.
HHSC must investigate provider claims of contract violations. In the event HHSC
identifies any contract deficiency or violation, HHSC takes corrective action
to remedy such deficiency or violation, as authorized by §
RSA
353.5 of this chapter (relating to Internet
Posting of Sanctions Imposed For Contractual Violations).
(j) Disallowance of federal funds. If
payments under this subchapter are disallowed by CMS , 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.
(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.