Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 355 - REIMBURSEMENT RATES › Subchapter J - PURCHASED HEALTH SERVICES › Division 17 - LONESTAR SELECT CONTRACTING PROGRAM › Section 355.8321 - LoneSTAR Select Contracting Process for Inpatient Hospital Services

Current through Reg. 49, No. 28; July 12, 2024
(a) Introduction. This section implements the
					 provisions of Senate Bill 79, 73rd Texas Legislature, 1993, mandating selective
					 contracting for non-emergency inpatient hospital services.
(b) Definitions. The following words and
					 terms, when used in this section, shall have the following meanings, unless the
					 context clearly indicates otherwise.
(1)
					 Market area--A geographic subdivision of the State of Texas defined as a group
					 of geographically contiguous counties in which the Texas Department of Health
					 (department) determines that health care providers will be invited to apply for
					 selective contracting agreements. In general, each Metropolitan Statistical
					 Area (MSA) in the State will be considered for designation as a market area.
					 Where warranted by historical patient migration patterns, the department may
					 designate certain non-MSA counties that are geographically contiguous to an MSA
					 to be included with MSA counties within a market area.
(2) Effective service area--For each health
					 care provider in a market area, the geographic area, as defined on a zip code
					 basis, in which the health care provider has historically provided inpatient
					 hospital services to Medicaid patients. For purposes of subsections (f) and (g)
					 of this section, the effective service area will be determined based on
					 historical Medicaid inpatient claims data.
(3) Executive Oversight Committee--The
					 executive committee established by the department to direct the selective
					 contracting initiative.
(4)
					 Hospital capacity to provide specialized service offerings--
(A) For the LoneSTAR Select Contracting
					 Program I, the presence or absence of specific acute care hospital services,
					 including, but not limited to, trauma centers, burn units, neonatal intensive
					 care unit services, and psychiatric services, that are required to be available
					 in the market to ensure adequate access to quality care.
(B) For the LoneSTAR Select Contracting
					 Program II, the presence or absence of specific inpatient psychiatric services,
					 including, but not limited to, separate units for young children and
					 adolescents, separate psychiatric and substance abuse treatment services,
					 closed and open units, and distinct programs (e.g., dual diagnosis, eating
					 disorder) that may be required to be available in the market to ensure adequate
					 access to quality.
(5)
					 New facility--A health care provider facility substantially constructed after
					 the time the department determined the network of health care providers that
					 would be contracted under selective provider agreements. Such term shall not
					 include facilities that were built and operational at the time the department
					 determined the network of selective providers for the affected market area;
					 regardless of whether the facility's corporate structure and/or name have
					 changed due to merger, acquisition, or other corporate
					 reorganization.
(6) Potential
					 network--Any combination of applicant health care providers (whether the result
					 of a joint proposal or determined by the department) that offer a:
(A) combined effective service area that
					 provides geographic coverage of the market area to the same extent that
					 coverage is provided under current practice;
(B) combined service capacity equal to at
					 least:
(i) 115% of the most recently
					 available historic service volume experience for the market area for the
					 LoneSTAR Select Contracting Program I; or
(ii) 125% of the most recently available
					 historic service volume experience for the market area for the LoneSTAR Select
					 Contracting Program II; and
(C) combination of specialized services
					 available within the market area that is at least as broad as the range of
					 specialized services presently available to Medicaid recipients in that market
					 area.
(7) Selective
					 contracting--A method of contracting, granted through waivers of certain
					 provisions of the Social Security Act, that allows the department to contract
					 selectively with health care providers for non-emergency inpatient services,
					 thereby improving its ability to act as a prudent purchaser of services and to
					 manage the Medical Assistance Program in a more effective and efficient manner,
					 as required by Senate Bill 79.
(8)
					 Selective provider agreement--An agreement which includes an amendment to a
					 health care provider's existing provider agreement with the department and
					 involves selective contracting.
(9)
					 Disproportionate share hospital--A health care provider participating in the
					 Medicaid program that, according to state Medicaid criteria, meets the
					 conditions of participation and serves a disproportionate share of indigent
					 patients. Additional requirements for disproportionate share hospitals are
					 specified in § 29.609 of this title (relating to Additional Reimbursement
					 to Disproportionate Share Hospitals) and § 29.610 of this title (relating
					 to Disproportionate Share Hospital Reimbursement Methodology for State-Owned
					 Teaching Hospitals).
(10) Health
					 care provider--
(A) any acute care hospital
					 that is eligible to provide inpatient hospital services to Medicaid recipients;
					 or
(B) any inpatient mental health
					 facility, as defined within this section.
(11) Optional volume management
					 activities--Those activities that acute care hospitals may propose to furnish
					 to Medicaid recipients in a market area to expand access to primary care
					 services and ensure more appropriate use of acute care hospital facilities.
					 Such activities may include, but not be limited to, furnishing ambulatory
					 primary care clinic services to Medicaid recipients, and furnishing nurse
					 hotlines which Medicaid recipients may call to receive professional advice
					 about the most appropriate means to obtain medical care.
(12) Hardship exemption procedure--A method
					 for non-contracted health care providers to obtain prior authorization from the
					 department to provide non-emergency inpatient services to Medicaid recipients
					 who would experience an unreasonable travel burden under the LoneSTAR Select
					 Contracting Program(s).
(13)
					 Emergency inpatient services--An admission into a health care provider with a
					 diagnosis meeting the definition of a medical emergency.
(14) Non-emergency inpatient services--An
					 admission into a health care provider with a diagnosis not meeting the
					 definition of a medical emergency.
(15) LoneSTAR Select Contracting Program
					 I--The selective contracting program designed and implemented for acute care
					 hospitals.
(16) LoneSTAR Select
					 Contracting Program II--The selective contracting program designed and
					 implemented for inpatient mental health facilities as defined in the Health and
					 Safety Code, §
												RSA
					 571.003.
(17) Inpatient mental health facility--A
					 mental health facility that can provide 24-hour residential and acute inpatient
					 psychiatric services that is:
(A) a facility
					 operated by the Texas Department of Mental Health and Mental
					 Retardation;
(B) a private mental
					 hospital licensed by the department;
(C) a community center;
(D) a facility operated by a community center
					 or other entity the Texas Department of Mental Health and Mental Retardation
					 designates to provide mental health services;
(E) an identifiable part of a general
					 hospital in which diagnosis, treatment, and care for persons with mental
					 illness is provided and that is licensed by the department; or
(F) a hospital operated by a federal
					 agency.