Current through Reg. 49, No. 38; September 20, 2024
(a) Introduction. Texas Healthcare
Transformation and Quality Improvement Program §1115(a) Medicaid
demonstration waiver Delivery System Reform Incentive Payment (DSRIP) program
payments for demonstration year (DY) 7 and DY8 are available under this section
for eligible performers described in subsection (c) of this section. DSRIP
payments to performers must be in compliance with the Centers for Medicare
& Medicaid Services (CMS) approved Program Funding and Mechanics Protocol,
Health and Human Services Commission (HHSC) instructions, and this
section.
(b) Definitions.
(1) Demonstration Year (DY) 6--Federal fiscal
year 2017 (October 1, 2016 - September 30, 2017).
(2) Demonstration Year (DY) 7--Federal fiscal
year 2018 (October 1, 2017 - September 30, 2018).
(3) Demonstration Year (DY) 8--Federal fiscal
year 2019 (October 1, 2018 - September 30, 2019).
(4) Performer--A provider enrolled in Texas
Medicaid that participates in DSRIP and receives DSRIP payments.
(5) Regional Healthcare Partnership (RHP)
Plan Update--An RHP plan for the initial demonstration period and DY6 that is
updated for DY7-8, as further described in § 354.1697 of this title
(relating to RHP Plan Update).
(c) Eligibility for DSRIP. For a performer to
be eligible to receive DSRIP, the performer must:
(1) be a provider enrolled in Texas
Medicaid;
(2) submit to HHSC
documentation of completion of a milestone identified in the approved RHP plan
update; and
(3) for a private
performer only, comply with the eligibility requirements in §
RSA
355.8201(c)(1)(B) of this
title (relating to Waiver Payments to Hospitals for Uncompensated Care) or
§
RSA
355.8202(c)(3) of this title
(relating to Waiver Payments to Physician Group Practices for Uncompensated
Care), as applicable.
(d) Source of funding. The non-federal share
of funding for payments under this section is limited to timely receipt by HHSC
of public funds from a governmental entity.
(e) Payment frequency. DSRIP payments will be
distributed at least annually, not to exceed two payments per performer per
year, upon achievement of RHP plan update milestones as reviewed and approved
by HHSC. The payment schedule or frequency may be modified as specified by CMS
or HHSC.
(f) Funding limitations.
Payments made under this section are limited by the maximum aggregate amount of
funds approved by CMS for DSRIP for each year that the waiver is in
effect.
(g) DSRIP maximum payment
amounts. The approved RHP plan update establishes the payment amount associated
with a particular milestone. DSRIP payments cannot exceed the amount in the RHP
plan update.
(h) Payment
methodology.
(1) Notice. Prior to making any
DSRIP payments, HHSC will give notice of the following information:
(A) the maximum payment amount for the
payment period;
(B) the maximum
intergovernmental transfer (IGT) amount necessary for a performer to receive
the amount described in subparagraph (A) of this paragraph; and
(C) the deadline for completing the
IGT.
(2) Payment amount.
The approved RHP plan update establishes the payment amount associated with a
milestone. DSRIP payments cannot exceed the amount established in the approved
RHP plan update. The amount of the payment to a performer will be determined
based on the amount of funds transferred by a governmental entity as follows.
(A) If a governmental entity transfers the
maximum amount referenced in paragraph (1) of this subsection on behalf of each
performer owned by or affiliated with that governmental entity, each performer
owned by or affiliated with that governmental entity will receive the full
payment amount calculated for that payment period.
(B) If a governmental entity does not
transfer the maximum amount referenced in paragraph (1) of this subsection on
behalf of each performer owned by or affiliated with that governmental entity,
each performer owned by or affiliated with that governmental entity will
receive a portion of the value associated with that milestone (as specified in
the RHP plan update) that is proportionate to the total value of all milestones
that are completed and eligible for payment for that period by all performers
owned by or affiliated with that governmental entity.
(3) Final payment opportunity. If a performer
does not receive a full DSRIP payment as a result of paragraph (2)(B) of this
subsection, a governmental entity may provide the necessary IGT to make up the
non-federal share of that shortfall until the last reporting period of the DY
following the DY in which the applicable milestone is listed in the RHP plan
update. Any shortfall remains the obligation of the original governmental
entity until that governmental entity informs HHSC that it will no longer agree
to fund that obligation.
(A) If the
governmental entity will no longer fund the obligation or a proportion of the
obligation, that governmental entity must inform HHSC no later than the last
date of the reporting period for the applicable payment period.
(B) A performer may utilize any affiliated
governmental entity to fund the shortfall but must inform HHSC of the identity
of this governmental entity no later than the last date of a reporting period
in order for that affiliated entity to fund the shortfall during the associated
payment period.
(i) Recoupment.
(1) In the event of an overpayment identified
by HHSC or a disallowance by CMS of federal financial participation related to
a performer's receipt or use of payments under this section, HHSC may recoup an
amount equivalent to the amount of the overpayment or disallowance. The
non-federal share of any funds recouped from the performer will be returned to
the governmental entity that was the source of those funds.
(2) Payments under this section may be
subject to adjustment for payments made in error, including, without
limitation, adjustments under §
RSA
371.1711 of this title (relating to
Recoupment of Overpayments and Debts), 42 CFR Part 455, and Chapter 403, Texas
Government Code. HHSC may recoup an amount equivalent to any such
adjustment.
(3) HHSC may recoup
from any current or future Medicaid payments as follows.
(A) HHSC will recoup from the performer
against which any overpayment was made or disallowance was directed.
(B) If, within 30 days of the performer's
receipt of HHSC's written notice of recoupment, the performer has not paid the
full amount of the recoupment or entered into a written agreement with HHSC to
do so, HHSC may withhold any or all future Medicaid payments from the performer
until HHSC has recovered an amount equal to the amount overpaid or
disallowed.
