Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 355 - REIMBURSEMENT RATES › Subchapter J - PURCHASED HEALTH SERVICES › Division 11 - TEXAS HEALTHCARE TRANSFORMATION AND QUALITY IMPROVEMENT PROGRAM REIMBURSEMENT › Section 355.8214 - Waiver Payments to Physician Group Practices for Uncompensated Charity Care

Current through Reg. 49, No. 28; July 12, 2024
(a) Introduction. Beginning October 1, 2019,
					 payments are available under this section to help defray the uncompensated
					 charity-care costs incurred by eligible physician group practices described in
					 subsection (c) of this section. Waiver payments to physician group practices
					 for uncompensated care provided before October 1, 2019, are described in
					 §355.8202 of this division (relating to Waiver Payments to Physician Group
					 Practices for Uncompensated Care). Waiver payments to an eligible physician
					 group practice must be in compliance with the Centers for Medicare &
					 Medicaid Services approved waiver Program Funding and Mechanics Protocol, HHSC
					 waiver instructions, and this section.
(b) Definitions.
(1) Allocation amount--The amount of funds
					 approved by the Centers for Medicare & Medicaid Services for
					 uncompensated-care payments for the demonstration year that is allocated to the
					 physician group practice uncompensated-care pool, as described in
					 §355.8212 of this division (relating to Waiver Payments to Hospitals for
					 Uncompensated Charity Care). Starting in demonstration year eleven, the
					 physician group practice uncompensated-care pool will be further divided into a
					 state-owned physician group practice pool and a non-state-owned physician group
					 practice pool.
(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, or its successor.
(3) Charity care--Healthcare services
					 provided without expectation of reimbursement to uninsured patients who meet
					 the provider's charity-care policy. The charity-care policy should adhere to
					 the charity-care principles of the Healthcare Financial Management Association
					 Principles and Practices Board Statement 15 (December 2012). Charity care
					 includes full or partial discounts given to uninsured patients who meet the
					 provider's financial assistance policy. Charity care does not include bad debt,
					 courtesy allowances, or discounts given to patients who do not meet the
					 provider's charity-care policy or financial assistance policy.
(4) Demonstration year--The 12-month period
					 beginning October 1 for which the payments calculated under this section are
					 made. Demonstration year one was October 1, 2011, through September 30,
					 2012.
(5) Governmental entity--A
					 state agency or a political subdivision of the state. A governmental entity
					 includes a hospital authority, hospital district, city, county, or state
					 entity.
(6) HHSC--The Texas Health
					 and Human Services Commission or its designee.
(7) Intergovernmental transfer (IGT)--A
					 transfer of public funds from a governmental entity to HHSC.
(8) Mid-Level Professional--Medical
					 practitioners which include the following professions only:
(A) Certified Registered Nurse
					 Anesthetists;
(B) Nurse
					 Practitioners;
(C) Physician
					 Assistants;
(D) Dentists;
(E) Certified Nurse Midwives;
(F) Clinical Social Workers;
(G) Clinical Psychologists; and
(H) Optometrists.
(9) Non-state-owned physician group--Any
					 physician group not included in the definition of state-owned physician group
					 that qualifies for uncompensated care payments.
(10) Public funds--Funds derived from taxes,
					 assessments, levies, investments, and 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) Regional Healthcare Partnership (RHP)--A
					 collaboration of interested participants that work collectively to develop and
					 submit to the state a regional plan for health care delivery system reform.
					 Regional Healthcare Partnerships will support coordinated, efficient delivery
					 of quality care and a plan for investments in system transformation that is
					 driven by the needs of local hospitals, communities, and populations.
(12) Service Delivery Area (SDA)--The
					 counties included in any HHSC-defined geographic area as applicable to each
					 Managed Care Organization.
(13)
					 State-owned physician group--An eligible physician group practice that is
					 state-owned or state-operated. Physicians under contract with such a physician
					 group practice are not included. Eligible state-owned or state-operated
					 physician group practices consist of those affiliated with:
(A) University of
					 Texas--Southwestern;
(B) University
					 of Texas--San Antonio;
(C)
					 University of Texas--Tyler;
(D)
					 University of Texas--Houston;
(E)
					 University of Texas Medical Branch--Galveston;
(F) University of Texas--MD Anderson Cancer
					 Center;
(G) University of North
					 Texas;
(H) Texas Tech
					 University--Amarillo;
(I) Texas
					 Tech University--El Paso;
(J) Texas
					 Tech University--Lubbock;
(K) Texas
					 Tech University--Odessa; or
(L)
					 Texas A&M Health Science Center.
(14) Uncompensated-care payments--Payments
					 intended to defray the uncompensated costs of charity care as defined in
					 paragraph (3) of this subsection.
(15) Uncompensated-care physician
					 application--A form prescribed by HHSC to identify uncompensated costs for
					 Medicaid-enrolled providers.
(16)
					 Uninsured patient--An individual who has no health insurance or other source of
					 third-party coverage for services, as defined by CMS. The term includes an
					 individual enrolled in Medicaid who received services that do not meet the
					 definition of medical assistance in section 1905(a) of the Social Security Act
					 (Medicaid services), if such inclusion is specified in the hospital's
					 charity-care policy or financial assistance policy and the patient meets the
					 hospital's policy criteria.
(17)
					 Waiver--The Texas Healthcare Transformation and Quality Improvement Program
					 Medicaid demonstration waiver under §1115 of the Social Security
					 Act.