Current through Reg. 49, No. 38; September 20, 2024
(a) Introduction. This section establishes
the Public Health Provider - Charity Care Program (PHP-CCP). PHP-CCP is
designed to allow qualified providers to receive reimbursement for the cost of
delivering healthcare services, including behavioral health services, vaccine
services, public health services, and other preventative services, when those
costs are not reimbursed by another source. The program is authorized under the
1115 waiver.
(b) Definitions. The
following words and terms, when used in this section, have the following
meanings, unless the context clearly indicates otherwise.
(1) Centers for Medicare and Medicaid
Services (CMS)--The federal agency within the United States Department of
Health and Human Services responsible for overseeing and directing Medicare and
Medicaid, or its successor.
(2)
Medicaid shortfall--The unreimbursed cost to a qualifying provider of providing
Medicaid services to Medicaid clients.
(3) Preventative services--For clients 21
years of age or older, services described in Section 9.2.56.3.2, Preventative
Care Visits of the Texas Medicaid Provider Procedures Manual as of the
effective date of this section. For clients birth through 20 years of age,
services covered under the Early and Periodic Screening, Diagnosis, and
Treatment (EPSDT) service.
(4)
Program period--A period of time for which eligible and enrolled providers may
receive the PHP-CCP amounts described in this section. Each PHP-CCP period is
equal to a Federal Fiscal Year (FFY) beginning October 1 and ending September
30 of the following year.
(5)
Public health services--Services designed to protect and promote the general
population's health and to prevent higher cost interventions such as
hospitalizations. These services include, but are not limited to, tuberculosis
identification, diagnosis, and treatment; sexually transmitted diseases
identification, diagnosis, and treatment; immunization (clinical services and
administration); dental care; and chronic disease screening, monitoring, and
self-management.
(6) Qualifying
Providers--Publicly-owned and operated Community Mental Health Clinics (CMHCs),
community centers, Local Behavioral Health Authorities (LBHAs) and Local Mental
Health Authorities (LMHAs) that are established under the Texas Health &
Safety Code Chapter 533 or 534 and are primarily providing behavioral health
services, and publicly-owned and operated Local Health Departments (LHDs) and
Public Health Districts (PHDs) that are established under the Texas Health and
Safety Code Chapter 121.
(7) Total
program value--The maximum amount available under PHP-CCP for a program period,
as determined by the Texas Health and Human Services Commission (HHSC) and
CMS.
(8) Uncompensated care
costs--The sum of the Medicaid shortfall and the uninsured costs.
(9) Uncompensated care payments--Payments
intended to defray the uncompensated costs of providing services.
(10) Uncompensated care tool--A form
prescribed by HHSC to identify uncompensated costs for Medicaid-enrolled
providers and used to enroll in the program.
(11) Uninsured costs--The unreimbursed cost
to a qualifying provider of providing services that meet the definition of
"medical assistance" in Social Security Act §1905(a) to uninsured patients
as defined by CMS.
(12) Uninsured
patient--An individual who has no health insurance or other source of
third-party coverage for the services provided. The term includes an individual
enrolled in Medicaid who received services that do not meet the definition of
"medical assistance" in the Social Security Act §1905(a).
(13) Waiver--The Texas Healthcare
Transformation and Quality Improvement Program Medicaid demonstration waiver
under Social Security Act §1115.
(c) Participation requirements.
(1) Qualifying provider. A provider must
indicate it is a qualifying provider as defined in subsection (b) of this
section to be considered for reimbursement in the application
process.
(2) PHP-CCP financial
training. HHSC provides annual training to participating qualifying providers.
(A) A PHP-CCP financial contact must attend
and receive credit for training for each program period in which the provider
chooses to participate. Multiple individuals from a qualifying provider may
attend and receive credit for training for each program period.
(B) Training is provided for each program
period and is not retroactive. The qualifying provider must have at least one
financial contact attend the annual training directly prior to the program
period to participate.
(C) A
provider that does not have a trained PHP-CCP financial contact who is an
employee of the provider is prohibited from submitting a PHP-CCP application.
Provider-contracted vendors are permitted to enter a provider's data into the
cost report for any provider as a report preparer.
(3) Cost reports. Qualifying providers must
submit an annual uncompensated care tool for uncompensated care costs.
Uncompensated care tools must be completed for a full year based on the federal
fiscal year.
(A) The uncompensated care tool
format will be specified by HHSC. Qualifying providers certify through the cost
report process their total actual federal and non-federal costs and
expenditures for the program period. Costs must be reported in a manner that is
consistent with the PHP-CCP protocol that is approved under the 1115
Waiver.
(B) The cost report is due
on or before November 14 of the year of the program period ending date and must
be certified in a manner specified by HHSC.
(i) If November 14 falls on a federal or
state holiday or weekend, the due date is the first working day after November
14.
(ii) A provider whose cost
report is not received by the due date is ineligible for PHP-CCP payment for
the federal fiscal year.
(C) HHSC reserves the right to request a
corrective action plan (CAP) from providers who submit incorrect cost reports
or bill incorrectly. PHP-CCP payments will be withheld until the CAP is
accepted by the HHSC.
(D) Costs for
care delivered to persons who are incarcerated at the time of the care must be
excluded from the cost report.
(E)
Costs for care delivered as part of an Institution of Mental Disease (IMD) must
be excluded from the cost report. If a provider includes costs for Crisis
Stabilization Units on their cost report, and the unit is later determined by
CMS to be an IMD, associated PHP-CCP payments are subject to
recoupment.
(4)
Certification. The provider must certify, on a form prescribed by HHSC, that no
part of any PHP-CCP payment will be used to pay a contingent fee and that the
entity's agreement with a billing entity or cost report preparer 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 PHP-CCP funds. The certification
must be received by HHSC with the enrollment application described in paragraph
(3) of this subsection.
(d) Source of funding. The non-federal share
of funding for payments under this section is limited to certified public
expenditures from governmental entities.
(e) Payment frequency. HHSC will distribute
uncompensated care payments on a schedule to be determined by HHSC and posted
on HHSC's website.
(f) Calculation
of supplemental payment.
(1) Supplemental
payment. A qualifying provider may be eligible to receive a supplemental
payment equal to a percentage of its Medicaid shortfall and uncompensated care
costs for the cost reporting period.
(2) Funding limitations. Payments made under
this section are limited by the amount of funds allocated to the total program
value for the demonstration year. If payments for uncompensated care for the
provider pool attributable to a demonstration year are expected to exceed the
amount of funds allocated to that pool by HHSC for that demonstration year,
HHSC will reduce payments to providers in the pool by the same percentage as
required to remain within the pool allocation amount.
(g) Recoupment.
(1) Overpayment or disallowance. In the event
of an overpayment identified by HHSC or a disallowance by CMS of federal
financial participation related to a provider's receipt or use of payments
under this section, HHSC may recoup an amount equivalent to the amount of the
overpayment or disallowance.
(2)
Adjustments. 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 Texas Government
Code Chapter 403. HHSC may recoup an amount equivalent to any such
adjustment.
(3) Recoupment method.
HHSC may recoup from any current or future Medicaid payments as follows:
(A) HHSC will recoup from the provider
against which any overpayment was made, or disallowance was directed.
(B) If, within 30 days of the provider's
receipt of HHSC's written notice of recoupment, the provider 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 provider
until HHSC has recovered an amount equal to the amount overpaid or disallowed.
Electronic notice and electronic agreement may be used as alternative options
at HHSC's discretion.
(h) 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 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 the HHSC Provider Finance Department receives the
notice.
(i) General information. In
addition to the requirements of this section, the cost reporting guidelines
will be governed by §
RSA
355.101 of this chapter (relating to
Introduction); §
RSA
355.102 of this chapter (relating to General
Principles of Allowable and Unallowable Costs); §
RSA
355.103 of this chapter (relating to
Specifications for Allowable and Unallowable Costs); §
RSA
355.104 of this chapter (relating to
Revenues); §
RSA
355.105 of this chapter (relating to General
Reporting and Documentation Requirements, Methods, and Procedures); §
RSA
355.106 of this chapter (relating to Basic
Objectives and Criteria for Audit and Desk Review of Cost Reports); §
RSA
355.107 of this chapter (relating to
Notification of Exclusions and Adjustments); §
RSA
355.108 of this chapter (relating to
Determination of Inflation Indices); §
RSA
355.109 of this chapter (relating to
Adjusting Reimbursement When New Legislation, Regulations, or Economic Factors
Affect Costs); and §
RSA
355.110 of this chapter (relating to Informal
Reviews and Formal Appeals).
