SECTION 355.8216. Delivery System Reform Incentive Payments for Demonstration Years 9-10

(a) Introduction. Texas Healthcare Transformation and Quality Improvement Program §1115(a) Medicaid demonstration waiver Delivery System Reform Incentive Payment (DSRIP) program payments for demonstration year (DY) 9-10 are available under this section for eligible performers described in subsection (c) of this section. DSRIP payments to performers must be in compliance with the Centers for Medicare & Medicaid Services (CMS) approved Program Funding and Mechanics Protocol, Health and Human Services Commission (HHSC) instructions, and this section.

(b) Definitions.

(1) Demonstration Year (DY) 7--Federal fiscal year 2018 (October 1, 2017 - September 30, 2018).

(2) Demonstration Year (DY) 8--Federal fiscal year 2019 (October 1, 2018 - September 30, 2019).

(3) Demonstration Year (DY) 9--Federal fiscal year 2020 (October 1, 2019 - September 30, 2020).

(4) Demonstration Year (DY) 10--Federal fiscal year 2021 (October 1, 2020 - September 30, 2021).

(5) Performer--A provider enrolled in Texas Medicaid that participates in DSRIP and receives DSRIP payments.

(6) Regional Healthcare Partnership (RHP) Plan Update--An RHP plan for DY7-8 that is updated for DY9-10, as further described in §354.1737 of this title (relating to RHP Plan Update for DY9-10).

(c) Eligibility for DSRIP. For a performer to be eligible to receive DSRIP, the performer must:

(1) be a provider enrolled in Texas Medicaid;

(2) submit documentation of completion of a milestone identified in the approved RHP plan update to HHSC; and

(3) for a private performer only, comply with the eligibility requirements in §355.8201(c)(1)(B) of this division (relating to Waiver Payments to Hospitals for Uncompensated Care) or §355.8202(c)(3) of this division (relating to Waiver Payments to Physician Group Practices for Uncompensated Care), as applicable.

(d) Source of funding. The non-federal share of funding for payments under this section is limited to timely receipt by HHSC of public funds from a governmental entity.

(e) Payment frequency. DSRIP payments will be distributed at least annually, not to exceed two payments per performer per year, upon achievement of RHP plan update milestones as reviewed and approved by HHSC. The payment schedule or frequency may be modified as specified by CMS or HHSC.

(f) Funding limitations. Payments made under this section are limited by the maximum aggregate amount of funds approved by CMS for DSRIP for each year that the waiver is in effect.

(g) DSRIP maximum payment amounts. The approved RHP plan update establishes the payment amount associated with a particular milestone. DSRIP payments cannot exceed the amount in the RHP plan update.

(h) Payment methodology.

(1) Notice. Prior to making any DSRIP payments, HHSC will give notice of the following information:

(A) the maximum payment amount for the payment period;

(B) the maximum intergovernmental transfer (IGT) amount necessary for a performer to receive the amount described in subparagraph (A) of this paragraph; and

(C) the deadline for completing the IGT.

(2) Payment amount. The approved RHP plan update establishes the payment amount associated with a milestone. DSRIP payments cannot exceed the amount established in the approved RHP plan update. The amount of the payment to a performer will be determined based on the amount of funds transferred by a governmental entity as follows.

(A) If a governmental entity transfers the maximum amount referenced in paragraph (1) of this subsection on behalf of each performer owned by or affiliated with that governmental entity, each performer owned by or affiliated with that governmental entity will receive the full payment amount calculated for that payment period.

(B) If a governmental entity does not transfer the maximum amount referenced in paragraph (1) of this subsection on behalf of each performer owned by or affiliated with that governmental entity, each performer owned by or affiliated with that governmental entity will receive a portion of the value associated with that milestone (as specified in the RHP plan update) that is proportionate to the total value of all milestones that are completed and eligible for payment for that period by all performers owned by or affiliated with that governmental entity.

(3) Final payment opportunity. If a performer does not receive a full DSRIP payment as a result of paragraph (2)(B) of this subsection, a governmental entity may provide the necessary IGT to make up the non-federal share of that shortfall until the last reporting period of the DY following the DY in which the applicable milestone is listed in the RHP plan update. Any shortfall remains the obligation of the original governmental entity until that governmental entity informs HHSC that it will no longer agree to fund that obligation.

(A) If the governmental entity will no longer fund the obligation or a proportion of the obligation, that governmental entity must inform HHSC no later than the last date of the reporting period for the applicable payment period.

(B) A performer may utilize any affiliated governmental entity to fund the shortfall but must inform HHSC of the identity of this governmental entity no later than the last date of a reporting period in order for that affiliated entity to fund the shortfall during the associated payment period.

(i) Recoupment.

(1) In the event of an overpayment identified by HHSC or a disallowance by CMS of federal financial participation related to a performer's receipt or use of payments under this section, HHSC may recoup an amount equivalent to the amount of the overpayment or disallowance. The non-federal share of any funds recouped from the performer will be returned to the governmental entity that was the source of those funds.

(2) Payments under this section may be subject to adjustment for payments made in error, including, without limitation, adjustments under §371.1711 of this title (relating to Recoupment of Overpayments and Debts), 42 CFR Part 455, and Chapter 403, Texas Government Code. HHSC may recoup an amount equivalent to any such adjustment.

(3) HHSC may recoup from any current or future Medicaid payments as follows.

(A) HHSC will recoup from the performer against which any overpayment was made or disallowance was directed.

(B) If, within 30 days of the performer's receipt of HHSC's written notice of recoupment, the performer has not paid the full amount of the recoupment or entered into a written agreement with HHSC to do so, HHSC may withhold any or all future Medicaid payments from the performer until HHSC has recovered an amount equal to the amount overpaid or disallowed.

Source Note: The provisions of this §355.8216 adopted to be effective November 12, 2019, 44 TexReg 6856