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

Current through Reg. 49, No. 28; July 12, 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.