Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 355 - REIMBURSEMENT RATES › Subchapter C - REIMBURSEMENT METHODOLOGY FOR NURSING FACILITIES › Section 355.309 - Performance-Based Add-On Payment Methodology

Current through Reg. 49, No. 28; July 12, 2024
(a) Purpose of methodology. Performance-based
				  add-on payments provide additional funding to nursing facilities that meet
				  specific performance criteria.
(b)
				  Funding source. Each fiscal year, the Commissioner of the Texas Health and
				  Human Services Commission (HHSC) will identify the portion, if any, of Medicaid
				  nursing facility service provider funding that will be designated for
				  performance-based add-on payments. This amount is subsequently called the
				  Performance-based Add-on Fund (PAF).
(c) Provider defined. For the purposes of
				  this methodology, a nursing facility provider is a Medicaid long-term care
				  contracted provider licensed and regulated by the Texas Department of Human
				  Services (DHS).
(d) Provider
				  eligibility. To be eligible for performance-based add-on payments, a provider
				  must have had Medicaid-certified beds during the entire service period as
				  defined in subsection (e) of this section.
(e) Service period. The service period for
				  the first year of performance-based add-on payments will begin on September 1,
				  2000. Each service period will correspond to a state fiscal year that begins
				  September 1 of one year and continues through August 31 of the following
				  year.
(f) Performance criteria.
				  Provider performance will be judged on the basis of compliance with state and
				  federal regulations as well as on the basis of resident outcomes.
(g) Regulatory compliance. Compliance with
				  state and federal regulations is a prerequisite for performance-based add-on
				  payments.
(h) Regulatory compliance
				  accountability period. Each provider's regulatory compliance will be determined
				  as the lowest level of compliance attained on any regulatory visit to that
				  provider during the service period and recorded in the Long-Term
				  Care-Regulatory (LTC-R) data warehouse as of November 30 of the calendar year
				  in which the service period ends. If the service period does not encompass a
				  certification survey to the provider, then the most recently recorded
				  certification visit prior to the service period will be included in the
				  determination of the provider's regulatory compliance.
(i) Levels of regulatory compliance. The
				  levels of regulatory compliance are based on Health Care Financing
				  Administration (HCFA) State Operations Manual, Transmittal 274, June 1995,
				  HCFA-Pub.7. The following table provides the precise definition for each
				  compliance level.
Attached
					 Graphic
(j)
				  Resident outcomes. Resident outcomes are determined using a system of Quality
				  Indicators (QIs) whose definitions were designed by the Center for Health
				  Systems Research and Analysis (CHSRA) under contract to HCFA. These QIs are
				  computed from resident assessment data transmitted directly from the facilities
				  to the HCFA Minimum Data Set (MDS) automation system. The QI automation that
				  will be used in the performance-based add-on system is the DHS implementation
				  already in use for the Quality Reporting System (QRS).
(k) Resident outcomes performance indices.
				  Provider performance with respect to resident outcomes is scored using two
				  indices derived from QI scores. These indices are called the Potential
				  Advantages Score (PAS) and the Potential Disadvantages Score (PDS).
(l) Potential advantages score. The following
				  table provides the definitions for the PAS scale.
Attached
					 Graphic
(m)
				  Potential disadvantages score. The following table provides the definitions for
				  the PDS scale.
Attached
					 Graphic
(n)
				  Determination of PAS and PDS. The PAS index is calculated by counting the
				  number of QIs on which a provider appears at or below the 10th percentile
				  performance threshold. The PDS index is calculated by counting the number of QI
				  conditions on which either a provider appears at or above the 90th percentile
				  performance threshold or on which it has a non-zero numerator for any one of
				  three sentinel event QIs. The sentinel event QIs are dehydration, fecal
				  impaction, and pressure sores in low risk residents. PAS and PDS indices are
				  converted to PAS and PDS ratings using the definitions in the tables in
				  subsection (l) and subsection (m) of this section.
(o) Determination of the 10th and 90th
				  percentile QI performance thresholds.
(1) For
				  defining the 10th and 90th percentile performance thresholds, the QI scale is
				  divided into 100 steps. The PAS threshold is defined as the smallest QI value
				  (in .01 steps) that yields the largest percentile less than or equal to 10%.
				  The PDS threshold is defined as the largest QI value (in .01 steps) that yields
				  the smallest percentile greater than or equal to 90%.
(2) If because of the distribution of QI
				  scores, the 10th percentile performance threshold for a particular QI cannot be
				  determined, then that QI is excluded from those that can count toward PAS.
				  Similarly, a QI is excluded from those that can count toward PDS if the 90th
				  percentile threshold cannot be determined.
(3) For the three QIs that HCFA identifies as
				  sentinel events (dehydration, pressure sores in low risk residents, and fecal
				  impaction), a single occurrence counts toward the PDS. Sentinel event QIs have
				  neither a PAS nor PDS threshold.