Texas Administrative Code
Title 1 - ADMINISTRATION
Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION
Chapter 354 - MEDICAID HEALTH SERVICES
Subchapter D - TEXAS HEALTHCARE TRANSFORMATION AND QUALITY IMPROVEMENT PROGRAM
Division 6 - HOSPITAL SERVICES
Section 354.1667 - Requirements for Continuing DSRIP Projects

Universal Citation: 1 TX Admin Code § 354.1667

Current through Reg. 49, No. 52; December 27, 2024

(a) A performer's total value for demonstration year (DY) 6A is equal to the performer's total value for DY5 with the following exceptions:

(1) HHSC notifies a performer that a DSRIP project's value may be reduced if the DSRIP project fails to complete DSRIP project or metric goals by the end of DY5.

(2) Performers with a total value less than $250,000 for DY5 may increase their total value to up to $250,000 per each subsequent DY beginning in DY6A. The increase in value is contingent on funds availability as described in §354.1673 of this division (relating to Remaining DSRIP Funds). Categories 1-4 will each be increased proportionately. However, any funds in excess of the 10 percent maximum for Category 4 will be allocated to Category 3. A performer may need to increase a DSRIP project's MLIU QPI goal for DY6A and beyond in order to obtain the increased value. Performers eligible for this option must make this choice by a date to be determined by HHSC.

(b) The DY5 IGT process, payment calculations, and monitoring IGT are continued in the extension period. IGT entities from DY5 will continue to provide funding for the extension period unless a performer submits changes during the reporting period. No new certifications (RHP Plan Section VI) are required for continuing RHP participants.

(c) If a performer participated in Category 4 in DY5, the performer will continue to participate in Category 4 in DY6A. The performer's Category 4 value for DY6A will be equal to the performer's Category 4 value for DY5, unless the performer's DY5 Category 4 value is greater than 10 percent of the performer's total DY5 value. In such a situation, the performer's DY6A Category 4 value will be reduced to 10 percent of the performer's total DY5 value, and the funds above the 10 percent threshold will be allocated to Category 3 in DY6A.

(d) The following Category 1 and 2 requirements must be met in DY6A:

(1) Each DSRIP project must have the following four milestones:
(A) a total Quantifiable Patient Impact (QPI) milestone valued at 25 percent of each DSRIP project's Category 1 or 2 value;

(B) a Medicaid and Low-income or Uninsured (MLIU) QPI milestone valued at 25 percent of each DSRIP project's Category 1 or 2 value;

(C) a core component reporting milestone valued at 25 percent of each DSRIP project's Category 1 or 2 value; and

(D) a sustainability planning milestone valued at 25 percent of each DSRIP project's Category 1 or 2 value.

(2) Total Quantitative Patient Impact (QPI) Milestone.
(A) HHSC will convert each total QPI metric to a total QPI milestone with standardized language. However, if a DSRIP project has multiple QPI metrics in DY5, that project may be exempted from this conversion, based on criteria determined by HHSC and CMS.

(B) The total QPI goal is equal to the DY5 total QPI goal.
(i) Certain DSRIP projects are eligible for an adjustment to the total QPI goal. These DSRIP projects include projects for which the provider reported 66 percent achievement or less of their DY4 total QPI metric as of April DY5 reporting, and for which:
(I) the value per MLIU individual is less than or equal to $1,000; or

(II) the value per MLIU encounter is less than or equal to $500.

(ii) Performers of a DSRIP project described in clause (i) of this subparagraph may, by a date determined by HHSC in a form determined by HHSC, request an adjustment to the DSRIP project's total QPI goal.

(C) DSRIP projects must retain the same QPI grouping from the initial demonstration period for total QPI.

(D) DSRIP projects must retain the same pre-DSRIP baseline for total QPI from the initial demonstration period. If multiple metrics are combined to form one total QPI milestone, the pre-DSRIP baselines will also be combined.

(E) DSRIP projects may carry forward total QPI milestones from DY6A to DY6B and DY7.

(3) MLIU QPI Milestone.
(A) Beginning in DY6A, there is an MLIU QPI milestone.

(B) For DSRIP projects that have an MLIU QPI requirement in DY5:
(i) The MLIU QPI goal is equal to the DY5 MLIU QPI goal. If, based on a determination pursuant to paragraph (2)(B) of this subsection, the total QPI goal is changed, the MLIU QPI goal will also be changed in proportion to the total QPI goal.

(ii) If the DSRIP project has an MLIU QPI metric in DY5, it retains the same pre-DSRIP baseline for MLIU QPI used in the initial demonstration period.

(iii) If the DSRIP project does not have an MLIU QPI metric in DY5, the pre-DSRIP baseline for MLIU QPI is equal to the pre-DSRIP baseline for total QPI multiplied by the earliest MLIU percentage goal on record with HHSC.

(iv) The MLIU QPI milestone must be pay-for-performance (P4P).

(C) For DSRIP projects that do not have an MLIU QPI requirement in DY5:
(i) The MLIU QPI goal is equal to the DY5 MLIU percentage goal multiplied by the DY5 total QPI goal, or as indicated in the DY5 goal language. If, based on a determination pursuant to paragraph (2)(B) of this subsection, the total QPI goal is changed, the MLIU QPI goal will also be changed in proportion to the total QPI goal.

(ii) The pre-DSRIP baseline for MLIU QPI is equal to the pre-DSRIP baseline for total QPI multiplied by the earliest MLIU percentage goal on record with HHSC.

(iii) Although all DSRIP projects must include an MLIU QPI goal, DSRIP projects under this subparagraph, with the exception of projects subject to clause (iv) of this subparagraph, must include an MLIU QPI milestone that is pay-for-reporting (P4R). This means that the performer is eligible to receive payment for the project's MLIU QPI milestone by reporting their actual MLIU QPI achievement, regardless of whether the performer achieved the MLIU QPI goal.

(iv) HHSC may determine that some of these DSRIP projects must include an MLIU QPI milestone that is P4P, meaning that the performer must demonstrate achievement of the project's MLIU QPI goal in order to receive payment for the MLIU QPI milestone.
(I) These DSRIP projects include the following:
(-a-) all Project Area 1.9 DSRIP projects, as described by the RHP Planning Protocol;

(-b-) DSRIP projects that did not achieve the estimated MLIU percentage in DY3, DY4, or DY5, and that caused them to have a higher than expected value per MLIU individual/encounter;

(-c-) DSRIP projects for which HHSC notified the performer that the project was eligible to continue with changes, but the project's MLIU QPI milestone must be P4P; and

(-d-) DSRIP projects that included an MLIU goal in their QPI metric Baseline/Goal statement (an embedded goal) of the performer's own choosing or that were required to include MLIU to receive CMS initial DSRIP project approval.

(II) A performer of a DSRIP project with an MLIU QPI milestone that is P4P under this section may request to adjust the pre-DSRIP baseline for MLIU QPI by a date determined by HHSC in a form determined by HHSC. HHSC will consider requests to adjust the pre-DSRIP baseline for MLIU QPI and may approve those requests with a strong justification.

(D) Certain DSRIP projects are eligible for an adjustment to the MLIU QPI goal. These DSRIP projects include:
(i) a DSRIP project that HHSC identifies as underperforming on MLIU QPI estimates in the initial demonstration period;

(ii) a DSRIP project that is reporting on individuals or encounters that meet the MLIU definition for the initial demonstration period, but will not meet the MLIU definition for the extension period; and

(iii) any other DSRIP project that HHSC determines has a strong justification for an adjustment.

(E) Performers of a DSRIP project described in subparagraph (D) of this paragraph may, by a date to be determined by HHSC, request an adjustment to the DSRIP project's MLIU QPI goal.

(F) DSRIP projects must retain the same total QPI grouping from the initial demonstration period for MLIU QPI.

(G) DSRIP projects may carry forward MLIU QPI milestones from DY6A to DY6B and DY7.

(H) If a DSRIP project's DY6A MLIU QPI milestone is P4R, the performer is eligible to report on, and receive payment for, the DY6A MLIU QPI milestone once the performer has done the following:
(i) achieved or forfeited a DSRIP project's DY5 QPI metric; and

(ii) provided at least one encounter or served at least one individual toward the DSRIP project's DY6A MLIU QPI milestone goal.

(I) If a DSRIP project's DY6A MLIU QPI milestone is P4P, and the project does not have a DY5 MLIU-specific QPI metric, the performer is eligible to report on, and receive payment for, the DY6A MLIU QPI milestone once the performer has done the following:
(i) achieved or forfeited a DSRIP project's DY5 QPI metric; and

(ii) achieved the DSRIP project's DY6A MLIU QPI milestone goal.

(J) If a DSRIP project's DY6A MLIU QPI milestone is P4P, and the project has a DY5 MLIU-specific QPI metric, the performer is eligible to report on, and receive payment for, the DY6A MLIU QPI milestone once the performer has done the following:
(i) achieved or forfeited the DSRIP project's DY5 MLIU-specific QPI metric; and

(ii) achieved the DSRIP project's DY6A MLIU QPI milestone goal.

(K) A performer may only begin to count individuals served or encounters provided toward a DSRIP project's DY6A MLIU QPI milestone goal after the performer has achieved or forfeited a DY5 QPI metric or a DY5 MLIU-specific QPI metric.

(L) A performer is only eligible to report on, and receive payment for, a DSRIP project's DY6A MLIU QPI milestone during DY6A or the DY6A carry forward period.

(4) Non-QPI Milestones.
(A) DSRIP projects must include the following non-QPI milestones:
(i) project summary and core components, which may include continuous quality improvement (CQI); and

(ii) sustainability planning, which may include activities toward furthering the exchange of health information, integration into managed care, collaboration with other community partners, or a project level-evaluation.

(B) Performers must attend at least one learning collaborative, stakeholder forum, or other stakeholder meeting during DY6A and report on their activities for these milestones in order to be eligible for milestone payment.

(C) DSRIP projects may report on DY6A non-QPI milestones only during the second reporting period of DY6A.

(D) DSRIP projects may not carry forward non-QPI milestones from DY6A to DY6B or DY7.

(e) The following Category 3 requirements must be met in DY6A:

(1) The Category 3 outcome values are equal to the Category 3 outcome values for DY5. However, if a performer's Category 4 value is greater than 10 percent of the performer's total value, the Category 4 funds in excess of the 10 percent will be redistributed to the performer's Category 3 outcomes proportionately.

(2) If a Category 3 outcome has multiple parts, the Category 3 outcome's value is equally divided among the parts.

(3) Each Category 3 outcome is designated as pay-for-performance (P4P), pay-for-reporting (P4R), or maintenance. The direction of an outcome (positive or negative) necessary to demonstrate improvement is described in the Category 3 Compendium. An outcome designated as maintenance was high performing at baseline with no reasonable room for improvement and was approved to use a milestone structure for DYs 3-5 that includes an alternate improvement activity.

(4) If a Category 3 outcome is designated as pay-for-performance (P4P) in DY5, 100 percent of the Category 3 outcome's value is P4P.

(5) If a Category 3 outcome is designated as pay-for-reporting (P4R) or maintenance with a population focused priority measure (PFPM) in DY5, 100 percent of the Category 3 outcome's value is P4P of the PFPM.

(6) If a Category 3 outcome is designated as P4R with an associated stretch activity in DY5, the performer must choose one of the following options by a date determined by HHSC in a form determined by HHSC:
(A) Maintain the Category 3 outcome designated as P4R from DY5 and select a new stretch activity that does not duplicate the DY5 stretch activity.
(i) The performer must select a new stretch activity from the following:
(I) program evaluation (alternate approaches to program and outcome linkages);

(II) new participation in health information exchange (HIE) or improvement of existing HIE infrastructure; or

(III) cost analysis and value-based purchasing planning.

(ii) Under this option, 50 percent of the Category 3 outcome's value is P4R of the Category 3 outcome and 50 percent is for completion of the stretch activity.

(B) Select a PFPM. Under this option, 100 percent of the Category 3 outcome's value is P4P of the selected PFPM.

(7) If a Category 3 outcome is designated as maintenance with an associated stretch activity in DY5, 100 percent of the Category 3 outcome's value is for statistically significant maintenance of the baseline.

(8) If a Category 3 outcome is designated as P4P in DY5, performance year (PY) 3 is the 12-month period immediately following the PY2 approved for use in DYs 3-5, or a performer may request, by a date to be determined by HHSC, to use DY6A as PY3. PY4 is the 12-month period immediately following PY3.

(9) If a Category 3 outcome is designated as P4R in DY5, PY3 is the 12-month period immediately following the PY2 approved for use in DYs 3-5.

(10) If a Category 3 outcome is designated as P4P in DY5, the outcome's goal is set as an improvement over the baseline from DYs 3-5 to be achieved in PY3, or PY4 if not fully achieved in PY3.
(A) One of the following methodologies is used to set the outcome's goal, as described in the RHP Planning Protocol:
(i) Quality Improvement System for Managed Care (QISMC);

(ii) Improvement over self (IOS); or

(iii) IOS - Survey.

(B) If an outcome is designated as QISMC in DY5, the outcome's PY3 goal is calculated as follows, using the baseline, minimum performance level (MPL), and high performance level (HPL) that were used for goal setting in DYs 3-5:

Attached Graphic

(C) If an outcome is designated as IOS in DY5, the outcome's PY3 goal is a 12.5 percent gap closure towards perfect over the baseline.

(D) If an outcome is a P4P survey-based outcome in outcome domain 10 or 11 as defined in the RHP Planning Protocol, and is designated as IOS-survey in DY5, the outcome's PY3 goal is calculated as follows, using the reporting scenario approved for goal setting in DY5:

Attached Graphic

(E) If an outcome has an HHSC approved alternate achievement request in DY5, the performer must submit to HHSC, by a date determined by HHSC in a form determined by HHSC, a request to use a PY3 goal that is a continuation of the goals approved in DYs 4-5. Such requests will be approved by HHSC on a case-by-case basis.

(F) If an outcome is designated as QISMC in DY5, with a baseline that is below the MPL, and the performer is measuring a population substantially dissimilar from the population used to establish the MPL benchmark, the performer may submit, by a date determined by HHSC in a form determined by HHSC, an alternate achievement request to set the PY3 goal as a 12.5 percent gap closure towards perfect over the baseline.

(11) Partial payment for a Category 3 P4P outcome is available in quartiles as defined in the RHP Planning Protocol, measured between the outcome's PY1 goal and PY3 goal.
(A) Each Category 3 P4P outcome has an associated achievement milestone that is assigned an achievement value based on the performer's achievement of the outcome's goal as follows:
(i) if 100 percent of the goal is achieved, the achievement milestone is assigned an achievement value of 1.0;

(ii) if at least 75 percent of the goal is achieved, the achievement milestone is assigned an achievement value of 0.75;

(iii) if at least 50 percent of the goal is achieved, the achievement milestone is assigned an achievement value of 0.5;

(iv) if at least 25 percent of the goal is achieved, the achievement milestone is assigned an achievement value of 0.25; or

(v) if less than 25 percent of the goal is achieved, the achievement milestone is assigned an achievement value of 0.

(B) The percent of the goal achieved is determined as follows:

Attached Graphic

(i) If an outcome is approved to use a baseline established in DY4, partial payment will be measured over a PY1 equivalent goal. The PY1 equivalent goal will follow the QISMC or IOS goal calculations for PY1 as approved in the RHP Planning Protocol.

(ii) If a QISMC outcome has a PY3 goal that was determined using the improvement floor, partial payment will be measured over the PY1 equivalent goal. If a higher rate indicates improvement for the outcome, the PY1 equivalent goal is the baseline plus 40 percent of the improvement floor. If a lower rate indicates improvement for the outcome, the PY1 equivalent goal is the baseline minus 40 percent of the improvement floor.

(iii) If an IOS - Survey outcome is approved to use goal setting Scenario 2 or Scenario 3, partial payment will be measured over a PY1 equivalent goal. The PY1 equivalent goal fill follow the IOS goal calculations for PY1 as approved in the RHP Planning Protocol.

(12) Performers may carry forward Category 3 milestones from DY6A to DY6B and DY7.

(f) The following Category 4 requirements must be met in DY6A:

(1) Requirements for Category 4 are the same as the requirements for Category 4 Reporting Domains (RDs) 1-5 in DY5.

(2) If a performer's Category 4 value is greater than 10 percent of the performer's total value, the funds in excess of the 10 percent will be redistributed to Category 3.

(3) The optional RD6 will be removed as it was required to value Category 4 at the 15 percent maximum in DYs 3-5.

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