Texas Administrative Code
Title 1 - ADMINISTRATION
Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION
Chapter 353 - MEDICAID MANAGED CARE
Subchapter O - DELIVERY SYSTEM AND PROVIDER PAYMENT INITIATIVES
Section 353.1309 - Texas Incentives for Physicians and Professional Services
Universal Citation: 1 TX Admin Code ยง 353.1309
Current through Reg. 49, No. 38; September 20, 2024
(a) Introduction. This section establishes the Texas Incentives for Physicians and Professional Services (TIPPS) program. TIPPS is designed to incentivize physicians and certain medical professionals to improve quality, access, and innovation in the provision of medical 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 managed care quality strategy.
(b) Definitions. The following definitions apply when the terms are used in this section. Terms that are used in this section may be defined in § 353.1301 of this subchapter (relating to General Provisions) or § 353.1311 of this subchapter (relating to Quality Metrics for the Texas Incentives for Physicians and Professional Services Program).
(1) Health
Related Institution (HRI) physician group--A network physician group owned or
operated by an institution named in Texas Education Code §
63.002.
(2) Indirect Medical Education (IME)
physician group--A network physician group contracted with, owned, or operated
by a hospital receiving either a medical education add-on or a teaching medical
education add-on as described in §
355.8052 of this title (relating to
Inpatient Hospital Reimbursement) for which the hospital is assigned or retains
billing rights for the physician group.
(3) Intergovernmental Transfer (IGT)
Notification--Notice and directions regarding how and when IGTs should be made
in support of the program.
(4)
Network physician group--A physician group located in the state of Texas that
has a contract with a Managed Care Organization (MCO) for the delivery of
Medicaid-covered benefits to the MCO's enrollees.
(5) Network status--A provider's network
status with a contracted MCO, as determined by the national provider
identification (NPI) number and Plan Code combination.
(6) Other physician group--A network
physician group other than those specified under paragraphs (1) and (2) of this
subsection.
(7) Plan code--A unique
2-digit alphanumeric code established by HHSC denoting the individual managed
care organization, program, and service delivery area.
(8) Program period--A period of time for
which an eligible and enrolled physician group may receive the TIPPS amounts
described in this section. Each TIPPS program period is equal to a state fiscal
year beginning September 1 and ending August 31 of the following
year.
(9) Suggested IGT
responsibility--Notice of potential amounts that a governmental entity may wish
to consider transferring in support of the program.
(10) Total program value--The maximum amount
available under the TIPPS program for a program period, as determined by
HHSC.
(c) Eligibility for participation in TIPPS. A physician group is eligible to participate in TIPPS if it complies with the requirements described in this subsection.
(1) Physician group composition. A physician
group must indicate the eligible physicians, clinics, and other locations to be
considered for payment and quality measurement purposes in the application
process.
(2) Minimum volume. For
program periods beginning on or before September 1, 2023, but on or after
September 1, 2021, physician groups must have a minimum denominator volume of
30 Medicaid managed care patients in at least 50 percent of the quality metrics
in each component to be eligible to participate in the component. For program
periods beginning on or after September 1, 2024, no minimum denominator volume
is required.
(3) The physician
group is:
(A) an HRI physician
group;
(B) an IME physician group;
or
(C) any other physician group
that:
(i) can achieve the minimum volume
during program periods beginning on or before September 1, 2023, but on or
after September 1, 2021, as described in paragraph (2) of this
subsection;
(ii) is located in a
service delivery area with at least one sponsoring governmental entity;
and
(iii) for program periods
beginning on or before September 1, 2023, but on or after September 1, 2021,
served at least 250 unique Medicaid managed care clients in the prior state
fiscal year. For program periods beginning on or after September 1, 2024, no
minimum volume is required.
(d) Data sources for historical units of service and clients served. Historical units of service are used to determine a physician group's eligibility status and the estimated distribution of TIPPS funds across enrolled physician groups.
(1)
HHSC will use encounter data and will identify encounters based upon the
billing provider's NPI number and taxonomy code combination that are billed as
a professional encounter only.
(2)
HHSC will use the most recently available Medicaid encounter data for a
complete state fiscal year to determine the eligibility status of other
physician groups for program periods beginning on or before September 1, 2023,
but on or after September 1, 2021.
(3) HHSC will use the most recently available
Medicaid encounter data for a complete state fiscal year to determine
distribution of TIPPS funds across eligible and enrolled physician
groups.
(4) In the event of a
disaster, HHSC may use data from a different state fiscal year at HHSC's
discretion.
(5) The data used to
estimate eligibility and distribution of funds will align with the data used
for purposes of setting the capitated rates for managed care organizations for
the same period.
(6) HHSC will
calculate the estimated rate that an average commercial payor would have paid
for the same services using either data that HHSC obtains independently or data
that is collected from providers through the application process described in
subsection (c) of this section.
(7)
If HHSC is unable to compute an actuarially sound payment rate based on private
payor information described in paragraph (6) of this subsection for any
services, then those services will be removed from consideration from the TIPPS
program.
(8) All services billed
and delivered at a Federally Qualified Health Center, dental services, and
ambulance services are excluded from the scope of the TIPPS program.
(9) Encounter data used to calculate payments
for this program must be designated as paid status. Encounters reported as a
paid status, but with zero or negative dollars as a reported paid amount will
not be included in the data used to calculate payments for the TIPPS
program.
(10) If a provider with
the same Tax Identification Number as the payor is being paid more than 200
percent of the Medicaid reimbursement on average for the same services in a
one-year period, then a related-party-adjustment will be applied to the
encounter data for those encounters. This adjustment will apply a calculated
average payment rate from the rest of the provider pool to the related parties
paid units of service.
(e) Conditions of Participation. As a condition of participation, all physician groups participating in TIPPS must allow for the following.
(1) The physician
group must submit a properly completed enrollment application by the due date
determined by HHSC. The enrollment period will be no less than 21 calendar
days, and the final date of the enrollment period will be at least nine days
prior to the release of suggested IGT responsibilities.
(2) Enrollment is conducted annually, and
participants may not join the program after the enrollment period closes. Any
updates to enrollment information must be submitted prior to the publication of
the suggested IGT responsibilities under subsection (f)(1) of this section. For
each program period, a physician group must be located in a Service Delivery
Area (SDA) in which at least one sponsoring governmental entity that agrees to
transfer to HHSC some or all of the non-federal share under this section is
also located. An SDA is designated by HHSC for each provider, or physician
group with multiple locations, based on the SDA in which the majority of a
physician group's claims are billed. Services that are provided outside of a
designated SDA may be included in the designated SDA.
(3) Network status for providers for the
entire program period will be determined at the time of enrollment based on the
submission of documentation through the enrollment process that shows an MCO
has identified the provider as having a network agreement.
(4) The entity that bills on behalf of the
physician group must certify, on a form prescribed by HHSC, that no part of any
TIPPS payment will be used to pay a contingent fee nor may the entity's
agreement with the physician group use a reimbursement methodology that
contains any type of incentive, directly or indirectly, for inappropriately
inflating, in any way, claims billed to the Medicaid program, including the
physician group's receipt of TIPPS funds. The certification must be received by
HHSC with the enrollment application described in paragraph (1) of this
subsection.
(5) If a provider has
changed ownership in the past five years in a way that impacts eligibility for
the TIPPS program, the provider 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, the TIPPS program.
(6) Report all quality data denoted as
required as a condition of participation in §
353.1311(d)(1) of
this subchapter.
(7) Failure to
meet any conditions of participation described in this subsection will result
in the removal of the provider from the program and recoupment of all funds
previously paid during the program period.
(f) Non-federal share of TIPPS payments. The non-federal share of all TIPPS payments is funded through IGTs from sponsoring governmental entities. No state general revenue is available to support TIPPS.
(1) HHSC will communicate suggested IGT
responsibilities for the program period with all TIPPS eligible and enrolled
HRI physician groups and IME physician groups at least 10 calendar days prior
to the IGT declaration of intent deadline. Suggested IGT responsibilities will
be based on the maximum dollars available under the TIPPS program for the
program period as determined by HHSC, plus eight percent; forecasted member
months for the program period as determined by HHSC; and the distribution of
historical Medicaid utilization across HRI physician groups and IME physician
groups, plus estimated utilization for eligible and enrolled other physician
groups within the same service delivery area, for the program period. HHSC will
also communicate the estimated maximum revenues each eligible and enrolled
physician group could earn under TIPPS for the program period with those
estimates based on HHSC's suggested IGT responsibilities and an assumption that
all enrolled physician groups will meet 100 percent of their quality
metrics.
(2) Sponsoring
governmental entities will determine the amount of IGT they intend to transfer
to HHSC for the entire program period and provide a declaration of intent to
HHSC 21 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 intends to transfer to HHSC.
(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) HHSC will issue an IGT notification to
specify the date that IGT is requested to be transferred no fewer than 14
business days before IGT transfers are due. Sponsoring governmental entities
will transfer the first half of the IGT amount by a date determined by HHSC,
but no later than June 1. Sponsoring governmental entities will transfer the
second half of the IGT amount by a date determined by HHSC, but no later than
December 1. HHSC will publish the IGT deadlines and all associated dates on its
Internet website by March 15 of each year.
(4) Reconciliation. HHSC will reconcile the
amount of the non-federal funds actually expended under this section during
each program 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) TIPPS capitation rate components. TIPPS funds will be paid to Managed Care Organizations (MCOs) through three components of the managed care per member per month (PMPM) capitation rates. The MCOs' distribution of TIPPS funds to the enrolled physician groups will be based on each physician group's performance related to the quality metrics as described in § 353.1311 of this subchapter. The physician group must have provided at least one Medicaid service to a Medicaid client in each reporting period to be eligible for payments.
(1) Component One.
(A) For program periods beginning on or
before September 1, 2023, but on or after September 1, 2021, the total value of
Component One will be equal to 65 percent of the total program value.
(i) Allocation of funds across qualifying HRI
and IME physician groups will be proportional, based on historical Medicaid
clients served.
(ii) Monthly
payments to HRI and IME physician groups will be a uniform rate
increase.
(iii) Other physician
groups are not eligible for payments from Component One.
(iv) Providers must report quality data as
described in §
353.1311 of this subchapter as a
condition of participation in the program.
(v) HHSC will reconcile the interim
allocation of funds across qualifying HRI and IME physician groups to the
actual distribution of Medicaid clients served across these physician groups
during the program period, as captured by Medicaid MCOs contracted with HHSC
for managed care 120 days after the last day of the program period.
(vi) Redistribution resulting from the
reconciliation will be based on the actual utilization of enrolled
NPIs.
(vii) If a provider eligible
for TIPPS payments was not included in the monthly scorecards, the provider may
be included in the reconciliation by HHSC.
(B) For the program period beginning on
September 1, 2024, the total value of Component One will be equal to 90 percent
of the total program value.
(i) Allocation of
funds across qualifying HRI and IME physician groups will be proportional,
based upon historical Medicaid utilization.
(ii) Payments to physician groups will be a
uniform rate increase paid at the time of claim adjudication.
(iii) Other physician groups are not eligible
for payments from Component One.
(iv) Providers must report quality data as
described in §
353.1311 of this subchapter as a
condition of participation in the program.
(C) For program periods beginning on or after
September 1, 2025, the total value of component one will be equal to 55 percent
of the total program value.
(i) Allocation of
funds across qualifying HRI and IME physician groups will be proportional,
based upon historical Medicaid utilization.
(ii) Payments to physician groups will be a
uniform rate increase paid at the time of claim adjudication.
(iii) Other physician groups are not eligible
for payments from Component One.
(iv) Providers must report quality data as
described in §
353.1311 of this subchapter as a
condition of participation in the program.
(2) Component Two.
(A) For program periods beginning on or
before September 1, 2023, but on or after September 1, 2021, the total value of
Component Two will be equal to 25 percent of the total program value.
(i) Allocation of funds across qualifying HRI
and IME physician groups will be proportional, based upon historical Medicaid
utilization.
(ii) Payments to
physician groups will be a uniform rate increase.
(iii) Other physician groups are not eligible
for payments from Component Two.
(iv) Providers must report quality data as
described in §
353.1311 of this subchapter as a
condition of participation in the program.
(v) HHSC will reconcile the interim
allocation of funds across qualifying HRI and IME physician groups to the
actual distribution of Medicaid clients served across these physician groups
during the program period as captured by Medicaid MCOs contracted with HHSC for
managed care 120 days after the last day of the program period.
(vi) Redistribution resulting from the
reconciliation will be based on the actual utilization of enrolled
NPIs.
(vii) If a provider eligible
for TIPPS payments was not included in the monthly scorecards, the provider may
be included in the reconciliation by HHSC.
(B) For the program period beginning
September 1, 2024, Component Two will be equal to 0 percent of the
program.
(C) For program periods
beginning on or after September 1, 2025, the total value of Component Two will
be equal to 35 percent of the total program value.
(i) Allocation of funds across qualifying HRI
and IME physician groups will be proportional, based upon historical Medicaid
utilization.
(ii) Payments to
physician groups will be made through a pay-for-performance model based on
their achievement of quality measures and paid through a scorecard.
(iii) Other physician groups are not eligible
for payments from Component Two.
(3) Component Three.
(A) The total value of Component Three will
be equal to 10 percent of the total program value.
(B) Allocation of funds across physician
groups will be proportional, based upon actual Medicaid utilization of specific
procedure codes as identified in the final quality metrics or performance
requirements described in §
353.1311 of this
subchapter.
(C) Payments to
physician groups will be a uniform rate increase.
(D) Providers must report quality data as
described in §
353.1311 of this subchapter as a
condition of participation in the program.
(h) Distribution of TIPPS payments.
(1) Before the beginning of the program
period, HHSC will calculate the portion of each PMPM associated with each TIPPS
enrolled practice group broken down by TIPPS capitation rate component and
payment period. The model for scorecard payments and the reconciliation
calculations will be based on the enrolled NPIs and the MCO network status at
the time of the application under subsection (e)(1) of this section. For
example, for a physician group, HHSC will calculate the portion of each PMPM
associated with that group that would be paid from the MCO to the physician
group as follows.
(A) Payments from Component
One.
(i) For program periods beginning on or
before September 1, 2023, but on or after September 1, 2021, payments will be
monthly and will be equal to the total value of Component One for the physician
group divided by twelve.
(ii) For
program periods beginning on or after September 1, 2024, payments will be made
as a uniform percentage increase paid at the time of claim adjudication.
(B) Payments from
Component Two.
(i) For program periods
beginning on or before September 1, 2023, but on or after September 1, 2021,
payments will be semi-annual and will be equal to the total value of Component
Two for the physician group divided by 2.
(ii) For the program period beginning on
September 1, 2024, no payments will be made for Component Two.
(iii) For program periods beginning on or
after September 1, 2025, payment will be made on a scorecard basis at payments
based on the reporting of quality measures and paid through a scorecard at the
time of achievement.
(C)
Payments from Component Three will be equal to the total value of Component
Three attributed as a uniform rate increase based upon historical
utilization.
(2) MCOs
will distribute payments to enrolled physician groups as directed by HHSC.
Payments will be equal to the portion of the TIPPS PMPM associated with the
achievement for the time period in question multiplied by the number of member
months for which the MCO received the TIPPS PMPM.
(i) Changes in operation. If an enrolled physician group closes voluntarily or ceases to provide Medicaid services, the physician group must notify the HHSC Provider Finance Department by hand delivery, United States (U.S.) mail, or special mail delivery within 10 business days of closing or ceasing to provide Medicaid services. Notification is considered to have occurred when the HHSC Provider Finance Department receives the notice.
(j) Reconciliation. HHSC will reconcile the amount of the non-federal funds actually expended under this section during each program 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.
(k) Recoupment. Payments under this section may be subject to recoupment as described in § 353.1301(j) and § 353.1301(k) of this subchapter.
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