SECTION 354.1661. Definitions

The following terms, when used in this division, have the following meanings unless the context clearly indicates otherwise.

(1) Alternate improvement activity--An activity that must be selected in conjunction with a Category 3 outcome designated as pay-for-reporting (P4R) or maintenance. There are two types of alternate improvement activities: stretch activities and Population-Focused Priority Measures (PFPMs).

(2) Baseline--The baseline that HHSC has on record for a Category 3 outcome, typically the baseline that the performer most recently submitted to HHSC.

(3) Baseline measurement period--The time period used to set the baseline for a Category 3 outcome.

(4) Category 3 outcome--An outcome measure for which a performer can earn Category 3 payments.

(5) Demonstration Year (DY) 6--The initial 15-month time period, as approved by CMS, for which the waiver is extended beyond the initial demonstration period, or October 1, 2016 - December 31, 2017.

(A) DY6A--Federal fiscal year (FFY) 2017, or the first 12 months of DY6 (October 1, 2016 to September 30, 2017).

(B) DY6B--The last three months of DY6 (October 1, 2017 to December 31, 2017).

(6) Extension period--The entire time period, as approved by CMS, for which the waiver is extended beyond the initial demonstration period.

(7) Federal poverty level--The household income guidelines issued annually and published in the Federal Register by the United States Department of Health and Human Services.

(8) Improvement floor--A fixed value equal to ten percent of the difference between the minimum performance level (MPL) and the high performance level (HPL) for a Category 3 outcome. It is used to set the performance year (PY) goal for certain Category 3 outcomes designated as pay-for-performance (P4P) and Quality Improvement System for Managed Care (QISMC) that have a baseline that is either close to the HPL or above the HPL.

(9) Improvement over self (IOS)--A goal-setting methodology for certain Category 3 outcomes designated as pay-for-performance (P4P). Under IOS, an outcome's goal is set as closing the gap between the baseline and the perfect rate.

(10) Initial demonstration period--The first five DYs of the waiver, or December 12, 2011, through September 30, 2016.

(11) Medicaid and Low-income or Uninsured (MLIU) Quantifiable Patient Impact (QPI)--The number of MLIU individuals served, or encounters provided to MLIU individuals, during an applicable DY that are attributable to the DSRIP project.

(12) Medicaid and Low-income or Uninsured (MLIU) Quantifiable Patient Impact (QPI) Goal--The number of MLIU individuals that a performer intends to serve, or the number of MLIU encounters that a performer intends to provide, during an applicable DY that are attributable to the DSRIP project.

(13) Medicaid and Low-income or Uninsured (MLIU) Quantifiable Patient Impact (QPI) - Specific Metric--A QPI metric in the initial demonstration period that is specific to counting the MLIU population. This metric usually represents a subpopulation of another QPI metric and has a metric ID of I-34.1.

(14) Performance level--The benchmark level used to determine a Category 3 outcome's performance year (PY) goal relative to the baseline under the Quality Improvement System for Managed Care (QISMC) goal-setting methodology. There is a high performance level (HPL) and minimum performance level (MPL) for each outcome, as described in the RHP Planning Protocol.

(15) Performance Year (PY)--The 12-month measurement period that follows the baseline measurement period for a Category 3 outcome. For most outcomes, PY1 is the 12-month period that immediately follows the baseline measurement period, and PY2 is the 12-month period that immediately follows PY1.

(16) Population-Focused Priority Measure (PFPM)--A Category 3 outcome designated as pay-for-performance (P4P) that is an alternate improvement activity.

(17) Pre-DSRIP baseline--The service volume prior to the implementation of a DSRIP project, as measured by the number of individuals served or encounters provided during the 12-month period preceding the implementation of the DSRIP project. There is a pre-DSRIP baseline for total QPI and a pre-DSRIP baseline for MLIU QPI.

(18) Quality Improvement System for Managed Care (QISMC)--A goal-setting methodology for certain Category 3 outcomes designated as pay-for-performance (P4P). Under QISMC, an outcome's goal is set as closing the gap relative to the baseline and a high performance level (HPL) and minimum performance level (MPL) benchmark.

(19) Quantifiable Patient Impact (QPI) Grouping--The category of the QPI measurement. The category may be either individuals served or encounters provided.

(20) Reporting Domain (RD)--Category 4 contains five domains upon which hospital performers must report, as specified in the Program Funding and Mechanics (PFM) Protocol.

(21) Stretch activity--A pay-for-reporting (P4R) activity that is an alternate improvement activity.

(22) Total Quantifiable Patient Impact (QPI)--The total number of individuals served or encounters provided during an applicable DY that are attributable to the DSRIP project.

(23) Total Quantifiable Patient Impact (QPI) Goal--The total number of individuals that a performer intends to serve, or the total number of encounters that a performer intends to provide, during an applicable DY that are attributable to the DSRIP project.

(24) Uncompensated Care (UC) Hospital--A hospital eligible to be a performer that is not a performer, but receives UC payments.

Source Note: The provisions of this §354.1661 adopted to be effective October 30, 2016, 41 TexReg 8274