SECTION 353.1304. Quality Metrics for the Quality Incentive Payment Program for Nursing Facilities on or after September 1, 2019

(a) Introduction. This section establishes the quality metrics that may be used in the Quality Incentive Payment Program (QIPP) for nursing facilities (NFs) on or after September 1, 2019.

(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 §353.1301 (relating to General Provisions) or §353.1302 (relating to Quality Incentive Payment Program for Nursing Facilities on or after September 1, 2019) of this subchapter.

(1) Baseline--A NF-specific initial standard used as a comparison against NF performance in each metric throughout the program period to determine progress in the QIPP quality metrics.

(2) Benchmark--A metric-specific initial standard set prior to the start of the program period and used as a comparison against a NF's progress throughout the program period.

(c) Quality metrics. For each program period, HHSC will designate one or more quality metrics. Any quality metric included in QIPP will be evidence-based. HHSC may modify quality metrics from one program period to the next. The proposed quality metrics for a program period will be presented to the public for comment in accordance with subsection (f) of this section.

(d) Performance requirements. For each program period, HHSC will specify the performance requirements associated with designated quality metrics. The proposed performance requirements for a program period will be presented to the public for comment in accordance with subsection (f) of this section. Achievement of performance requirements will trigger payments for the QIPP capitation rate components as described in §353.1302 of this subchapter.

(e) Quality assurance. All data and documentation supplied to HHSC by the NF to demonstrate achievement of performance requirements is subject to validation and audit. HHSC will select a random, representative sample of participating NFs for quality assurance review each program period and will conduct reviews on one-fourth of the total sample each program quarter.

(1) If selected, the NF will have 14 business days from the date of the request from HHSC to submit to HHSC the required data and documentation.

(2) If the selected NF fails to participate in the review or to provide the required data or documentation, any payments to the provider for the quality metric or component under review may be considered an Overpayment and subject to recoupment or adjustment as described in §353.1301(k) of this subchapter.

(f) Notice and hearing.

(1) HHSC will publish notice of the proposed metrics and their associated performance requirements no later than December 1 of the calendar year that precedes the first month of the program period. The notice must be published either by publication on HHSC's Internet web site or in the Texas Register. The notice required under this section will include the following:

(A) instructions for interested parties to submit written comments to the HHSC regarding the proposed metrics and performance requirements; and

(B) the date, time, and location of a public hearing.

(2) Written comments will be accepted within 15 business days of publication. There will also be a public hearing within that 15-day period to allow interested persons to present comments on the proposed metrics and performance requirements.

(g) Quality metric publication. Final quality metrics and performance requirements will be provided through the QIPP webpage on HHSC's website on or before February 1 of the calendar year that also contains the first month of the program period.

(h) Substitution of Measures. Alternate measures may be substituted for measures proposed under subsection (f) of this section or adopted under subsection (g) of this section if required by the Centers for Medicare and Medicaid Services for federal approval of the program.

Source Note: The provisions of this §353.1304 adopted to be effective December 30, 2018, 43 TexReg 8079; amended to be effective August 19, 2021, 46 TexReg 5015; amended to be effective May 31, 2022, 47 TexReg 3113