Texas Administrative Code
Title 1 - ADMINISTRATION
Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION
Chapter 355 - REIMBURSEMENT RATES
Subchapter J - PURCHASED HEALTH SERVICES
Division 4 - MEDICAID HOSPITAL SERVICES
Section 355.8070 - Hospital Augmented Reimbursement Program
Universal Citation: 1 TX Admin Code ยง 355.8070
Current through Reg. 49, No. 38; September 20, 2024
(a) Introduction. This section establishes the Hospital Augmented Reimbursement (HARP) Program, wherein the Texas Health and Human Services Commission (HHSC) directs payments to certain providers that serve Texas Medicaid fee-for-service patients, including eligible non-state government owned hospitals, private hospitals, state-owned hospitals, state government-owned Institutions for Mental Diseases (IMDs), and private IMDs. This section also describes the methodology used by HHSC to calculate and administer such payments. A provider is eligible for a payment under this section only if HHSC has submitted and CMS has approved a state plan amendment permitting HHSC to make payments under this section to the hospital class to which the provider belongs.
(b) Definitions. The following definitions apply when the terms are used in this section.
(1) Fee-for-Service (FFS)--A system
of the health insurance payment in which a health care provider is paid a fee
by HHSC through the contracted Medicaid claims administrator directly, for each
service rendered. For Texas Medicaid purposes, fee-for-service excludes any
service rendered under a managed care program through a managed care
organization.
(2) Inpatient
hospital services--Services ordinarily furnished in a hospital for the care and
treatment of inpatients under the direction of a physician or dentist, or a
subset of these services identified by HHSC. Inpatient hospital services do not
include services furnished in a skilled nursing facility, intermediate care
facility services furnished by a hospital with swing-bed approval, or any other
services that HHSC determines should not be subject to payment.
(3) Intergovernmental transfer (IGT)--A
transfer of public funds from another state agency or a non-state governmental
entity to HHSC.
(4) Medicare
payment gap--The difference between what Medicare is estimated to pay for the
services and what Medicaid actually paid for the same services from the most
recent FFS upper payment limit (UPL) demonstration.
(5) Non-state government-owned and operated
hospital--A hospital that is owned and operated by a local government entity,
including but not limited to a city, county, or hospital district.
(6) Outpatient hospital services--Preventive,
diagnostic, therapeutic, rehabilitative, or palliative services that are
furnished to outpatients of a hospital under the direction of a physician or
dentist, or a subset of these services identified by HHSC.
(7) Private hospital--Any hospital that is
not government-owned and operated.
(8) Private Institution for Mental Diseases
(IMD)--A hospital that is primarily engaged in providing psychiatric diagnosis,
treatment or care of individuals with mental illness and that is not
government-owned and operated.
(9)
Program period--Each program period is equal to a federal fiscal year beginning
October 1 and ending September 30 of the following year.
(10) Prospective Payment System--A method of
reimbursement in which payment is made based on a predetermined, fixed
amount.
(11) Sponsoring
governmental entity--A state or non-state governmental entity that agrees to
transfer to HHSC some or all of the non-federal share of program expenditures
under this subchapter.
(12) State
government-owned hospital--Any hospital owned by the state of Texas that is not
considered an IMD.
(13) State
government-owned IMD--A hospital that is primarily engaged in providing
psychiatric diagnosis, treatment or care of individuals with mental illness and
that is owned by the state of Texas that is considered an IMD.
(c) Participation requirements. As a condition of participation, all hospitals participating in the program must allow for the following.
(1) The hospital must
submit a properly completed enrollment application by the due date determined
by HHSC. The enrollment period must be no less than 15 business days, and the
final date of the enrollment period will be at least nine days prior to the
intergovernmental transfer (IGT) notification.
(2) If a provider has changed ownership in
the past five years in a way that impacts eligibility for this program, the
provider must submit to HHSC, upon demand, copies of contracts it has with
third parties with respect to the transfer of ownership or the management of
the provider and which reference the administration of, or payment from, this
program.
(d) Payments for non-state government-owned and operated hospitals.
(1) Eligible hospitals. Payments under this
subsection will be limited to hospitals defined as "non-state government owned
and operated hospital" that are enrolled in Medicare and participate in Texas
Medicaid fee-for-service.
(2)
Non-federal share of program payments. The non-federal share of the payments is
funded through IGTs from sponsoring governmental entities. No state general
revenue is available to support the program.
(A) HHSC will communicate suggested IGT
responsibilities. Suggested IGT responsibilities will be based on the maximum
dollars to be available under the program for the program period as determined
by HHSC. HHSC will also communicate estimated revenues each enrolled hospital
could earn under the program for the program period with those estimates based
on HHSC's suggested IGT responsibilities.
(B) HHSC will issue an IGT notification to
specify the date that IGT is requested to be transferred not fewer than 14
business days before IGT transfers are due. HHSC may post the IGT deadlines and
other associated information on HHSC's website, send the information through
the established Medicaid notification procedures used by HHSC's fiscal
intermediary, send through other direct mailing, send through GovDelivery, or
provide the information to the hospital associations to disseminate to their
member hospitals.
(3)
Payment Methodology. To determine each participating non-state government-owned
and operated hospital's payment under this section, HHSC will sum the
hospital's inpatient FFS Medicare payment gap and the hospital's outpatient FFS
Medicare payment gap.
(e) Payments for private hospitals.
(1) Eligible
hospitals. Payments under this subsection will be limited to hospitals defined
as "private hospital" in subsection (b) of this section that are enrolled in
Medicare and participate in Texas Medicaid fee-for-service.
(2) Non-federal share of program payments.
The non-federal share of the payments is funded through IGTs from sponsoring
governmental entities. No state general revenue is available to support the
program.
(A) HHSC must receive the
non-federal portion of reimbursement for HARP through a method approved by HHSC
and Centers for Medicare & Medicaid Services (CMS) for reimbursement
through this program.
(B) A
hospital under this subsection must designate a single local governmental
entity to provide the non-federal share of the payment through a method
determined by HHSC. If the single local governmental entity transfers less than
the full non-federal share of a hospital's payment amount calculated in any
paragraph under this subchapter, HHSC will recalculate that specific hospital's
payment based on the amount of the non-federal share actually
transferred.
(C) HHSC will
communicate suggested IGT responsibilities. Suggested IGT responsibilities will
be based on the maximum dollars to be available under the program for the
program period as determined by HHSC. HHSC will also communicate estimated
revenues each enrolled hospital could earn under the program for the program
period with those estimates based on HHSC's suggested IGT
responsibilities.
(D) HHSC will
issue an IGT notification to specify the date that IGT is requested to be
transferred not fewer than 14 business days before IGT transfers are due. HHSC
may post the IGT deadlines and other associated information on HHSC's website,
send the information through the established Medicaid notification procedures
used by HHSC's fiscal intermediary, send through other direct mailing, send
through GovDelivery, or provide the information to the hospital associations to
disseminate to their member hospitals.
(3) Payment Methodology. To determine each
participating private hospital's payment under this section, HHSC will sum the
hospital's inpatient FFS Medicare payment gap and the hospital's outpatient FFS
Medicare payment gap.
(f) Payments for state government-owned hospitals.
(1) Eligible hospitals. Payments
under this subsection will be limited to hospitals defined as "state
government-owned hospital" in subsection (b) of this section that are enrolled
in Medicare and participate in Texas Medicaid fee-for-service.
(2) Non-federal share of program payments.
The non-federal share of the payments is funded through IGTs from sponsoring
governmental entities. No state general revenue is available to support the
program.
(A) HHSC must receive the non-federal
portion of reimbursement for HARP through a method approved by HHSC and CMS for
reimbursement through this program.
(B) A hospital under this subsection must
designate a single local governmental entity to provide the non-federal share
of the payment through a method determined by HHSC. If the single local
governmental entity transfers less than the full non-federal share of a
hospital's payment amount calculated in any paragraph under this subchapter,
HHSC will recalculate that specific hospital's payment based on the amount of
the non-federal share actually transferred.
(C) HHSC will communicate suggested IGT
responsibilities. Suggested IGT responsibilities will be based on the maximum
dollars to be available under the program for the program period as determined
by HHSC. HHSC will also communicate estimated revenues each enrolled hospital
could earn under the program for the program period with those estimates based
on HHSC's suggested IGT responsibilities.
(D) HHSC will issue an IGT notification to
specify the date that IGT is requested to be transferred not fewer than 14
business days before IGT transfers are due. HHSC will publish the IGT deadlines
and all associated dates on its Internet website.
(3) Payment Methodology.
(A) To determine payment under this section
for each participating state-owned hospital reimbursed through Prospective
Payment System (PPS), HHSC will sum the hospital's inpatient FFS Medicare
payment gap and the hospital's outpatient FFS Medicare payment gap.
(B) To determine payment under this section
for each participating state-owned hospital not reimbursed through Prospective
Payment System (PPS), HHSC will use the hospital's FFS outpatient Medicare
payment gap.
(g) Payments for state government-owned IMDs.
(1) Eligible hospitals.
(A) Payments under this subsection will be
limited to hospitals defined as "state government-owned IMD" in subsection (b)
of this section that are enrolled in Medicare and participate in Texas Medicaid
fee-for-service.
(B) The hospital
must have submitted at least one adjudicated FFS Medicaid claim for each
reporting period to be eligible for payment.
(2) Non-federal share of program payments.
The non-federal share of the payments is funded through IGTs from sponsoring
governmental entities. No state general revenue is available to support the
program.
(A) HHSC must receive the non-federal
portion of reimbursement for HARP through a method approved by HHSC and CMS for
reimbursement through this program.
(B) A hospital under this subsection must
designate a single local governmental entity to provide the non-federal share
of the payment through a method determined by HHSC. If the single local
governmental entity transfers less than the full non-federal share of a
hospital's payment amount calculated in any paragraph under this subchapter,
HHSC will recalculate that specific hospital's payment based on the amount of
the non-federal share actually transferred.
(C) HHSC will communicate suggested IGT
responsibilities. Suggested IGT responsibilities will be based on the maximum
dollars to be available under the program for the program period as determined
by HHSC. HHSC will also communicate estimated revenues each enrolled hospital
could earn under the program for the program period with those estimates based
on HHSC's suggested IGT responsibilities.
(D) HHSC will issue an IGT notification to
specify the date that IGT is requested to be transferred not fewer than 14
business days before IGT transfers are due. HHSC may post the IGT deadlines and
other associated information on HHSC's website, send the information through
the established Medicaid notification procedures used by HHSC's fiscal
intermediary, send through other direct mailing, send through GovDelivery, or
provide the information to the hospital associations to disseminate to their
member hospitals.
(3)
Payment Methodology. To determine each participating state government-owned IMD
hospital's payment under this section, HHSC will use the hospital's inpatient
FFS Medicare payment gap.
(h) Payments for private IMDs.
(1) Eligible hospitals.
(A) Payments under this subsection will be
limited to hospitals defined as "private IMD" in subsection (b) of this section
that participate in Texas Medicaid fee-for-service.
(B) The hospital must have submitted at least
one adjudicated FFS Medicaid claim for each reporting period to be eligible for
payment.
(2) Non-federal
share of program payments. The non-federal share of the payments is funded
through IGTs from sponsoring governmental entities. No state general revenue is
available to support the program.
(A) HHSC
must receive the non-federal portion of reimbursement for HARP through a method
approved by HHSC and CMS for reimbursement through this program.
(B) A hospital under this subsection must
designate a single local governmental entity to provide the non-federal share
of the payment through a method determined by HHSC. If the single local
governmental entity transfers less than the full non-federal share of a
hospital's payment amount calculated in any paragraph under this subchapter,
HHSC will recalculate that specific hospital's payment based on the amount of
the non-federal share actually transferred.
(C) HHSC will communicate suggested IGT
responsibilities. Suggested IGT responsibilities will be based on the maximum
dollars to be available under the program for the program period as determined
by HHSC. HHSC will also communicate estimated revenues each enrolled hospital
could earn under the program for the program period with those estimates based
on HHSC's suggested IGT responsibilities.
(D) HHSC will issue an IGT notification to
specify the date that IGT is requested to be transferred not fewer than 14
business days before IGT transfers are due. HHSC may post the IGT deadlines and
other associated information on HHSC's website, send the information through
the established Medicaid notification procedures used by HHSC's fiscal
intermediary, send through other direct mailing, send through GovDelivery, or
provide the information to the hospital associations to disseminate to their
member hospitals.
(3)
Payment Methodology. To determine each participating private IMD hospital's
payment under this section, HHSC will use the hospital's inpatient FFS Medicare
payment gap.
(i) Changes in operation. If an enrolled hospital closes voluntarily or ceases to provide hospital services in its facility, the hospital 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 hospital services. Notification is considered to have occurred when the HHSC Provider Finance Department receives the notice.
(j) Reconciliation. HHSC will reconcile the amount of the non-federal funds actually expended under this section during the program period with the amount of funds transferred to HHSC by the sponsoring governmental entities for that same period. If the amount of non-federal funds actually expended under this section is less than the amount transferred to HHSC, HHSC will refund the balance proportionally to how it was received.
(k) Payments under this section will be made on a semi-annual basis.
Disclaimer: These regulations may not be the most recent version. Texas may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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