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 355.8201 - Waiver Payments to Hospitals for Uncompensated 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 for services
					 provided between October 1, 2017 and September 30, 2019, by eligible hospitals
					 described in subsection (c) of this section. Waiver payments to hospitals for
					 uncompensated charity care provided beginning October 1, 2019, are described in
					 §355.8212 of this division (relating to Waiver Payments to Hospitals for
					 Uncompensated Charity 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) Affiliation agreement--An agreement,
					 entered into between one or more privately-operated hospitals and a
					 governmental entity that does not conflict with federal or state law. HHSC does
					 not prescribe the form of the agreement.
(2) Aggregate limit--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, as described in subsection (f)(2) of
					 this section.
(3) Anchor--The
					 governmental entity identified by HHSC as having primary administrative
					 responsibilities on behalf of a Regional Healthcare Partnership
					 (RHP).
(4) 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.
(5) Clinic--An outpatient health care
					 facility, other than an Ambulatory Surgical Center or Hospital Ambulatory
					 Surgical Center, that is owned and operated by a hospital but has a nine-digit
					 Texas Provider Identifier (TPI) that is different from the hospital's
					 nine-digit TPI.
(6) Data year--A
					 12-month period that is described in §
												RSA
					 355.8066 of this title (relating to
					 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.
(7) Delivery System Reform Incentive Payments
					 (DSRIP)--Payments related to the development or implementation of a program of
					 activity that supports a hospital's efforts to enhance access to health care,
					 the quality of care, and the health of patients and families it serves. These
					 payments are not considered patient-care revenue and are not offset against the
					 hospital's costs when calculating the hospital-specific limit as described in
					 §
												RSA
					 355.8066 of this title.
(8) 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 program
					 year.
(9) Disproportionate Share
					 Hospital (DSH)--A hospital participating in the Texas Medicaid program that
					 serves a disproportionate share of low-income patients and is eligible for
					 additional reimbursement from the DSH fund.
(10) 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.
(11) HHSC--The Texas Health and Human
					 Services Commission or its designee.
(12) Institution for mental diseases (IMD)--A
					 hospital that is primarily engaged in providing psychiatric diagnosis,
					 treatment, or care of individuals with mental illness.
(13) Intergovernmental transfer (IGT)--A
					 transfer of public funds from a governmental entity to HHSC.
(14) Large public hospital--An urban public
					 hospital - Class one as defined in §
												RSA
					 355.8065 of this title (relating to
					 Disproportionate Share Hospital Reimbursement Methodology).
(15) Mid-Level Professional--Medical
					 practitioners which include only these professions: Certified Registered Nurse
					 Anesthetists, Nurse Practitioners, Physician Assistants, Dentists, Certified
					 Nurse Midwives, Clinical Social Workers, Clinical Psychologists, and
					 Optometrists.
(16) Private
					 hospital--A hospital that is not a large public hospital as defined in
					 paragraph (14) of this subsection, a small public hospital as defined in
					 paragraph (21) of this subsection or a state-owned hospital.
(17) 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.
(18) 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.
(19) RHP plan--A multi-year plan within which
					 participants propose their portion of waiver funding and DSRIP
					 projects.
(20) Rural hospital--A
					 hospital enrolled as a Medicaid provider that is:
(A) located in a county with 60,000 or fewer
					 persons according to the 2010 U.S. Census; or
(B) designated by Medicare as a Critical
					 Access Hospital (CAH) or a Sole Community Hospital (SCH); or
(C) designated by Medicare as a 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 is located in
					 an MSA but has 100 or fewer beds.
(21) Small public hospital--An urban public
					 hospital - Class two or a non-urban public hospital as defined in §
												RSA
					 355.8065 of this title.
(22) Transition payment--Payments available
					 only during the first demonstration year to hospitals that previously
					 participated in a supplemental payment program under the Texas Medicaid State
					 Plan. For a hospital participating in the 2012 DSH program, the maximum amount
					 a hospital may receive in transition payments is the lesser of:
(A) the hospital's 2012 DSH room;
					 or
(B) the amount the hospital
					 received in supplemental payments for claims adjudicated between October 1,
					 2010, and September 30, 2011.
(23) Uncompensated-care application--A form
					 prescribed by HHSC to identify uncompensated costs for Medicaid-enrolled
					 providers.
(24) Uncompensated-care
					 payments--Payments intended to defray the uncompensated costs of services that
					 meet the definition of "medical assistance" contained in §1905(a) of the
					 Social Security Act that are provided by the hospital to Medicaid eligible or
					 uninsured individuals.
(25)
					 Uninsured patient--An individual who has no health insurance or other source of
					 third-party coverage for services, as defined by CMS.
(26) Urban rural referral center--A hospital
					 designated by Medicare as a Rural Referral Center (RRC) that is located in a
					 Metropolitan Statistical Area (MSA), as defined by the U.S. Office of
					 Management and Budget, and that has more than 100 beds.
(27) Waiver--The Texas Healthcare
					 Transformation and Quality Improvement Program Medicaid demonstration waiver
					 under §1115 of the Social Security Act.