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 8 - DSRIP PROGRAM DEMONSTRATION YEARS 9-10
Section 354.1753 - Category C Requirements for Performers

(A) A hospital or physician practice, with the exception of those described in subparagraph (J) of this paragraph, must select Measure Bundles from the Hospital and Physician Practice Measure Bundle Menu of the Measure Bundle Protocol in accordance with the requirements in subparagraphs (B) - (I) of this paragraph in the RHP plan update for DY9-10 for its RHP.

(B) Each Measure Bundle is assigned a point value for DY9-10 as described in the Measure Bundle Protocol.

(C) A hospital or physician practice is assigned a minimum point threshold (MPT) for Measure Bundle selection as described in paragraphs (6) and (7) of this subsection.

(D) A hospital or physician practice must select Measure Bundles worth enough points to meet its MPT in order to maintain its total valuation for DY9 and DY10. If a hospital or physician practice does not select Measure Bundles worth enough points to meet its MPT, its total DY9 valuation will be reduced proportionately across its Categories B-D funds for DY9, and its total DY10 valuation will be reduced proportionately across its Categories B-D funds for DY10, based on the point values of the Measure Bundles it selects.

(E) A hospital or physician practice may request to delete a maximum of 20 points worth of its DY7-8 Measure Bundles and measures for DY9-10 with good cause. In this context, good cause is defined as:

(F) A hospital or physician practice may only select a Measure Bundle for which its denominators for the baseline measurement period for at least half of the required measures in the Measure Bundle have significant volume.

(G) A hospital or physician practice with a valuation greater than $2,500,000 per demonstration year (DY) for DY7-8 or with a valuation greater than $2,000,000 in DY10 must:

(H) A hospital or physician practice with an MPT of 75 must report at least two population-based clinical outcome measures as P4P as specified in the Measure Bundle Protocol.

(I) A hospital or physician practice may only select an optional measure in a selected Measure Bundle for which its denominator for the baseline measurement period has significant volume.

(J) If a hospital or physician practice has a limited scope of practice, cannot reasonably report on at least half of the required measures in the Measure Bundle(s) appropriate for it based on its scope of practice and community partnerships, and consequently cannot meet its MPT for Measure Bundle selection, the hospital or physician practice may request HHSC approval to select measures, rather than Measure Bundles, from the Measure Bundle Protocol. The hospital or physician practice must submit a request for such approval to HHSC prior to the RHP plan update for DY9-10 submission, by a date determined by HHSC. Such a request may be subject to review by the Centers for Medicare & Medicaid Services (CMS). If HHSC and CMS, as appropriate, approve such a request, the following requirements apply:

(A) If a Measure Bundle includes the innovative measure:

(B) If a hospital's or physician practice's denominator for a required measure or numerator for a population-based clinical outcome measure in a selected Measure Bundle for the baseline measurement period or a performance year has no volume, the measure is removed from the Measure Bundle, and its valuation for the applicable DY is redistributed among the remaining measures in the Measure Bundle for which the hospital's or physician practice's denominator for the baseline measurement period or performance year has significant volume for the applicable DY. The valuation for the applicable DY for each of the remaining measures is equal to the valuation for the Measure Bundle for the applicable DY divided by the number of measures for which the hospital's or physician practice's denominator for the baseline measurement period or performance year has significant volume, so that the valuations for the applicable DY for the measures in the Measure Bundle for which the hospital's or physician practice's denominator for the baseline measurement period or performance year has significant volume are equal.

(C) If a hospital's or physician practice's denominator for a required measure or numerator for a P4R population-based clinical outcome measure in a selected Measure Bundle for the baseline measurement period or a performance year has insignificant volume, the measure's milestone valuations are adjusted in accordance with subsection (e)(2) of this section.

(A) The MPT for hospitals, with the exception of those described in subparagraphs (B) and (C) of this paragraph, is calculated as follows:

(B) If a hospital does not have the data needed for the SHF calculation in paragraph (5)(A)(i) of this subsection, or if a hospital did not participate in DSRIP during the initial demonstration period or DY6, its MPT is the lesser of:

(C) The MPT for a hospital for DY9-10 must not be reduced by more than 10 points from the hospital's MPT for DY7-8.

(D) If a hospital has a limited scope of practice, cannot reasonably report on at least half of the required measures in the Measure Bundle(s) appropriate for it based on its scope of practice and community partnerships, and consequently cannot meet its MPT for Measure Bundle selection, the hospital may request HHSC approval for a reduced MPT equal to the sum of the points for all the Measure Bundles for which the hospital could reasonably report on at least half of the required measures in the Measure Bundle. The hospital must submit a request for such approval to HHSC prior to the RHP plan update submission, by a date determined by HHSC. Such a request may be subject to review by the Centers for Medicare & Medicaid Services (CMS). If HHSC and CMS, as appropriate, approve such a request, the hospital's total valuation for DY9 and DY10 may be reduced.

(A) The MPT for a physician practice for DY9-10, with the exception of a physician practice described in subparagraph (C) of this paragraph, is the lesser of:

(B) The MPT for a physician practice for DY9-10 must not be reduced by more than 10 points from the physician practice's MPT for DY7-8.

(C) If a physician practice has a limited scope of practice, cannot reasonably report on at least half of the required measures in the Measure Bundles appropriate for it based on its scope of practice and community partnerships, and consequently cannot meet its MPT for Measure Bundle selection, the physician practice may request HHSC approval for a reduced MPT equal to the sum of the points for all the Measure Bundles for which the physician practice could reasonably report on at least half of the required measures in the Measure Bundle. The physician practice must submit a request for such approval to HHSC prior to the RHP plan update submission, by a date determined by HHSC. Such a request may be subject to review by CMS. If HHSC and CMS, as appropriate, approve such a request, the physician practice's total valuation for DY9 and DY10 may be reduced.

(A) A CMHC must select measures from the Community Mental Health Center Measure Menu of the Measure Bundle Protocol.

(B) Each measure is assigned a point value as described in the Measure Bundle Protocol.

(C) A CMHC is assigned an MPT for measure selection as described in paragraph (3) of this subsection.

(D) A CMHC must select measures worth enough points to meet its MPT in order to maintain its total valuation for DY9 and DY10. If a CMHC does not select measures worth enough points to meet its MPT, its total DY9 valuation will be reduced proportionately across its Categories B-D funds for DY9, and its total DY10 valuation will be reduced proportionately across its Categories B-D funds for DY10, based on the point values of the measures it selects.

(E) A CMHC may request to delete a maximum of 20 points worth of its DY7-8 measures for DY9-10 with good cause. In this context, good cause is defined as:

(F) A CMHC may only select a measure for which its denominator for the baseline measurement period has significant volume.

(G) A CMHC must select at least two measures.

(H) A CMHC with a valuation greater than $2,500,000 per DY for DY7-8 and a valuation of more than $2,000,000 for DY10 must select at least one three-point measure.

(A) A CMHC's MPT is the lesser of:

(B) A CMHC's MPT for DY9-10 must not be reduced by more than 10 points from the CMHC's MPT for DY7-8.

(A) An LHD must select measures from the Local Health Department Measure Menu of the Measure Bundle Protocol, unless the LHD selected one of its DY6 Category 3 pay-for-performance (P4P) measures for DY7-8, in which case the LHD may select that measure for DY9-10.

(B) Each measure on the Local Health Department Measure Menu is assigned a point value as described in the Measure Bundle Protocol.

(C) Each LHD DY6 Category 3 P4P measure is assigned a point value as described in the Measure Bundle Protocol.

(D) An LHD is assigned an MPT for measure selection as described in paragraph (4) of this subsection.

(E) An LHD must select measures worth enough points to meet its MPT in order to maintain its total valuation for DY9 and DY10. If an LHD does not select measures worth enough points to meet its MPT, its total DY9 valuation will be reduced proportionately across its Categories B-D funds for DY9, and its total DY10 valuation will be reduced proportionately across its Categories B-D funds for DY10, based on the point values of the measures it selects.

(F) An LHD may request to delete a maximum of 20 points worth of its DY7-8 measures for DY9-10 with good cause. In this context, good cause is defined as:

(G) An LHD may only select a measure for which its denominator for the baseline measurement period has significant volume.

(H) An LHD must select at least two measures.

(I) An LHD with a valuation of more than $2,500,000 per DY for DY7-8 and a valuation of more than $2,000,000 for DY10 must select at least one three-point measure.

(A) An LHD's MPT is the lesser of:

(B) An LHD's MPT for DY9-10 must not be reduced by more than 10 points from the LHD's MPT for DY7-8.

(A) The baseline measurement period for a measure selected for DY7-10 is calendar year 2017 with the following exceptions:

(B) The baseline measurement period for a measure newly selected for DY9-10 is calendar year 2019 with the following exceptions:

(A) Performance Year (PY) 1 for a measure is calendar year 2018 unless otherwise specified in the Measure Bundle Protocol or one of its appendices;

(B) PY2 for a measure is calendar year 2019 unless otherwise specified in the Measure Bundle Protocol or one of its appendices;

(C) PY3 for a measure is calendar year 2020 unless otherwise specified in the Measure Bundle Protocol or one of its appendices; and

(D) PY4 for a measure is calendar year 2021 unless otherwise specified in the Measure Bundle Protocol or one of its appendices.

(A) Reporting Year (RY) 1 for a measure is DY7;

(B) RY2 for a measure is DY8;

(C) RY3 for a measure is DY9; and

(D) RY4 for a measure is DY10.

(A) the valuation for the DY9 goal achievement milestone is equal to 75 percent of the valuation for the Measure Bundle divided by the number of measures in the Measure Bundle for which the hospital's or physician practice's denominator has significant volume, so that the valuations for the DY9 goal achievement milestones for the measures in the Measure Bundle for which the hospital's or physician practice's denominator has significant volume are equal; and

(B) the valuation for the DY10 goal achievement milestone is equal to 75 percent of the valuation for the Measure Bundle divided by the number of measures in the Measure Bundle for which the hospital's or physician practice's denominator has significant volume, so that the valuations for the DY10 goal achievement milestones for the measures in the Measure Bundle for which the hospital's or physician practice's denominator has significant volume are equal.

(A) A measure with multiple parts has one baseline reporting milestone per DY, one PY reporting milestone per DY, and multiple goal achievement milestones per DY.

(B) The valuation for each measure part's goal achievement milestone is equal to the measure's total goal achievement milestone valuation divided by the number of measure parts so that the measure parts' goal achievement milestone valuations are equal.

(C) All measure parts' baseline reporting milestones must be reported during the same reporting period.

(D) All measure parts' PY reporting milestones must be reported during the same reporting period.

(E) Each measure part's goal achievement milestone will have its own goal. Therefore, the percent of goal achieved, as described in §354.1757 of this division (relating to Disbursement of Funds) will be determined for a measure part's goal achievement milestone independently of the percent of goal achieved for the other measure parts' goal achievement milestones.

(A) A performer must adhere to measure specifications and maintain a record of any variances approved by HHSC prior to reporting a baseline for a measure.

(B) HHSC's approval of a reported baseline for reporting purposes does not constitute approval for a performer to report a measure outside measure specifications. If at any point HHSC or the independent assessor finds that a performer is reporting a measure outside measure specifications, reporting milestone payment and goal achievement milestone payment may be withheld or recouped while the performer works to bring reporting into compliance with measure specifications.

(A) A hospital or physician practice must do the following to be eligible for payment of a measure's reporting milestones for each DY, with the exceptions described in subparagraphs (C) and (D) of this paragraph:

(B) A CMHC or LHD must do the following to be eligible for payment of a measure's reporting milestones for each DY, with the exceptions described in subparagraphs (C) and (D) of this paragraph:

(C) A performer that demonstrates good cause may request in the RHP plan update submission to be exempted from reporting its performance on a measure for the Medicaid-only payer type or the LIU-only payer type as specified in the Program Funding and Mechanics Protocol.

(D) A performer that demonstrates good cause may submit a RHP plan update modification request to HHSC to be exempted from reporting its performance on a measure for the Medicaid-only payer type or the LIU-only payer type as specified in the Program Funding and Mechanics Protocol.

(A) A performer that demonstrates good cause may request in the RHP plan update submission that payment for a P4P measure's goal achievement milestone be based on the performer's performance on the measure for the all-payer, Medicaid-only, or LIU-only payer type as specified in the Program Funding and Mechanics Protocol.

(B) A performer that demonstrates good cause may submit a RHP plan update modification request to HHSC to change the payer type on which payment for a P4P measure's goal achievement milestone is based as specified in the Program Funding and Mechanics Protocol.

(A) A performer may request to carry forward achievement of a measure's DY9 goal achievement milestone so that the DY9 goal achievement milestone may be achieved in PY3 or PY4, with the exception described in subparagraph (B) of this paragraph.

(B) If a measure newly selected for DY9-10 has a delayed baseline measurement period, a performer will carry forward achievement of its goal achievement milestone so that the DY9 goal achievement milestone may be achieved in PY4.

(C) The performer must report the carried forward achievement of a measure's goal achievement milestone during the first reporting period after the end of the milestone's carried forward measurement period.