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 353.1306 - Comprehensive Hospital Increase Reimbursement Program for Program Periods on or after September 1, 2021

Current through Reg. 49, No. 28; July 12, 2024
(a)
				  Introduction. This section establishes the Comprehensive Hospital Increase
				  Reimbursement Program (CHIRP) for program periods on or after September 1,
				  2021, wherein the Health and Human Services Commission (HHSC) directs a managed
				  care organization (MCO) to provide a uniform reimbursement increase to
				  hospitals in the MCO's network in a designated service delivery area (SDA) for
				  the provision of inpatient services, outpatient services, or both. This section
				  also describes the methodology used by HHSC to calculate and administer such
				  reimbursement increases. CHIRP is designed to incentivize hospitals to improve
				  access, quality, and innovation in the provision of hospital 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).
(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) Average Commercial Reimbursement (ACR)
				  Upper Payment Limit (UPL)--A calculated estimation of what an average
				  commercial payor pays for the same Medicaid services.
(3) Children's hospital--A children's
				  hospital as defined by §
											355.8052 of this title (relating to
				  Inpatient Hospital Reimbursement).
(4) 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 skilled nursing
				  facility or intermediate care facility services furnished by a hospital with
				  swing-bed approval, or any other services that HHSC determines should not be
				  subject to the rate increase.
(5)
				  Institution for mental diseases (IMD)--A hospital that is primarily engaged in
				  providing psychiatric diagnosis, treatment, or care of individuals with mental
				  illness. IMD hospitals are reimbursed as freestanding psychiatric facilities
				  under §
											355.8060 of this title (relating to
				  Reimbursement Methodology for Freestanding Psychiatric Facilities).
(6) Medicare payment gap--The difference
				  between what Medicare is estimated to pay for the services and what Medicaid
				  actually paid for the same services.
(7) 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. HHSC may, in its
				  contracts with MCOs governing rate increases under this section, exclude from
				  the definition of outpatient hospital services such services as are not
				  generally furnished by most hospitals in the state, or such services that HHSC
				  determines should not be subject to the rate increase.
(8) Program period--A period of time for
				  which HHSC will contract with participating 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.
(9) Rural
				  hospital--A hospital that is a rural hospital as defined in §
											355.8052 of this title.
(10) State-owned non-IMD hospital--A hospital
				  that is owned and operated by a state university or other state agency that is
				  not primarily engaged in providing psychiatric diagnosis, treatment, or care of
				  individuals with mental disease.
(11) Urban hospital--An urban hospital as
				  defined by §
											355.8052 of this
				  title.