SECTION 354.1624. Independent Assessment of DSRIP Projects

(a) Mid-point assessment. An independent assessor will initiate a mid-point assessment of DSRIP projects prior to the fourth demonstration year, consistent with the requirements of the PFM Protocol.

(1) The independent assessor will review a DSRIP project for the following elements:

(A) Compliance with the approved RHP plan.

(B) Compliance with the required core components described in the RHP Planning Protocol, including continuous quality improvement activities.

(C) Ensuring that activities funded through DSRIP do not duplicate activities funded through other federal funds.

(D) The clarity of the improvement milestones for the fourth and fifth demonstration years and those milestones' connection to DSRIP project activities and patient impact.

(E) The benefit of the DSRIP project to the patients served by the project, including the Medicaid and uninsured populations.

(F) The opportunity for DSRIP project improvement.

(2) Any change to an RHP plan resulting from this process will be reviewed by HHSC.

(3) Based upon the recommendations of the independent assessor, HHSC or CMS may require changes to the RHP plan for the fourth and fifth demonstration years.

(b) Compliance Monitoring. The independent assessor will continually monitor DSRIP projects.

(1) In addition to generally monitoring for compliance with DSRIP program requirements and objectives, the independent assessor may, at HHSC’s discretion:

(A) review and make recommendations regarding DSRIP project values determined by HHSC or CMS to be outliers;

(B) provide recommendations to HHSC regarding a request from a performer to use a Category 3 achievement target that varies from the standard target setting methodology, as described in §354.1633 of this subchapter (relating to DSRIP Requirements for Performers); and

(C) provide secondary review of a request for a substantial reduction in project scope through plan modification.

(2) All RHP plans are subject to potential audits, including review by the independent assessor, during ongoing compliance monitoring. Upon request, performers must have available for review by the independent assessor, HHSC, and CMS, all supporting data and back-up documentation demonstrating performance as described under an RHP plan for DSRIP payments.

(c) Effect on DSRIP Payments. Future payments for a non-compliant DSRIP project may be withheld in whole or in part until the necessary changes identified by HHSC or CMS are addressed. In addition, the findings of the independent assessor may form the basis of a recoupment of a DSRIP payment. Failure of a performer to provide supporting documentation of metric or milestone achievement may result in recoupment of DSRIP payments.

Source Note: The provisions of this §354.1624 adopted to be effective September 30, 2014, 39 TexReg 7570; amended to be effective October 30, 2016, 41 TexReg 8274