reglab/statecodes huggingface dataset:
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 354 - MEDICAID HEALTH SERVICES › Subchapter A - PURCHASED HEALTH SERVICES › Division 30 - IN-HOME TOTAL PARENTERAL HYPERALIMENTATION SERVICES › Section 354.1391 - In-Home Total Parenteral Hyperalimentation Services

Current through Reg. 49, No. 28; July 12, 2024
(a) Subject to the specifications,
					 conditions, limitations, and requirements established by HHSC or its designee,
					 in-home total parenteral hyperalimentation services shall be available to
					 eligible recipients who require long-term nutritional support because of
					 extensive bowel resection and/or severe advanced bowel disease in which the
					 bowel cannot absorb nutrition. Covered services must be reasonable, medically
					 necessary, and prescribed by the recipient's physician (M.D. or D.O.). The
					 physician must be licensed in the state in which the physician
					 practices.
(b) HHSC or its designee
					 must prior authorize the services. Prior authorization requests must include
					 all pertinent medical records and other documentation as required by HHSC or
					 its designee to justify the medical necessity of the long-term total parenteral
					 hyperalimentation. Prior authorization is a mandatory requirement for
					 payment.
(c) Covered services
					 include, but are not necessarily limited to:
(1) parenteral hyperalimentation solutions
					 and additives as ordered by the recipient's physician;
(2) supplies and equipment including
					 refrigeration, if necessary, that are required for the administration of
					 prescribed solutions and additives;
(3) education of the recipient and/or
					 appropriate caregivers regarding the in-home administration of total parenteral
					 hyperalimentation before administration initially begins. Education must
					 include the use and maintenance of required supplies and equipment;
(4) visits by a registered nurse (RN)
					 appropriately trained in the administration of hyperalimentation. The RN must
					 visit the recipient at least once per month to monitor the recipient's status
					 and to provide ongoing education to the recipient and/or caregivers regarding
					 the administration of hyperalimentation; and
(5) enteral supplies, nutritional products
					 and equipment used in conjunction with total parenteral
					 hyperalimentation.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 354 - MEDICAID HEALTH SERVICES › Subchapter A - PURCHASED HEALTH SERVICES › Division 31 - IN-HOME RESPIRATORY THERAPY SERVICES FOR VENTILATOR-DEPENDENT PERSONS › Section 354.1401 - In-Home Respiratory Therapy Services for Ventilator-Dependent Persons

Current through Reg. 49, No. 28; July 12, 2024
(a) Subject to the specifications,
					 conditions, limitations, and requirements established by HHSC or its designee,
					 in-home respiratory therapy services are available to eligible recipients who:
(1) are ventilator-dependent for life support
					 at least six hours per day;
(2)
					 have been so dependent for at least 30 consecutive days as an inpatient in one
					 or more hospitals, skilled nursing facilities (SNF), or intermediate care
					 facilities (ICF);
(3) but for the
					 availability of these respiratory care services at home, would require
					 respiratory care as an inpatient in a hospital, SNF, or ICF;
(4) would be eligible to have payment made
					 for such inpatient care under the state Medicaid plan;
(5) have adequate social support services to
					 be cared for at home; and
(6) wish
					 to be cared for at home.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 354 - MEDICAID HEALTH SERVICES › Subchapter A - PURCHASED HEALTH SERVICES › Division 32 - TEXAS MEDICAID WELLNESS PROGRAM › Section 354.1415 - Vendor Requirements and Conditions for Participation

Current through Reg. 49, No. 28; July 12, 2024
(a) In addition to the general requirements
					 for contractors listed in Chapter 391, Purchase of Goods and Services by the
					 Health and Human Services Agencies and Chapter 392, Procurements by the Health
					 and Human Services Commission, care management companies must meet all of the
					 following program requirements to be considered for a contract with the state.
					 Entities who wish to contract with the Health and Human Services Commission
					 (HHSC) to provide wellness program services must meet the following conditions:
(1) Use HHSC-approved predictive modeling
					 approaches to identify high-cost and high-risk populations;
(2) Use approaches that are based on
					 nationally recognized evidence-supported models, standards of care in the
					 medical community and clinical outcomes;
(3) Have collaborative healthcare practice
					 models in place to include HHSC's contracted physicians, support service
					 providers, and existing community resources;
(4) Ensure that a recipient's primary care
					 provider, and other appropriate specialty physicians, or registered nurses,
					 advance practice nurses, or physician assistants become directly involved in
					 the Texas Medicaid Wellness Program;
(5) Ensure that providers serving as medical
					 homes take an active role in helping clients or their caregivers make informed
					 health-care decisions;
(6) Use
					 patient self-care management strategies, so that clients become informed and
					 active participants in the management of their physical and mental health
					 conditions and co-morbidities;
(7)
					 Provide client and provider educational materials that are culturally sensitive
					 and appropriate to the targeted population;
(8) Have process and outcome measurements,
					 evaluations, and management systems that incorporate nationally recognized
					 evidence-based clinical practice guidelines;
(9) Have routine reporting processes that are
					 proven to properly support wellness goals;
(10) Provide access to 24 hour-a-day, seven
					 days-per-week nurse consultation/triage line;
(11) Provide coordination of client care
					 during a transition period for clients that move from enrollment in one disease
					 management or wellness program to another; and
(12) Have the ability to guarantee program
					 savings.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 354 - MEDICAID HEALTH SERVICES › Subchapter A - PURCHASED HEALTH SERVICES › Division 32 - TEXAS MEDICAID WELLNESS PROGRAM › Section 354.1416 - Eligibility Criteria

Current through Reg. 49, No. 28; July 12, 2024
(a) The Texas
					 Medicaid Wellness Program serves people with disabilities who receive Medicaid
					 services and people who receive Temporary Assistance for Needy Families (TANF)
					 who:
(1) Receive medical services through
					 fee-for-service;
(2) Are able, or
					 have a caregiver who is able, to respond actively to health information and
					 care coordination activities; and
(3) Are identified by the Health and Human
					 Services Commission (HHSC) and the Texas Medicaid Wellness Program vendor as
					 being high-cost and/or high-risk due to chronic illness or condition.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 354 - MEDICAID HEALTH SERVICES › Subchapter A - PURCHASED HEALTH SERVICES › Division 33 - ADVANCED TELECOMMUNICATIONS SERVICES › Section 354.1430 - Definitions

Current through Reg. 49, No. 28; July 12, 2024
The following words and terms, when used in this
						division, have the following meanings unless the context clearly indicates
						otherwise.
(1) Audio-only--An
					 interactive, two-way audio communication that uses only sound and meets the
					 privacy requirements of the Health Insurance Portability and Accountability
					 Act. Audio-only includes the use of telephonic communication.
(2) Behavioral health services--This term
					 includes mental health and substance use disorder services.
(3) Declaration of state of disaster--An
					 executive order or proclamation by the governor declaring a state of disaster
					 in accordance with Texas Government Code §
											418.014.
(4) In-Person--Within the physical presence
					 of another person. In-person does not include interacting with a client via a
					 telemedicine medical service or a telehealth service.
(5) Non-behavioral health service--Any health
					 service that is not a behavioral health service.
(6) Platform--This term has the meaning
					 assigned by Texas Government Code §
											531.001
					 (4-d).
(7) Telehealth service--This
					 term has the meaning assigned by Texas Occupations Code §
											111.001.
(8) Telemedicine medical service--This term
					 has the meaning assigned by Texas Occupations Code §
											111.001.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 354 - MEDICAID HEALTH SERVICES › Subchapter A - PURCHASED HEALTH SERVICES › Division 33 - ADVANCED TELECOMMUNICATIONS SERVICES › Section 354.1432 - Telemedicine and Telehealth Benefits and Limitations

Current through Reg. 49, No. 28; July 12, 2024
Telemedicine medical services and telehealth services are
						authorized service delivery methods for Texas Medicaid covered services as
						provided in this section. All telemedicine medical services and telehealth
						services are subject to the specifications, conditions, limitations, and
						requirements established by the Texas Health and Human Services Commission
						(HHSC) or its designee.
(1) A client
					 must not be required to receive a covered service as a telemedicine medical
					 service or telehealth service except in the event of an active declaration of
					 state of disaster and at the direction of HHSC.
(2) In the event of a declaration of state of
					 disaster, HHSC may issue direction to providers regarding the use of
					 telemedicine medical services and telehealth services, including the use of an
					 audio-only platform, to provide covered services to clients who reside in the
					 area subject to the declaration of state of disaster.
(3) HHSC considers the following criteria
					 when determining whether a covered service may be delivered as telemedicine
					 medical service or telehealth service, including via an audio-only platform:
(A) clinical effectiveness;
(B) cost effectiveness;
(C) health and safety;
(D) patient choice and access to care;
					 and
(E) other criteria specific to
					 the service.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 354 - MEDICAID HEALTH SERVICES › Subchapter A - PURCHASED HEALTH SERVICES › Division 33 - ADVANCED TELECOMMUNICATIONS SERVICES › Section 354.1434 - Home Telemonitoring Benefits and Limitations

Current through Reg. 49, No. 28; July 12, 2024
(a) Home telemonitoring services are a
					 benefit of the Texas Medicaid Program as provided in this section and are
					 subject to the specifications, conditions, limitations, and requirements
					 established by the Texas Health and Human Services Commission (HHSC) or its
					 designee.
(b) Home telemonitoring
					 services require scheduled remote monitoring of data related to a patient's
					 health and transmission of the data to a licensed home health agency or a
					 hospital, as those terms are defined by Texas Government Code §
											531.02164(a).
(c) Home telemonitoring service providers
					 must:
(1) comply with all applicable federal,
					 state, and local laws and regulations;
(2) be enrolled and approved for
					 participation in the Texas Medicaid Program as home telemonitoring service
					 providers;
(3) bill for services
					 covered under the Texas Medicaid Program in the manner and format prescribed by
					 HHSC;
(4) share clinical
					 information gathered while providing home telemonitoring services with the
					 patient's physician; and
(5) not
					 duplicate disease management program services provided under Human Resources
					 Code §
												32.057 and
					 further described in Division 32 of this subchapter (relating to Texas Medicaid
					 Wellness Program).
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 354 - MEDICAID HEALTH SERVICES › Subchapter A - PURCHASED HEALTH SERVICES › Division 33 - ADVANCED TELECOMMUNICATIONS SERVICES › Section 354.1435 - Provision of Behavioral Health Services through an Audio-Only Platform

Current through Reg. 49, No. 28; July 12, 2024
The Texas Health and Human Services Commission (HHSC)
						recognizes that mental health services are expressly excluded from the
						provisions of Texas Occupations Code Chapter 111 and further, that the term
						"mental health services" is not defined in Texas Occupations Code Chapter 111.
						Additionally, HHSC recognizes the American Psychiatric Association's Diagnostic
						and Statistical Manual of Mental Disorders and the National Institute of Mental
						Health recognize substance use disorder as a mental disorder. Acknowledging the
						importance of access to substance use disorder and pursuant to HHSC's broad
						rulemaking authority in Texas Government Code §
											531.0055 and §
											531.033 and Texas
						Human Resources Code §
											32.021, for the
						purposes of this rule, HHSC considers the provision of mental health services,
						as that term is used in Texas Occupations Code Chapter 111, to be synonymous
						with the provision of behavioral health services. Conditions for reimbursement
						applicable to behavioral health services provided through an audio-only
						platform are described in this section.
(1) The provider must be enrolled in Texas
					 Medicaid.
(2) The provider must
					 obtain informed consent from the client, client's parent, or the client's
					 legally authorized representative prior to rendering a behavioral health
					 service via an audio-only platform; except when doing so is not feasible or
					 could result in death or injury to the client. Verbal consent is permissible
					 and must be documented in the client's medical record.
(3) The covered services must be provided in
					 compliance with the standards established by the respective licensing or
					 certifying board of the professional providing the audio-only telemedicine
					 medical service or audio-only telehealth service.
(4) Behavioral health services provided via
					 audio-only platform must be designated for reimbursement by HHSC. Behavioral
					 health services provided via an audio-only platform designated for
					 reimbursement are those that are clinically effective and cost-effective, as
					 determined by HHSC and in accordance with §
											354.1432(3) of
					 this subchapter (relating to Telemedicine and Telehealth Benefits and
					 Limitations). Behavioral health services that HHSC has determined are
					 clinically effective and cost-effective when provided via an audio-only
					 platform can be found in the Texas Medicaid Provider Procedures Manual
					 (TMPPM).
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 354 - MEDICAID HEALTH SERVICES › Subchapter A - PURCHASED HEALTH SERVICES › Division 33 - ADVANCED TELECOMMUNICATIONS SERVICES › Section 354.1436 - Provision of Non-behavioral Health Services Using an Audio-only Platform

Current through Reg. 49, No. 28; July 12, 2024
Conditions for reimbursement applicable to
						non-behavioral health services using an audio-only platform:
(1) Non-behavioral health services provided
					 via an audio-only platform must be designated for reimbursement by The Texas
					 Health and Human Services Commission (HHSC). Non-behavioral health services
					 provided via an audio-only platform designated for reimbursement are those that
					 are clinically effective and cost-effective, as determined by HHSC and in
					 accordance with §
											354.1432(3) of
					 this subchapter (relating to Telemedicine and Telehealth Benefits and
					 Limitations). Non-behavioral health services that HHSC has determined are
					 clinically effective and cost-effective when provided via an audio-only
					 platform can be found in the Texas Medicaid Provider Procedures Manual
					 (TMPPM).
(2) The provider must be
					 enrolled in Texas Medicaid.
(3) The
					 covered services must be provided in compliance with Texas Occupations Code
					 Chapter 111 and standards established by the respective licensing or certifying
					 board of the professional providing the audio-only telemedicine medical service
					 or audio-only telehealth service.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 354 - MEDICAID HEALTH SERVICES › Subchapter A - PURCHASED HEALTH SERVICES › Division 34 - OUT-OF-STATE SERVICES › Section 354.1440 - Medical Care or Services Provided to Medicaid Recipients Outside of Texas

Current through Reg. 49, No. 28; July 12, 2024
(a) Subject to certain conditions,
					 limitations, and exclusions, the Texas Medicaid program covers medical
					 assistance services provided to an eligible Texas recipient while away from
					 Texas in another state if the recipient does not leave Texas for the purpose of
					 receiving out-of-state medical care that the recipient can receive in Texas.
					 Services provided outside of Texas but within the United States are covered to
					 the same extent they are covered in Texas when:
(1) the medical services are needed because
					 of a medical emergency documented by the attending physician or other
					 provider;
(2) the services are
					 medically necessary, and, in the opinion of the attending physician or other
					 provider, the recipient's health would be endangered if the recipient were
					 required to travel to Texas;
(3)
					 HHSC or its designee determines that the medically necessary services are more
					 readily available in the state where the recipient is located;
(4) the customary or general practice for
					 recipients in a particular locality within Texas is to use medical resources in
					 the other state; or
(5) the Texas
					 Department of Family and Protective Services makes Title IV-E adoption
					 assistance or Title IV-E foster care maintenance payments to an out-of-state
					 provider for a child who is also eligible for Texas medical assistance
					 benefits.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 354 - MEDICAID HEALTH SERVICES › Subchapter B - GENERAL PROVISIONS › Section 354.1451 - Medicaid Recovery Audit Contractor Program

Current through Reg. 49, No. 28; July 12, 2024
(a) Purpose. The Medicaid Recovery Audit
				  Contractor (RAC) Program is established under §1902(a)(42)(B) of the
				  Social Security Act (RSA
				  1396a(a)(42)(B)) to review
				  and identify underpayments and overpayments, and to recoup overpayments for
				  items or services defined under the Medicaid State Plan or a waiver of the
				  Medicaid State Plan.
(b)
				  Definitions. The following words and terms, when used in this section, have the
				  following meanings unless the context clearly indicates otherwise:
(1) HHSC--The Texas Health and Human Services
				  Commission, the state Medicaid agency.
(2) HHS agency--One of the following health
				  and human services agencies:
(A) Department
				  of Aging and Disability Services (DADS).
(B) Department of Assistive and
				  Rehabilitative Services (DARS).
(C)
				  Department of Family and Protective Services (DFPS).
(D) Department of State Health Services
				  (DSHS).
(3) Improper
				  payment--An overpayment or an underpayment.
(4) Overpayment--An amount paid by HHSC or an
				  HHS agency to a provider that is in excess of the amount that is allowable for
				  services furnished under §1902 of the Social Security Act and its
				  implementing regulations and policies, as defined by the Centers for Medicare
				  & Medicaid Services (CMS), and that is required to be refunded under
				  §1903 of the Social Security Act.
(5) Recovery audit contractor (RAC)--An
				  eligible company or consultant contracted with HHSC to perform recovery audit
				  services.
(6) Underpayment--An
				  amount paid by HHSC or an HHS agency to a provider at a lesser amount due and
				  payable for items or services furnished under §1902 of the Social Security
				  Act and its implementing regulations and policies, as defined by CMS.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 354 - MEDICAID HEALTH SERVICES › Subchapter B - GENERAL PROVISIONS › Section 354.1452 - Provider Marketing

Current through Reg. 49, No. 28; July 12, 2024
(a) Prohibited
				  marketing activities. A provider participating in the Medicaid or child health
				  plan program, including a provider participating in the network of a managed
				  care organization that contracts with the Health and Human Services Commission
				  to provide services under the Medicaid or child health plan program, may not
				  engage in any marketing activity, including any dissemination of material or
				  other attempt to communicate, that:
(1)
				  Involves unsolicited personal contact, including by door-to-door solicitation,
				  solicitation at a child care facility or other type of facility, direct mail,
				  or telephone, with a Medicaid client or a parent whose child is enrolled in the
				  Medicaid or child health plan program;
(2) Is directed at the client or parent
				  solely because the client or the parent's child is receiving benefits under the
				  Medicaid or child health plan program; and
(3) Is intended to influence the client's or
				  parent's choice of provider.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 354 - MEDICAID HEALTH SERVICES › Subchapter D - TEXAS HEALTHCARE TRANSFORMATION AND QUALITY IMPROVEMENT PROGRAM › Division 1 - GENERAL › Section 354.1601 - Introduction

Current through Reg. 49, No. 28; July 12, 2024
(a) The purpose of this subchapter is to
					 govern implementation of the demonstration waiver under §1115 of the
					 Social Security Act, entitled "Texas Healthcare Transformation and Quality
					 Improvement Program" (the waiver).
(b) Subject to all agreements with the
					 Centers for Medicare and Medicaid Services, this subchapter describes the
					 criteria for participation in a Regional Healthcare Partnership and the
					 allocation and use of waiver funds.
(c) Rules related to reimbursement under the
					 waiver are codified at Chapter 355, Subchapter J, Division 11 of this title
					 (relating to Texas Healthcare Transformation and Quality Improvement Program
					 Reimbursement).
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 354 - MEDICAID HEALTH SERVICES › Subchapter D - TEXAS HEALTHCARE TRANSFORMATION AND QUALITY IMPROVEMENT PROGRAM › Division 2 - REGIONAL HEALTHCARE PARTNERSHIPS › Section 354.1611 - Organization

Current through Reg. 49, No. 28; July 12, 2024
(a) Each Regional Healthcare Partnership
					 (RHP) has geographic boundaries as prescribed by HHSC.
(b) An RHP is composed of one anchor and
					 other participants, which may include IGT entities, performers, and other
					 regional stakeholders. A single entity may act in multiple roles.
(c) An IGT entity may participate in more
					 than one RHP contingent upon HHSC approval.
(d) A performer may only participate in DSRIP
					 in the RHP where it is physically located. However, a physician group practice
					 affiliated with an academic health science center, major cancer hospital, or
					 children's hospital may participate in DSRIP in another region if it receives a
					 DSRIP allocation from that region.
(e) Only providers participating in an RHP
					 are eligible to receive a UC payment, although exceptions may be approved by
					 CMS on a case by case basis.
(f)
					 Each RHP is categorized into a tier as follows:
(1) Tier 1 consists of any RHP that contains
					 at least 15% of the state's total population under 200% of the federal poverty
					 level as determined by the 2006-2010 American Community Survey for
					 Texas.
(2) Tier 2 consists of any
					 RHP that contains at least 7% and less than 15% of the state's total population
					 under 200% of the federal poverty level as determined by the 2006-2010 American
					 Community Survey for Texas.
(3)
					 Tier 3 consists of any RHP that contains at least 3% and less than 7% of the
					 state's total population under 200% of the federal poverty level as determined
					 by the 2006-2010 American Community Survey for Texas.
(4) Tier 4 consists of any RHP that:
(A) contains less than 3% of the state's
					 total population under 200% of the federal poverty level as determined by the
					 2006-2010 American Community Survey for Texas;
(B) does not have a public hospital;
					 or
(C) has one or more public
					 hospitals that, when combined, provide less than 1% of the region's
					 uncompensated care.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 354 - MEDICAID HEALTH SERVICES › Subchapter D - TEXAS HEALTHCARE TRANSFORMATION AND QUALITY IMPROVEMENT PROGRAM › Division 2 - REGIONAL HEALTHCARE PARTNERSHIPS › Section 354.1612 - Anchors

Current through Reg. 49, No. 28; July 12, 2024
(a) Only one entity in a Regional Healthcare
					 Partnership (RHP) may be an anchor.
(b) An entity may be an anchor if it meets
					 the following criteria:
(1) The anchor must
					 be a governmental entity.
(2) If an
					 RHP includes a public hospital, the anchor must be a public hospital, except as
					 described in paragraph (3) of this subsection.
(3) If an RHP does not include a public
					 hospital, or if no public hospital wants to be an anchor, the anchor must be:
(A) a hospital district;
(B) a hospital authority;
(C) a county; or
(D) a state university with an academic
					 health science center.
(4) If a region cannot agree on an anchor,
					 HHSC will designate the anchor. HHSC will base its decision on criteria such as
					 ability to financially support necessary administrative activities, prior
					 relationships with other participants in the region, and history of
					 participating in community and regional activities outside of the
					 waiver.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 354 - MEDICAID HEALTH SERVICES › Subchapter D - TEXAS HEALTHCARE TRANSFORMATION AND QUALITY IMPROVEMENT PROGRAM › Division 2 - REGIONAL HEALTHCARE PARTNERSHIPS › Section 354.1613 - Participants

Current through Reg. 49, No. 28; July 12, 2024
(a) IGT entities. An IGT entity:
(1) determines the allocation of its
					 intergovernmental transfer (IGT) funding consistent with state and federal
					 requirements;
(2) participates in
					 Regional Healthcare Partnership (RHP) planning;
(3) if the IGT entity is itself acting as a
					 performer, selects DSRIP projects;
(4) if the IGT entity is not acting as a
					 performer, cooperates with a performer to select DSRIP projects;
(5) provides the non-federal share of
					 uncompensated care (UC) and delivery system reform incentive payment (DSRIP)
					 pool payments for the entities with which it collaborates; and
(6) may review DSRIP project data submitted
					 by associated performers.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 354 - MEDICAID HEALTH SERVICES › Subchapter D - TEXAS HEALTHCARE TRANSFORMATION AND QUALITY IMPROVEMENT PROGRAM › Division 3 - RHP PLAN CONTENTS AND APPROVAL › Section 354.1621 - RHP Plan

Current through Reg. 49, No. 28; July 12, 2024
(a) A performer may
					 receive DSRIP only if HHSC and the Centers for Medicare and Medicaid Services
					 have approved the RHP plan with which the performer is associated.
(b) An RHP plan must:
(1) meet the requirements listed in the
					 Program Funding and Mechanics Protocol (PFM Protocol) and the RHP Planning
					 Protocol;
(2) describe the Regional
					 Healthcare Partnership's (RHP's) health care needs, referencing sources
					 used;
(3) include a list of IGT
					 entities, performers, and UC hospitals;
(4) include a certification that all the
					 information contained within the RHP plan is true and accurate;
(5) describe the processes used to engage
					 stakeholders including the public meetings held, public posting of the RHP
					 plan, and the process for submitting public comment on the RHP plan;
(6) include a reasonable estimate of the
					 available non-federal funds in the region, by demonstration year, to support
					 the UC and DSRIP pools;
(7) include
					 the total amount of estimated UC and DSRIP funding to be used by demonstration
					 year;
(8) include the minimum
					 number of DSRIP projects as described in §
												RSA
					 354.1632 of this subchapter (relating to
					 DSRIP Requirements for Regional Healthcare Partnerships);
(9) list all DSRIP projects submitted to the
					 RHP for consideration, including those DSRIP projects proposed by RHP
					 participants that were not selected for inclusion in the RHP plan;
(10) include a narrative explaining how all
					 of the DSRIP projects selected by the RHP will:
(A) address the community needs outlined in
					 the RHP plan; and
(B) demonstrate
					 health care delivery transformation and improvement in the quality of care
					 provided in that RHP; and
(11) include a description of each DSRIP
					 project that must:
(A) include the milestones
					 and metrics associated with the project;
(B) for each milestone, include the estimated
					 DSRIP funding;
(C) contain a
					 reasonable estimate of the IGT provided by the IGT entity in connection with
					 the DSRIP project as well as the identity of the IGT entity;
(D) explain how the project addresses the
					 regional health care needs stated within the RHP plan;
(E) justify the amount of DSRIP funding
					 estimated for the project;
(F)
					 explain how the DSRIP funding will not duplicate the funding for federal
					 activities or initiatives funded by the U.S. Department of Health and Human
					 Services;
(G) address each core
					 component required for the project as identified in the RHP Planning Protocol;
					 and
(H) provide a reasonable,
					 quantifiable estimate of the impact the DSRIP project will have on all
					 patients, including Medicaid and low-income uninsured populations.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 354 - MEDICAID HEALTH SERVICES › Subchapter D - TEXAS HEALTHCARE TRANSFORMATION AND QUALITY IMPROVEMENT PROGRAM › Division 3 - RHP PLAN CONTENTS AND APPROVAL › Section 354.1622 - RHP Plan Assessment

Current through Reg. 49, No. 28; July 12, 2024
(a) If HHSC
					 assesses that the RHP plan meets the requirements in §354.1621(b) of this
					 division (relating to RHP Plan), HHSC will submit the RHP plan to the Centers
					 for Medicare and Medicaid Services (CMS) for review.
(b) Upon completion of HHSC's assessment,
					 HHSC notifies the anchor that HHSC:
(1) has
					 submitted the RHP plan to CMS for review;
(2) requires additional information to
					 complete its assessment;
(3)
					 requires modification of the RHP plan, including the specific deficiencies in
					 the RHP plan that HHSC has identified; or
(4) requires modification of a DSRIP project,
					 including the specific deficiencies in the DSRIP project that HHSC has
					 identified. If a particular DSRIP project needs modification, the funding IGT
					 entity and performer associated with that DSRIP project will be notified in
					 addition to the anchor.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 354 - MEDICAID HEALTH SERVICES › Subchapter D - TEXAS HEALTHCARE TRANSFORMATION AND QUALITY IMPROVEMENT PROGRAM › Division 3 - RHP PLAN CONTENTS AND APPROVAL › Section 354.1623 - RHP Plan Modifications and the Addition of Three-Year DSRIP Projects

Current through Reg. 49, No. 28; July 12, 2024
(a) A performer may submit an RHP plan
					 modification request to HHSC to modify elements of an existing DSRIP project
					 prospectively, including changes to milestones and metrics.
(1) The final opportunity to submit a plan
					 modification request for the fourth demonstration year will coincide with the
					 end of the mid-point assessment described in §354.1624 OF THIS DIVISION
					 (relating to the Independent Assessment of DSRIP Projects). A performer will
					 have an opportunity to initiate a plan modification for the fourth and fifth
					 demonstration years by August 2014. Any plan modifications after August 2014
					 will be initiated by either HHSC or the independent assessor as part of the
					 mid-point assessment.
(2) A
					 performer may submit a plan modification request during the fourth
					 demonstration year for changes during the fifth demonstration year only for
					 changes to Category 3 outcomes and three-year DSRIP projects.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 354 - MEDICAID HEALTH SERVICES › Subchapter D - TEXAS HEALTHCARE TRANSFORMATION AND QUALITY IMPROVEMENT PROGRAM › Division 3 - RHP PLAN CONTENTS AND APPROVAL › Section 354.1624 - Independent Assessment of DSRIP Projects

Current through Reg. 49, No. 28; July 12, 2024
(a) Mid-point assessment. An independent
					 assessor will initiate a mid-point assessment of DSRIP projects prior to the
					 fourth demonstration year, consistent with the requirements of the PFM
					 Protocol.
(1) The independent assessor will
					 review a DSRIP project for the following elements:
(A) Compliance with the approved RHP
					 plan.
(B) Compliance with the
					 required core components described in the RHP Planning Protocol, including
					 continuous quality improvement activities.
(C) Ensuring that activities funded through
					 DSRIP do not duplicate activities funded through other federal funds.
(D) The clarity of the improvement milestones
					 for the fourth and fifth demonstration years and those milestones' connection
					 to DSRIP project activities and patient impact.
(E) The benefit of the DSRIP project to the
					 patients served by the project, including the Medicaid and uninsured
					 populations.
(F) The opportunity
					 for DSRIP project improvement.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 354 - MEDICAID HEALTH SERVICES › Subchapter D - TEXAS HEALTHCARE TRANSFORMATION AND QUALITY IMPROVEMENT PROGRAM › Division 4 - DSRIP › Section 354.1631 - DSRIP Categories

Current through Reg. 49, No. 28; July 12, 2024
(a) A performer
					 must choose DSRIP projects from the following categories listed in the RHP
					 Planning Protocol:
(1) "Infrastructure
					 Development" (Category 1) includes DSRIP projects that lay the foundation for
					 delivery system transformation through investments in technology, tools, and
					 human resources.
(2) "Program
					 Innovation and Redesign" (Category 2) includes piloting, testing, and
					 replicating of innovative care models.
(3) "Quality Improvements" (Category 3)
					 requires an outcome related to Category 1 and Category 2 DSRIP
					 projects.
(4) "Population Focused
					 Improvements" (Category 4) includes reporting measures across several domains
					 of healthcare and public health.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 354 - MEDICAID HEALTH SERVICES › Subchapter D - TEXAS HEALTHCARE TRANSFORMATION AND QUALITY IMPROVEMENT PROGRAM › Division 4 - DSRIP › Section 354.1632 - DSRIP Requirements for Regional Healthcare Partnerships

Current through Reg. 49, No. 28; July 12, 2024
(a) Each Regional Healthcare Partnership
					 (RHP) must select a minimum number of projects from Categories 1 and 2.
(1) An RHP in Tier 1 must select a minimum of
					 twenty DSRIP projects from Categories 1 and 2 combined. Of those twenty DSRIP
					 projects, the RHP must select at least ten projects from Category 2.
(2) An RHP in Tier 2 must select a minimum of
					 twelve DSRIP projects from Categories 1 and 2 combined. Of those twelve DSRIP
					 projects, the RHP must select at least six projects from Category 2.
(3) An RHP in Tier 3 must select a minimum of
					 eight DSRIP projects from Categories 1 and 2 combined. Of those eight DSRIP
					 projects, the RHP must select at least four projects from Category 2.
(4) An RHP in Tier 4 must select a minimum of
					 four DSRIP projects from Categories 1 and 2 combined. Of those four DSRIP
					 projects, the RHP must select at least two projects from Category 2.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 354 - MEDICAID HEALTH SERVICES › Subchapter D - TEXAS HEALTHCARE TRANSFORMATION AND QUALITY IMPROVEMENT PROGRAM › Division 4 - DSRIP › Section 354.1633 - DSRIP Requirements for Performers

Current through Reg. 49, No. 28; July 12, 2024
(a) For any DSRIP project in Category 1 or 2,
					 a performer must select at least one process milestone and at least one
					 improvement milestone, as described in the Program Funding and Mechanics
					 Protocol (PFM Protocol). This subsection does not apply to the first
					 demonstration year.
(1) Every DSRIP project
					 must include a metric for quantifiable patient impact for the fifth
					 demonstration year.
(2) Every
					 three-year DSRIP project must include a metric for quantifiable patient impact
					 for both the fourth and fifth demonstrations years.
(3) The quantifiable patient impact metric
					 must include a certain level of Medicaid and low-income patients when specified
					 by HHSC and CMS.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 354 - MEDICAID HEALTH SERVICES › Subchapter D - TEXAS HEALTHCARE TRANSFORMATION AND QUALITY IMPROVEMENT PROGRAM › Division 4 - DSRIP › Section 354.1634 - Waiver Pool Allocation and Valuation

Current through Reg. 49, No. 28; July 12, 2024
(a)
					 Purpose. In an effort to provide certainty to waiver participants, HHSC will
					 provide performer specific allocations. This process requires that certain
					 individual entities receive an allocation based upon a Regional Healthcare
					 Partnership (RHP) specific allocation.
(b) RHP allocation. All available DSRIP funds
					 are allocated among the RHPs for each demonstration year. The share of the
					 DSRIP pool allocated to an RHP will be calculated using the formula: RHP Share
					 of DSRIP Pool = (200%FPL + %MedicaidAcute + 2011UPL)/3, where:
(1) "200%FPL" is the region's share of the
					 state's population with income below 200% of the federal poverty level as
					 determined by the 2006-2010 American Community Survey for Texas;
(2) "%MedicaidAcute" is the region's share of
					 all Texas Medicaid acute care payments in state fiscal year (SFY) 2011. Texas
					 Medicaid acute care payments consist of the sum of Medicaid fee-for-service,
					 Medicaid managed care, Vendor Drug Program, and Primary Care Case Management
					 payments; and
(3) "2011UPL" is the
					 region's share of the state's Medicaid supplemental payments through the former
					 Upper Payment Limit program made to providers in the RHP for SFY
					 2011.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 354 - MEDICAID HEALTH SERVICES › Subchapter D - TEXAS HEALTHCARE TRANSFORMATION AND QUALITY IMPROVEMENT PROGRAM › Division 4 - DSRIP › Section 354.1635 - DSRIP Project Valuation

Current through Reg. 49, No. 28; July 12, 2024
(a) Each
					 individual DSRIP project and domain must include a rational monetary value.
					 That value is determined by the performer within the strictures described in
					 this subsection and the PFM Protocol.
(1)
					 Except as described in paragraph (2) of this subsection, a hospital performer
					 must ensure that project values comport with the following funding
					 distribution:
Attached
						Graphic
(2) A
					 hospital that is exempted from Category 4 reporting may allocate the Category 4
					 funding to Categories 1, 2, or 3.
(3) A non-hospital performer must ensure that
					 the project values comport with the following funding distribution:
Attached
						Graphic
(4) A
					 Category 1 or 2 DSRIP project may be valued at no more than the greater of 10%
					 of a performer's Pass One allocation or $20 million in total for demonstration
					 years two through five. For DSRIP projects conducted under the collaboration
					 options, the project may be valued at no more that the greater of the sum of
					 10% of each collaborator's Pass One allocation or $20 million in total for
					 demonstration years two through five. For three-year DSRIP projects, the total
					 value for any pair of Category 1 and 3 or Category 2 and 3 projects may be no
					 more than $20 million for demonstration years three through five.
(5) Milestones for a Category 1 or 2 DSRIP
					 project must be valued equally within a demonstration year.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 354 - MEDICAID HEALTH SERVICES › Subchapter D - TEXAS HEALTHCARE TRANSFORMATION AND QUALITY IMPROVEMENT PROGRAM › Division 4 - DSRIP › Section 354.1636 - Payment for DSRIP Performance

Current through Reg. 49, No. 28; July 12, 2024
Payment for DSRIP project performance is based on
						achievement of a milestone bundle, outcome, or domain.
(1) A milestone bundle is the compilation of
					 milestones and related metrics associated with a project in a given
					 demonstration year.
(2) The amount
					 of the DSRIP to the performer is determined by the value assigned for the DSRIP
					 project for that demonstration year and the progress made within the milestone
					 bundle.
(3) To calculate the
					 payment for Categories 1 and 2:
(A) First, a
					 performer must fully achieve a metric to include that metric in the DSRIP
					 payment calculation.
(B) Second, a
					 milestone is assigned an achievement value of:
(i) 1.0 if all metrics are met;
(ii) 0.75 if at least 75% of the metrics are
					 met;
(iii) 0.5 if at least 50% of
					 the metrics are met;
(iv) 0.25 if
					 at least 25% of the metrics are met; and
(v) zero if less than 25% of the metrics are
					 met.
(C) Third, the
					 achievement values for each milestone are summed.
(D) Fourth, the result of subparagraph (C) of
					 this paragraph is divided by the total possible achievement value of the
					 milestone bundle.
(E) Fifth, the
					 value of the DSRIP project for that demonstration year, as determined under
					 §354.1635(a) of this division (relating to DSRIP Project Valuation), is
					 multiplied by the result of subparagraph (D) of this paragraph.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 354 - MEDICAID HEALTH SERVICES › Subchapter D - TEXAS HEALTHCARE TRANSFORMATION AND QUALITY IMPROVEMENT PROGRAM › Division 4 - DSRIP › Section 354.1637 - DSRIP Project Termination and Payment Recoupment

Current through Reg. 49, No. 28; July 12, 2024
(a) If a DSRIP project is terminated prior to
					 the mid-point assessment described in §354.1624 of this division (relating
					 to Independent Assessment of DSRIP Projects), HHSC will recoup all prior DSRIP
					 payments associated with the project.
(b) If a DSRIP project is terminated after
					 the mid-point assessment but before a payment is made for performance in the
					 fourth demonstration year, no prior DSRIP payments will be recouped.
(c) If a DSRIP project is terminated after
					 the performer receives a DSRIP payment following the end of the mid-point
					 assessment, any DSRIP payment made after the mid-point assessment will be
					 recouped.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 354 - MEDICAID HEALTH SERVICES › Subchapter D - TEXAS HEALTHCARE TRANSFORMATION AND QUALITY IMPROVEMENT PROGRAM › Division 5 - ACTIONS IN PREPARATION FOR EXTENSION OF THE DSRIP PROGRAM › Section 354.1641 - Definitions

Current through Reg. 49, No. 28; July 12, 2024
The following terms, when used in this division, have the
						following meanings unless the context clearly indicates otherwise.
(1) Extension period--The period of time, as
					 approved by the Centers for Medicare & Medicaid Services (CMS), for which
					 the waiver is extended beyond the initial demonstration period.
(2) Federal poverty level--The household
					 income guidelines issued annually and published in the
Federal
					 Register
by the United States Department of Health and Human
					 Services.
(3) Initial demonstration
					 period--The first five demonstration years (DYs) of the waiver, or December 12,
					 2011, through September 30, 2016.
(4) Medicaid and Low-income or Uninsured
					 (MLIU) Quantifiable Patient Impact (QPI)--The number of MLIU individuals served
					 or encounters provided to MLIU individuals during an applicable DY that are
					 attributable to the DSRIP project.
(5) Medicaid and Low-income or Uninsured
					 (MLIU) Quantifiable Patient Impact (QPI) Goal--The number of MLIU individuals
					 that a performer intends to serve, or the number of MLIU encounters that a
					 performer intends to provide, during an applicable DY that are attributable to
					 the DSRIP project.
(6) Transition
					 year--As it relates to DSRIP, the first DY of the extension period.
Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 354 - MEDICAID HEALTH SERVICES › Subchapter D - TEXAS HEALTHCARE TRANSFORMATION AND QUALITY IMPROVEMENT PROGRAM › Division 5 - ACTIONS IN PREPARATION FOR EXTENSION OF THE DSRIP PROGRAM › Section 354.1643 - Medicaid and Low-Income or Uninsured (MLIU) Quantifiable Patient Impact (QPI)

Current through Reg. 49, No. 28; July 12, 2024
(a) To qualify as a
					 Medicaid individual for purposes of MLIU QPI, the individual must be enrolled
					 in Medicaid at the time of at least one DSRIP project encounter during the
					 applicable demonstration year (DY).
(b) To qualify as a low-income or uninsured
					 individual for purposes of MLIU QPI, the individual must either be below 200
					 percent of the federal poverty level or must not have health insurance at the
					 time of at least one DSRIP project encounter during the applicable
					 DY.
(c) If an individual was
					 enrolled in Medicaid at the time of one DSRIP project encounter during the
					 applicable DY, and was low-income or uninsured at the time of a separate DSRIP
					 project encounter during the applicable DY, that individual is classified as a
					 Medicaid individual for purposes of MLIU QPI.