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 355.8212 - Waiver Payments to Hospitals for Uncompensated Charity Care

Current through Reg. 49, No. 28; July 12, 2024
(a) Introduction. Texas Healthcare
					 Transformation and Quality Improvement Program §1115(a) Medicaid
					 demonstration waiver payments are available under this section to help defray
					 the uncompensated cost of charity care provided by eligible hospitals on or
					 after October 1, 2019. Waiver payments to hospitals for uncompensated care
					 provided before October 1, 2019, are described in §355.8201 of this
					 division (relating to Waiver Payments to Hospitals for Uncompensated Care).
					 Waiver payments to hospitals 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
					 each uncompensated-care provider pool or individual hospital, as described in
					 subsections(f)(2) and (g)(6) of this section.
(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)
					 Data year--A 12-month period that is described in §
												355.8066 of this subchapter
					 (relating to State Payment Cap and Hospital-Specific Limit Methodology) and
					 from which HHSC will compile cost and payment data to determine
					 uncompensated-care payment amounts. This period corresponds to the
					 Disproportionate Share Hospital data year.
(5) Demonstration year--The 12-month period
					 beginning October 1 for which the payments calculated under this section are
					 made. This period corresponds to the Disproportionate Share Hospital (DSH)
					 program year. Demonstration year one corresponded to the 2012 DSH program year,
					 October 1, 2011, through September 30, 2012.
(6) Disproportionate Share Hospital (DSH)--A
					 hospital participating in the Texas Medicaid program as defined in §
												355.8065 of this subchapter
					 (relating to Disproportionate Share Hospital Reimbursement
					 Methodology).
(7) 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.
(8) HHSC--The Texas Health
					 and Human Services Commission, or its designee.
(9) Impecunious charge ratio--A ratio used to
					 determine if a hospital is eligible to receive payment from the HICH (High
					 Impecunious Charge Hospital) pool as described in subsection (f)(2)(C)(ii) of
					 this section.
(10) Institution for
					 mental diseases (IMD)--A hospital that is primarily engaged in providing
					 psychiatric diagnosis, treatment, or care of individuals with mental illness,
					 defined in §1905(i) of the Social Security Act. IMD hospitals are
					 reimbursed as freestanding psychiatric facilities under §
												355.8060 of this subchapter
					 (relating to Reimbursement Methodology for Freestanding Psychiatric Facilities)
					 and §
												355.761 of this chapter (relating
					 to Reimbursement Methodology for Institutions for Mental Diseases
					 (IMD)).
(11) Intergovernmental
					 transfer (IGT)--A transfer of public funds from a governmental entity to
					 HHSC.
(12) Medicaid cost
					 report--Hospital and Hospital Health Care Complex Cost Report (Form CMS 2552),
					 also known as the Medicare cost report.
(13) 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.
(14) Non-public hospital--A hospital that
					 meets the definition of non-public provider as defined in §
												355.8200 of this subchapter
					 (relating to Retained Funds for the Uncompensated Care Program).
(15) 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.
(16) Public Health Hospital (PHH)--The Texas
					 Center for Infectious Disease or any successor facility operated by the
					 Department of State Health Services.
(17) Rural hospital--A hospital enrolled as a
					 Medicaid provider that:
(A) is located in a
					 county with 68,750 or fewer persons according to most recent decennial census
					 U.S. Census; or
(B) was designated
					 by Medicare as a Critical Access Hospital (CAH) or a Sole Community Hospital
					 (SCH) before October 1, 2021; or
(C) is designated by Medicare as a CAH, SCH,
					 or Rural Referral Center (RRC); and is not located in a Metropolitan
					 Statistical Area (MSA), as defined by the U.S. Office of Management and Budget;
					 or
(D) meets all of the following:
(i) has 100 or fewer beds;
(ii) is designated by Medicare as a CAH, SCH,
					 or an RRC; and
(iii) is located in
					 an MSA.
(18)
					 Service Delivery Area (SDA)--The counties included in any HHSC-defined
					 geographic area as applicable to each Managed Care Organization
					 (MCO).
(19) State institution for
					 mental diseases (State IMD)--A hospital that is primarily engaged in providing
					 psychiatric diagnosis, treatment, or care of individuals with mental illness
					 defined in §1905(i) of the Social Security Act and that is owned and
					 operated by a state university or other state agency. State IMD hospitals are
					 reimbursed as freestanding psychiatric facilities under §
												355.761 of this chapter (relating
					 to Reimbursement Methodology for Institutions for Mental Disease
					 (IMD)).
(20) State-owned
					 hospital--A hospital that is defined as a state IMD, state-owned teaching
					 hospital, or a Public Health Hospital (PHH) in this section.
(21) State-owned teaching hospital--A
					 hospital that is a state-owned teaching hospital as defined in §
												355.8052 of this subchapter
					 (relating to Inpatient Hospital Reimbursement).
(22) State Payment Cap--The maximum payment
					 amount, as applied to payments that will be made for the program year, that a
					 hospital may receive in reimbursement for the cost of providing
					 Medicaid-allowable services to individuals who are Medicaid-eligible or
					 uninsured. The state payment cap is calculated using the methodology described
					 in §
												355.8066 of this
					 subchapter.
(23) Transferring
					 public hospital--A hospital that is a transferring public hospital as defined
					 in §
												355.8065 of this
					 subchapter.
(24) Uncompensated-care
					 application--A form prescribed by HHSC to identify uncompensated costs for
					 Medicaid-enrolled providers.
(25)
					 Uncompensated-care payments--Payments intended to defray the uncompensated
					 costs of charity care as defined in this subsection.
(26) Uninsured patient--An individual who has
					 no health insurance or other source of third-party coverage for the services
					 provided. 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.
(27) Waiver--The Texas Healthcare
					 Transformation and Quality Improvement Program Medicaid demonstration waiver
					 under §1115 of the Social Security Act.