Current through Reg. 49, No. 38; September 20, 2024
(a) Introduction. This section establishes
the Rural Access to Primary and Preventive Services (RAPPS) program. RAPPS is
designed to incentivize rural health clinics (RHCs) 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. Other terms used in this section
may be defined in §
353.1301 of this subchapter
(relating to General Provisions) or §
353.1317 of this subchapter
(relating to Quality Metrics for Rural Access to Primary and Preventive
Services Program).
(1) Freestanding rural
health clinic (RHC)--A network RHC that is not affiliated with a
hospital.
(2) Hospital-based RHC--A
network RHC that is affiliated with a hospital.
(3) Intergovernmental transfer (IGT)
notification--Notice and directions regarding how and when IGTs should be made
in support of RAPPS.
(4) Network
RHC--An RHC located in the state of Texas that has a contract with a managed
care organization (MCO) for the delivery of Medicaid-covered services to the
MCO's enrollees.
(5) Program
period--A period of time for which the Texas Health and Human Services
Commission (HHSC) contracts with MCOs to pay increased capitation rates for the
purpose of making RHC payments under this section. Each program period is equal
to a state fiscal year beginning September 1 and ending August 31 of the
following year.
(6) Rural health
clinic (RHC)--Has the meaning assigned by
42 U.S.C. §
1396d(l)(1).
(7) Suggested IGT responsibility--Notice of
potential amounts that a sponsoring governmental entity may wish to consider
transferring in support of RAPPS.
(8) Total program value--The maximum amount
available under the RAPPS program for a program period, as determined by
HHSC.
(c) Classes of
RHCs.
(1) HHSC may direct an MCO to provide an
increased payment or percentage rate increase for certain services to all
RAPPS-enrolled RHCs in one or more of the following classes of RHCs with which
the MCO contracts for Medicaid services:
(A)
hospital-based RHCs; and
(B)
freestanding RHCs.
(2) If
HHSC directs rate increases or payments to more than one RHC class in the
service delivery area (SDA), the rate increases or payments may vary by RHC
class. HHSC will consider the following factors in identifying the amount of
the rate increase or payment for each class:
(A) the RHC class's contribution to the goals
and objectives in the HHSC managed care quality strategy, as required in
42 C.F.R. §
438.340, relative to other classes;
(B) the class or classes of RHC the
sponsoring governmental entity wishes to support through IGTs of public funds,
as indicated on the application described in subsection (f) of this section;
and
(C) the actuarial soundness of
the capitation payment needed to support the rate increase or
payment.
(d)
Eligibility. An RHC is eligible to participate in RAPPS if it meets the
requirements described in this subsection.
(1)
Location. The RHC must be located in an SDA with at least one sponsoring
governmental entity.
(2) Minimum
number of Medicaid managed care encounters. The RHC must have provided at least
30 Medicaid managed care encounters in the prior state fiscal year.
(e) Data sources for historical
units of service and clients served. Historical units of service are used to
determine an RHC's eligibility status and the estimated distribution of RAPPS
funds across enrolled RHCs.
(1) HHSC will use
encounter data and will identify encounters based on the billing provider's
national provider identification (NPI) number and provider type code.
(2) HHSC will use the most recently available
Medicaid encounter data for a complete state fiscal year to determine the
eligibility status of an RHC.
(3)
HHSC will use the most recently available Medicaid encounter data for a
complete state fiscal year to determine the distribution of RAPPS funds across
enrolled RHCs.
(4) In the event
that the historical data are not deemed appropriate for use by actuarial
standards, HHSC may utilize 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 capitation rates for MCOs for the same
period.
(6) To determine total
program value, HHSC will calculate the estimated rate that Medicare would have
paid for the same services using either each RHC's state fiscal year 2019
federal cost report or its last submitted cost report. For RHCs where a filed
cost report was not found, the RHC's Medicare payments will be estimated using
the SDA weighted average ratio of Medicare encounter-based reimbursements
divided by MCO reimbursement data.
(7) Encounter data used to calculate RAPPS
payments must be designated as paid status with a reported paid amount greater
than zero. Encounters reported as paid status but with a reported paid amount
of zero or negative dollars will be excluded from the data used to calculate
RAPPS payments.
(8) 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 party's
paid units of service.
(f) Conditions of Participation. As a
condition of participation, all RHCs participating in RAPPS, as well as any
entities billing on their behalf, must meet the following requirements.
(1) The RHC 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 calendar days prior to the release of
suggested IGT responsibilities.
(A) 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 IGT notification under subsection
(g)(3) of this section.
(B) 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.
(2) An
entity that bills on behalf of the RHC must certify, on a form prescribed by
HHSC, that no part of any RAPPS payment will be used to pay a contingent fee
and that the entity's agreement with the RHC does not 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 RHC's receipt of RAPPS funds. The certification must be received
by HHSC with the enrollment application described in paragraph (1) of this
subsection.
(3) If an RHC has
changed ownership in the past five years in a way that impacts eligibility for
RAPPS, the RHC 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 RHC and which reference the administration of, or payments from,
RAPPS.
(4) Report all quality data
denoted as required as a condition of participation in subsection (h) of this
section.
(5) Failure to meet any
conditions of participation described in this subsection will result in removal
of the provider from the program and recoupment of all funds previously paid
during the program period.
(g) Non-federal share of RAPPS payments. The
non-federal share of all RAPPS payments is funded with IGTs from sponsoring
governmental entities. No state general revenue is available to support RAPPS.
(1) HHSC will communicate the following
information for the program period to all RAPPS-enrolled hospital-based RHCs
and sponsoring governmental entities at least 10 calendar days prior to the IGT
declaration of intent deadline:
(A) suggested
IGT responsibilities for the program period, which will be based on:
(i) the maximum funding amount available
under RAPPS for the program period as determined by HHSC, plus ten
percent;
(ii) forecasted member
months for the program period as determined by HHSC; and
(iii) the distribution of historical Medicaid
utilization across RHCs, plus the estimated utilization for enrolled RHCs
within the same SDA, for the program period; and
(B) the estimated maximum revenues each
enrolled RHC could earn under RAPPS for the program period will be based on
HHSC's suggested IGT responsibilities and the assumption that all enrolled RHCs
will meet 100 percent of their quality metrics.
(2) The estimated maximum revenues each
enrolled RHC could earn under RAPPS for the program period, which will be based
on HHSC's suggested IGT responsibilities and the assumption that all enrolled
RHCs will meet 100 percent of their quality metrics.
(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. The IGT notification will instruct
sponsoring governmental entities as to the required IGT amounts. Required IGT
amounts will include all costs associated with RHC payments and rate increases,
including costs associated with MCO premium taxes, risk margin, and
administration, plus ten percent.
(4) 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 the HHSC
website by March 15 of each year.
(h) RAPPS capitation rate components. RAPPS
funds will be paid to MCOs through the managed care per member per month (PMPM)
capitation rates. The MCOs' distribution of RAPPS funds to the enrolled RHCs
will be based on each RHC's performance related to the quality metrics as
described in §
353.1317 of this subchapter. The
RHC must have provided at least one Medicaid service to a Medicaid client for
each reporting period to be eligible for payments.
(1) Component One.
(A) The total value of Component One will be
equal to 75 percent of total program value for program periods beginning on or
before September 1, 2023. For program periods beginning on or after September
1, 2024, Component One will be 100 percent of the total program
value.
(B) Allocation of funds
across qualifying RHCs will be based on historical Medicaid utilization and RHC
class.
(C) Monthly payments to RHCs
will be paid prospectively.
(D)
HHSC will reconcile the interim allocation of funds across RAPPS-enrolled RHCs
to the actual Medicaid utilization across these RHCs 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.
(i)
Redistribution resulting from the reconciliation will be based on actual
utilization of enrolled NPIs.
(ii)
If a provider eligible for RAPPS payments was not included in the monthly
scorecards, the provider may be included in the reconciliation by HHSC.
(E) Providers must
report quality data as described in §
353.1317 of this subchapter as a
condition of participation in the program.
(2) Component Two.
(A) The total value of Component Two will be
equal to 25 percent of the total program value for program periods beginning on
or before September 1, 2023. For program periods beginning on or after
September 1, 2024, the total value of Component Two will be equal to zero
percent of the total program value.
(B) Allocation of funds across qualifying
RHCs will be based upon actual Medicaid utilization of specific procedure codes
as identified in the final quality metrics and performance requirements
described in §
353.1317 of this
subchapter.
(C) A percent increase
on all applicable services will begin when an RHC demonstrates achievement of
performance requirements as described in §
353.1317 of this subchapter during
the reporting period.
(D) Providers
must report quality data as described in §
353.1317 of this subchapter as a
condition of participation in the program.
(i) Distribution of RAPPS payments.
(1) Prior to the beginning of the program
period, HHSC will calculate the portion of each monthly prospective payment
associated with each RAPPS-enrolled RHC broken down by RAPPS capitation rate
component and payment period. The model for scorecard payments and the
reconciliation calculations will be based on the enrolled NPIs at the time of
the application under subsection (f)(1) of this section. For example, for an
RHC, HHSC will calculate the portion of each monthly prospective payment
associated with that RHC that would be paid from the MCO to the RHC as follows.
(A) Monthly payments from Component One will
be equal to the total value of Component One for the RHC divided by
twelve.
(B) For program periods
beginning on or before September 1, 2023, payments from Component Two will be
equal to the total value of Component Two attributed as a rate increase for
specific services based upon historical utilization.
(C) For purposes of the calculation described
in subparagraph (B) of this paragraph, an RHC must achieve quality metrics to
be eligible for full payment as determined by performance requirements
described in §
353.1317(d) of
this subchapter.
(2) An
MCO will distribute payments to an enrolled RHC based on criteria established
under this subsection.
(j) Changes in operation. If a RAPPS-enrolled
RHC closes voluntarily or ceases to provide Medicaid services, the RHC must
notify the HHSC Provider Finance Department by electronic mail to an address
designated by HHSC, by hand delivery, United States (U.S.) mail, or by 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.
(k) 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.
(l) Recoupment.
Payments under this section may be subject to recoupment as described in §
353.1301(j) and
§
353.1301(k) of
this subchapter.
