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 353.1301 - General Provisions

Current through Reg. 49, No. 28; July 12, 2024
(a) Purpose. The
				  purpose of this subchapter is to describe the circumstances and programs under
				  which the Texas Health and Human Services Commission may direct expenditures
				  for delivery system and provider payment initiatives through its contracts with
				  Medicaid managed care organizations. Federal authority for such directed
				  expenditures is codified at
				  RSA
				  438.6(c).
(b) Definitions. The following definitions
				  apply when the terms are used in this subchapter. Terms that are used in only
				  one program described in this subchapter may be defined in the section of this
				  subchapter describing that program.
(1)
				  Capitation rate--A fixed, predetermined fee paid by HHSC to the managed care
				  organization each month, in accordance with the contract, for each enrolled
				  member. In exchange for this, the managed care organization arranges for or
				  provides a defined set of covered services to the enrolled member, regardless
				  of the amount of covered services used by the enrolled member.
(2) Centers for Medicare & Medicaid
				  Services (CMS)--The federal agency within the United States Department of
				  Health and Human Services responsible for overseeing and directing Medicare and
				  Medicaid.
(3) HHSC--The Texas
				  Health and Human Services Commission or its designee.
(4) Intergovernmental transfer (IGT)--A
				  transfer of public funds from another state agency or a non-state governmental
				  entity to HHSC.
(5) Managed care
				  organization (MCO)--A Medicaid managed care organization contracted with HHSC
				  to provide health care services to Medicaid recipients.
(6) Non-federal share--The portion of program
				  expenditures that is not federal funds. The non-federal share is equal to 100
				  percent minus the federal medical assistance percentage (FMAP) for Texas for
				  the state fiscal year corresponding to the program year and for the population
				  served.
(7) Non-state governmental
				  entity--A hospital authority, hospital district, health district, city, or
				  county.
(8) Program rate
				  component--The fixed percentage of the capitation rate that is attributable to
				  the delivery system or provider payment initiative.
(9) Provider--A credentialed and licensed
				  individual, facility, agency, institution, organization, or other entity that
				  has a contract with the MCO for the delivery of covered services to the MCO's
				  members.
(10) Public funds--Funds
				  derived from taxes, assessments, levies, and investments. Public funds also
				  include other public revenues within the sole and unrestricted control of a
				  governmental entity. Public funds do not include gifts, grants, trusts, or
				  donations, the use of which is conditioned on supplying a benefit solely to the
				  donor or grantor of the funds.
(11)
				  Service delivery area (SDA)--The counties included in any HHSC-defined
				  geographic area as applicable to each MCO.
(12) 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.