Current through Reg. 49, No. 38; September 20, 2024
(a) Introduction. This section establishes
the Directed Payment Program for Behavioral Health Services (DPP BHS). DPP BHS
is designed to incentivize behavioral health providers to improve quality,
access, and innovation in the provision of medical and behavioral health
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 §
353.1322 of this subchapter
(relating to Quality Metrics for the Directed Payment Program for Behavioral
Health Services).
(1) Average Commercial
Reimbursement (ACR) gap--The difference between what an average commercial
payor is estimated to pay for the services and what Medicaid actually paid for
the same services.
(2) Certified
Community Behavioral Health Clinic (CCBHC)--A clinic certified by the state in
accordance with federal criteria and with the requirements of the Protecting
Access to Medicare Act of 2014 (PAMA).
(3) CCBHC cost-reporting gap--The difference
between what Medicaid pays for services and what the reimbursement would be
based on the CCBHC cost-reporting methodology.
(4) Community Mental Health Center (CMHC)--An
entity that is established under Texas Health and Safety Code §
534.0015 and
that:
(A) Provides outpatient services,
including specialized outpatient services for children, the elderly,
individuals with serious mental illness, and residents of its mental health
service area who have been discharged from inpatient treatment at a mental
health facility.
(B) Provides
24-hour-a-day emergency care services.
(C) Provides day treatment or other partial
hospitalization services, or psychosocial rehabilitation services.
(D) Provides screening for patients being
considered for admission to state mental health facilities to determine the
appropriateness of such admission.
(5) Intergovernmental transfer (IGT)
notification--Notice and directions regarding how and when IGTs should be made
in support of DPP BHS.
(6) Local
Behavioral Health Authority (LBHA)--An entity that is designated under Texas
Health and Safety Code §
533.0356.
(7) Program period--A period of time for
which the Texas Health and Human Services (HHSC) contracts with participating
managed care organizations (MCOs) to pay increased capitation rates for the
purpose of provider 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.
(8) Providers--For
program periods on or before August 31, 2022, an entity described in paragraph
(4) of this subsection. For program periods on or after September 1, 2022, an
entity described in paragraph (4) or (6) of this subsection.
(9) Suggested IGT responsibility--Notice of
potential amounts that a sponsoring governmental entity may wish to consider
transferring in support of DPP BHS.
(10) Total program value--The maximum amount
available under the Directed Payment Program for Behavioral Health Services for
a program period, as determined by HHSC.
(c) Classes of participating providers.
(1) HHSC may direct the MCOs to provide a
uniform percentage rate increase or a uniform dollar increase to all providers
within one or more of the following classes of providers with which the MCO
contracts for services:
(A) For program
periods beginning on or before September 1, 2023, providers that are certified
CCBHCs and providers that are not certified CCBHCs.
(B) For program periods beginning on or after
September 1, 2024, providers who are certified CCBHCs.
(2) If HHSC directs rate or dollar increases
to more than one class of providers within the service delivery area, the rate
or dollar increases directed by HHSC may vary between classes.
(d) Data sources for historical
units of service. Historical units of service are used to determine a
provider's eligibility status to receive the estimated distribution of program
funds across enrolled providers.
(1) HHSC will
use encounter data and will identify encounters based upon the billing
provider's national provider identification (NPI) number.
(2) The most recently available Medicaid
encounter data for a complete state fiscal year will be used to determine the
distribution of program funds across eligible and enrolled providers.
(3) In the event that the historical data are
not deemed appropriate for use by actuarial standards, HHSC may use data from a
different state fiscal year at the discretion of the HHSC actuaries.
(4) The data used to estimate the
distribution of funds will align to the extent possible with the data used for
purposes of setting the capitation rates for MCOs for the same
period.
(5) HHSC will calculate the
estimated rate that an average commercial payor or Medicare would have paid for
similar services or based on the CMS-approved CCBHC cost report rate
methodology using either data from Medicare cost reports or collected from
providers.
(6) Encounter data used
to calculate DPP BHS 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 DPP BHS payments.
(e) Conditions of Participation. As a
condition of participation, all providers participating in the program must
allow for the following.
(1) The provider must
submit a properly completed enrollment application by the due date determined
by HHSC. The enrollment period must 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 suggestion under subsection (j)(1) 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) The entity that bills on behalf of the
provider must certify, on a form prescribed by HHSC, that no part of any
payment made under the program will be used to pay a contingent fee and that
the entity's agreement with the provider 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 provider's receipt of program funds. The certification must be
received by HHSC with the enrollment application described in paragraph (1) of
this subsection.
(3) If a provider
contracts with another entity to provide DPP BHS-eligible services on behalf of
the provider, the provider must submit all claims to the MCO using an NPI
assigned to the provider as the billing provider's NPI.
(4) If a provider has changed ownership in
the past five years in a way that impacts eligibility for DPP BHS, 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, DPP BHS.
(5) Report all quality data denoted as
required as a condition of participation in subsection (h) of this
section.
(6) Failure to meet any
conditions of participation described in this section will result in removal of
the provider from the program and recoupment of all funds previously paid
during the program period.
(f) Determination of percentage of rate and
dollar increase.
(1) HHSC will determine the
percentage of rate or dollar increase applicable to providers by program
component.
(2) HHSC will consider
the following factors when determining the rate increase:
(A) the estimated Medicare gap for providers,
based upon the upper payment limit demonstration most recently submitted by
HHSC to the Centers for Medicare and Medicaid Services (CMS);
(B) the estimated Average Commercial
Reimbursement (ACR) gap for the class or individual providers, as indicated in
data collected from providers;
(C)
the estimated gap for providers, based on the CCBHC cost-reporting methodology
that is consistent with the CMS guidelines;
(D) the percentage of Medicaid costs incurred
by providers in providing care to Medicaid managed care clients that are
reimbursed by Medicaid MCOs prior to any rate increase administered under this
section; and
(E) the actuarial
soundness of the capitation payment needed to support the rate
increase.
(g)
Services subject to rate and dollar increase. HHSC may direct the MCOs to
increase rates or dollar amounts for all or a subset of provider
services.
(h) Program capitation
rate components. Program funds will be paid to MCOs through the managed care
per member per month (PMPM) capitation rates. The MCOs' distribution of program
funds to the enrolled providers will be based on each provider's performance
related to the quality metrics as described in §
353.1322 of this subchapter. The
provider must have provided at least one Medicaid service to a Medicaid managed
care client for each reporting period to be eligible for payments.
(1) Component One.
(A) The total value of Component One will be
equal to 65 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, Component One will be 100 percent of the total program
value.
(B) Allocation of funds
across all qualifying providers will be proportional, based upon historical
Medicaid utilization.
(C) Monthly
payments to providers will be a uniform rate increase.
(D) The interim allocation of funds across
qualifying providers will be reconciled to the actual Medicaid utilization
across these providers 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 DPP BHS 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 §
353.1322 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 35 percent of the total program value 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 0 percent of the
total program value.
(B) Allocation
of funds across all qualifying providers will be based upon historical Medicaid
utilization.
(C) Payments to
providers will be a uniform rate increase.
(D) Providers must report quality data as
described in §
353.1322 of this subchapter as a
condition of participation in the program.
(i) Distribution of the Directed Payment
Program for Behavioral Health Services payments.
(1) Prior to the beginning of the program
period, HHSC will calculate the portion of each payment associated with each
enrolled provider broken down by program 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
provider, HHSC will calculate the portion of each payment associated with that
provider that would be paid from the MCO to the provider as follows.
(A) Monthly payments in the form of a uniform
dollar increase for Component One will be equal to the total value of Component
One attributed based upon historical utilization of the provider divided by
twelve. An annual reconciliation will be performed for each provider based on
actual utilization.
(B) For program
periods beginning on or before September 1, 2023, rate increases from Component
Two will be a uniform percentage rate increase on applicable services
calculated based on the total value of Component Two for the providers divided
by historical utilization of the respective services.
(C) For purposes of the calculation described
in subparagraph (B) of this paragraph, a provider must achieve a minimum number
of measures as identified in §
353.1322 of this subchapter to be
eligible for full payment.
(2) MCOs will distribute payments to enrolled
providers based on criteria established under paragraph (1) of this subsection.
(j) Non-federal share of
DPP BHS payments. The non-federal share of all DPP BHS payments is funded
through IGTs from sponsoring governmental entities. No state general revenue
that is not otherwise available to providers is available to support DPP BHS.
(1) HHSC will communicate suggested IGT
responsibilities for the program period with all DPP BHS eligible and enrolled
providers 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 DPP BHS for the program period as determined by HHSC, plus 10
percent; forecasted member months for the program period as determined by HHSC;
and the distribution of historical Medicaid utilization across providers, for
the program period. HHSC will also communicate estimated maximum revenues each
eligible and enrolled provider could earn under DPP BHS for the program period
with those estimates based on HHSC's suggested IGT responsibilities and an
assumption that all enrolled providers 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. HHSC will instruct sponsoring
governmental entities as to the IGT amounts necessary to fund the program at
estimated levels. IGT amounts will include the non-federal share of all costs
associated with the provider rate increase, including costs associated with MCO
(Capitation) premium taxes, risk margin, and administration, plus 10
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 its Internet website by March 15 of each year.
(k) Effective date of rate and
dollar reimbursement increases. HHSC will direct MCOs to increase
reimbursements under this section beginning the first day of the program period
that includes the increased capitation rates paid by HHSC to each MCO pursuant
to the contract between them.
(l)
Changes in operation. If an enrolled provider closes voluntarily or ceases to
provide Medicaid services, the provider 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 special mail delivery within 10
business days of closing or ceasing to provide Medicaid services. Notification
is considered to have occurred when HHSC Provider Finance Department receives
the notice.
(m) 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.
(n) Recoupment.
Payments under this section may be subject to recoupment as described in
§353.1301(j) - (k) of this subchapter.
