Current through Reg. 49, No. 38; September 20, 2024
(a) Category A and
DSRIP payments. If a performer fails to fulfill all of the Category A
requirements described in §354.1749 of this division (relating to Category
A Requirements for Performers) for a demonstration year (DY), any DSRIP
payments the performer received for the DY will be recouped, and prospective
DSRIP payments to the performer will be withheld.
(1) DSRIP payments for DY9 include payments
for DY9 Category B, Category C, or Category D milestones.
(2) DSRIP payments for DY10 include payments
for DY10 Category B, Category C, or Category D milestones.
(b) Basis for payment of Category B. A
performer's payment for its MLIU PPP milestone for a DY is calculated as
follows.
(1) If the performer's MLIU PPP goal
achievement is greater than or equal to 100 percent minus its allowable MLIU
PPP goal variation, the performer's MLIU PPP milestone payment is equal to 100
percent of its MLIU PPP milestone valuation.
(2) If the performer's MLIU PPP goal
achievement is greater than or equal to 90 percent, and less than 100 percent
minus its allowable MLIU PPP goal variation, the performer's MLIU PPP milestone
payment is equal to 90 percent of its MLIU PPP milestone valuation.
(3) If the performer's MLIU PPP goal
achievement is greater than or equal to 75 percent, and less than 90 percent,
the performer's MLIU PPP milestone payment is equal to 75 percent of its MLIU
PPP milestone valuation.
(4) If the
performer's MLIU PPP goal achievement is greater than or equal to 50 percent,
and less than 75 percent, the performer's MLIU PPP milestone payment is equal
to 50 percent of its MLIU PPP milestone valuation.
(5) If the performer's MLIU PPP goal
achievement is less than 50 percent, the performer does not receive a MLIU PPP
milestone payment.
(c)
Basis for payment of Category C.
(1) Reporting
milestones. A performer must fully achieve a reporting milestone to be eligible
for payment related to the milestone.
(2) P4P measure goal achievement milestones.
A P4P measure has a goal achievement milestone for each DY. With the exception
of P4P measure goal achievement milestones described in subparagraph (B) of
this paragraph, partial payment for P4P measure goal achievement milestones is
available in quartiles for partial achievement measured over baseline in
Performance Year (PY) 1, PY2, PY3, and PY4.
(A) To calculate the payment for a P4P
measure goal achievement milestone, multiply the milestone valuation by the
achievement value calculated in clause (ii) of this subparagraph.
(i) The percent of the milestone's goal
achieved by the performer is determined as follows.
(I) Measures with a positive directionality
where higher scores indicate improvement:
(-a-) DY7 achievement = (PY1 Achieved -
Baseline/ (DY7 Goal - Baseline).
(-b-) Carryforward of DY7 achievement = (PY2
Achieved - Baseline)/ (DY7 Goal - Baseline).
(-c-) DY8 achievement = (PY2 Achieved -
Baseline)/ (DY8 Goal - Baseline).
(-d-) Carryforward of DY8 achievement = (PY3
Achieved - Baseline)/ (DY8 Goal - Baseline).
(-e-) DY9 achievement = (PY3 Achieved -
Baseline)/ (DY9 Goal - Baseline).
(-f-) Carryforward of DY9 achievement = (PY4
Achieved - Baseline)/ (DY9 Goal - Baseline).
(-g-) DY10 achievement = (PY4 Achieved -
Baseline)/ (DY10 Goal - Baseline).
(II) Measures with a negative directionality
where lower scores indicate improvement:
(-a-)
DY7 achievement = (Baseline - PY1 Achieved)/ (Baseline - DY7 Goal).
(-b-) Carryforward of DY7 achievement =
(Baseline - PY2 Achieved)/ (Baseline - DY7 Goal).
(-c-) DY8 achievement = (Baseline - PY2
Achieved)/ (Baseline - DY8 Goal).
(-d-) Carryforward of DY8 achievement =
(Baseline - PY3 Achieved)/ (Baseline - DY8 Goal).
(-e-) DY9 achievement = (Baseline - PY3
Achieved)/ (Baseline - DY9 Goal).
(-f-) Carryforward of DY9 achievement =
(Baseline - PY4 Achieved)/ (Baseline - DY9 Goal).
(-g-) DY10 achievement = (Baseline - PY4
Achieved)/ (Baseline - DY10 Goal).
(ii) The achievement value is determined as
follows.
(I) If 100 percent of the goal is
achieved, the achievement value is 1.0.
(II) If less than 100 percent but at least 75
percent of the goal is achieved, the achievement value is 0.75.
(III) If less than 75 percent but at least 50
percent of the goal is achieved, the achievement value is 0.5.
(IV) If less than 50 percent but at least 25
percent of the goal is achieved, the achievement value is 0.25.
(V) If less than 25 percent of the goal is
achieved, the achievement value is 0.
(B) If a P4P measure designated as Quality
Improvement System for Managed Care has a baseline above the High Performance
Level, the performer must achieve 100 percent of the goal achievement milestone
to be eligible for payment of the milestone; there is no payment for partial
achievement.
(C) If a P4P measure
identified as a hospital safety measure in the Measure Bundle Protocol has
perfect performance at baseline, the measure's goal achievement milestone is
eligible for full payment for maintenance of high performance.
(i) Perfect performance at baseline means
that for the baseline measurement period, the performer reports:
(I) zero numerator cases; and
(II) at least one denominator case.
(ii) Maintenance of high
performance means that for a performance year, the performer reports:
(I) zero numerator cases; and
(II) one numerator case that was not
preventable.
(iii) If a
performer wishes to report maintenance of high performance for a performance
year for a measure that is eligible for full payment for maintenance of high
performance, the performer must determine a valid definition for a numerator
case that is not preventable and submit documentation of that definition to
HHSC.
(iv) If HHSC determines that
maintenance of high performance is achieved, the achievement value for the goal
achievement milestone is 1.0.
(d) Basis for payment of Category D. A
performer must report on a measure in the Category D - Statewide Reporting
Measure Bundle for its provider type for a DY in accordance with
§354.1755(d) of this division (relating to Category D Requirements for
Performers) to be eligible for payment of the measure for that DY.
(e) At no point may a performer receive a
DSRIP payment for a milestone more than two years after the end of the DY in
which the milestone is to be completed.
(f) If a performer does not complete the
remaining milestones as described in §354.1751 of this division (relating
to Category B Requirements for Performers) or §354.1753 of this division
(relating to Category C Requirements for Performers), or the Category D -
Statewide Reporting Measure Bundle measures as described in subsection (d) of
this section, the associated DSRIP funding is forfeited by the
performer.
(g) Once the action
associated with a milestone is reported by the performer as complete, that
milestone may not be counted again toward DSRIP payment calculations.
