Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 353 - MEDICAID MANAGED CARE › Subchapter O - DELIVERY SYSTEM AND PROVIDER PAYMENT INITIATIVES › Section 353.1320 - Directed Payment Program for Behavioral Health Services

Current through Reg. 49, No. 28; July 12, 2024
(a) Introduction. This section establishes
				  the Directed Payment Program for Behavioral Health Services (DPP BHS). DPP BHS
				  is designed to incentivize behavioral health providers to improve quality,
				  access, and innovation in the provision of medical and behavioral health
				  services to Medicaid recipients through the use of metrics that are expected to
				  advance at least one of the goals and objectives of the state's managed care
				  quality strategy.
(b) Definitions.
				  The following definitions apply when the terms are used in this section. Terms
				  that are used in this section may be defined in §
										353.1301 of this subchapter
				  (relating to General Provisions) or §
										353.1322 of this subchapter
				  (relating to Quality Metrics for the Directed Payment Program for Behavioral
				  Health Services).
(1) Average Commercial
				  Reimbursement (ACR) gap--The difference between what an average commercial
				  payor is estimated to pay for the services and what Medicaid actually paid for
				  the same services.
(2) Certified
				  Community Behavioral Health Clinic (CCBHC)--A clinic certified by the state in
				  accordance with federal criteria and with the requirements of the Protecting
				  Access to Medicare Act of 2014 (PAMA).
(3) CCBHC cost-reporting gap--The difference
				  between what Medicaid pays for services and what the reimbursement would be
				  based on the CCBHC cost-reporting methodology.
(4) Community Mental Health Center (CMHC)--An
				  entity that is established under Texas Health and Safety Code §
											534.0015 and
				  that:
(A) Provides outpatient services,
				  including specialized outpatient services for children, the elderly,
				  individuals with serious mental illness, and residents of its mental health
				  service area who have been discharged from inpatient treatment at a mental
				  health facility.
(B) Provides
				  24-hour-a-day emergency care services.
(C) Provides day treatment or other partial
				  hospitalization services, or psychosocial rehabilitation services.
(D) Provides screening for patients being
				  considered for admission to state mental health facilities to determine the
				  appropriateness of such admission.
(5) Intergovernmental transfer (IGT)
				  notification--Notice and directions regarding how and when IGTs should be made
				  in support of DPP BHS.
(6) Local
				  Behavioral Health Authority (LBHA)--An entity that is designated under Texas
				  Health and Safety Code §
											533.0356.
(7) Program period--A period of time for
				  which the Texas Health and Human Services (HHSC) contracts with participating
				  managed care organizations (MCOs) to pay increased capitation rates for the
				  purpose of provider payments under this section. Each program period is equal
				  to a state fiscal year beginning September 1 and ending August 31 of the
				  following year.
(8) Providers--For
				  program periods on or before August 31, 2022, an entity described in paragraph
				  (4) of this subsection. For program periods on or after September 1, 2022, an
				  entity described in paragraph (4) or (6) of this subsection.
(9) Suggested IGT responsibility--Notice of
				  potential amounts that a sponsoring governmental entity may wish to consider
				  transferring in support of DPP BHS.
(10) Total program value--The maximum amount
				  available under the Directed Payment Program for Behavioral Health Services for
				  a program period, as determined by HHSC.