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 353.1305 - Uniform Hospital Rate Increase Program

Current through Reg. 49, No. 28; July 12, 2024
(a) Introduction. This section describes the
				  circumstances for program periods before September 1, 2022, or for the time
				  period as approved by the Centers for Medicare and Medicaid Services, under
				  which HHSC directs a Managed Care Organization (MCO) to provide a uniform
				  percentage rate 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 rate increase.
(b) Definitions. The following definitions
				  apply when the terms are used in this section. Terms that are used in this and
				  other sections of this subchapter may be defined in §
										RSA 353.1301
				  of this subchapter (relating to General Provisions).
(1) Children's hospital--A Medicaid hospital
				  designated by Medicare as a children's hospital.
(2) 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, and any other services that HHSC determines should not be
				  subject to the rate increase.
(3)
				  Institution for mental diseases (IMD)--A hospital that is primarily engaged in
				  providing psychiatric diagnosis, treatment, or care of individuals with mental
				  illness.
(4) Non-urban public
				  hospital--
(A) A hospital owned and operated
				  by a governmental entity, other than a hospital described in paragraph (8) of
				  this subsection, defining rural public hospital, or a hospital described in
				  paragraph (10) of this subsection, defining urban public hospital; or
(B) A hospital meeting the definition of
				  rural public-financed hospital in §
												RSA
				  355.8065(b)(37) of this
				  title (relating to Disproportionate Share Hospital Reimbursement Methodology),
				  other than a hospital described in paragraph (7) of this subsection defining
				  rural private hospital.
(5) 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.
(6) 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. An SDA that is unable to participate in the program
				  described in this section beginning September 1 may apply to participate
				  beginning March 1 of the program period and ending August 31. Participation
				  during such a modified program period is subject to the application and
				  intergovernmental-transfer deadlines described in subsection (g) of this
				  section.
(7) Rural private
				  hospital--A privately-operated hospital that is a rural hospital as defined in
				  §
											RSA
				  355.8052 of this title (relating to Inpatient
				  Hospital Reimbursement).
(8) Rural
				  public hospital--A hospital that is owned and operated by a governmental entity
				  and is a rural hospital as defined in §
											RSA
				  355.8052 of this title.
(9) State-owned hospital--A hospital that is
				  owned and operated by a state university or other state agency.
(10) Urban public hospital--A hospital that
				  is operated by or under a lease contract with one of the following entities:
				  the Dallas County Hospital District, the El Paso County Hospital District, the
				  Harris County Hospital District, the Tarrant County Hospital District, the
				  Travis County Healthcare District dba Central Health, the University Health
				  System of Bexar County, the Ector County Hospital District, the Lubbock County
				  Hospital District, or the Nueces County Hospital District.