health and human services commission mcac minutes 08-24 ... · 8/24/2017 · health and human...
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Health and Human Services Commission
Medical Care Advisory Committee
August 24, 2017
Meeting Minutes
Members Present:
Dr. Gilbert Handal, Chair
Colleen Horton, Vice Chair
Deshpande, Salil, M.D.
Edgar Walsh, R. Ph
Mary Helen Tieken, RN
David Webster, M.D.
William Galinsky, HPAC Representative
Members Absent:
Cynthia Jumper
Donna Smith, PT
George Smith, DO
Doug Svien
1. Opening comments: Gilbert Handal, M.D., Medical Care Advisory Committee (MCAC)
Chair.
Dr. Gilbert Handal called the meeting to order at 9:05 a.m. and based upon the members in
attendance, a quorum was present.
2. Approval of June 15, 2017, meeting minutes.
Bill Galinsky motioned for approval of the minutes
Mary Helen Tieken seconded the motion
The motion to approve the minutes passed unanimously
3. Comments from the Associate Commissioner for Medicaid and CHIP Services
Department, Jami Snyder, Health and Human Services Commission (HHSC).
Ms. Snyder provided Medicaid status updates on the Network Access Improvement Program
(NAIP), the 1115 Waiver and an update on the Special Legislative Session which followed
the 85th Legislative Session, 2017.
Ms. Snyder noted that originally the NAIP concept paper was approved in September, 2014;
in November, 2016, the Centers for Medicare and Medicaid Services (CMS) determined
NAIP to be a pass-through payment program under the new federal regulations. This has
changed the nature of the program and creates limitations as to how the Health and Human
Services Commission (HHSC) administers the program going forward. In 2018, ten
Managed Care Organizations (MCOs) will partner with five health related institutions and
ten public hospitals on a voluntary basis, regarding the NAIP pass-through payments. MCOs
will receive a small administrative fee for managing the payments but the All Funds amount
for the NAIP program in 2018 is 427 million dollars. As a pass-through program, CMS has
indicated the amounts for NAIP in 2018 cannot exceed those established for fiscal year 2017.
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That is a limitation imposed by CMS when they deemed it a pass-through program. It should
be noted that costs for the program are included in the budget neutrality calculation as HHSC
negotiates the 1115 Waiver. All participants in the 2017 NAIP program will also participate
in the 2018 program.
Ms. Snyder stated negotiations in relation to the 1115 Waiver are ongoing. There are three
areas of negotiation that continue, one is around the budget neutrality calculation and
ensuring that an agreement is reached in regard to understanding the room that's available
within the waiver which is a calculation that speaks to the cost of the program without a
waiver versus the cost of the program with a waiver. Arriving at a mutual agreement around
the size of the Uncompensated Care (UC) pool is a second point of discussion. The third area
of negotiation is the future of the Delivery System Reform Incentive Payments (DSRIP)
program. HHSC has been in very active negotiations with CMS to discuss the three
components of the waiver negotiation. HHSC has stressed to CMS the importance of
wrapping up negotiations around the 1115 Waiver by the end of September, 2017.
Dr. Handal noted there were original health partnerships that had money left over when the
program was incepted, the original idea was the Regional Health Partners that had money left
over, would have their funds transferred to other partnerships that had DSRIP; however, that
did not happen. Secondly, will there be opportunity for new projects; projects that are really
innovative are not funded. Dr. Handal asked if there will be opportunities to have new
DSRIPs; the 21 month timetable is not a lot of time.
Ms. Snyder replied, the original proposal from HHSC to CMS early in the 2017 calendar
year was for a 21-month extension of the waiver as it currently stands at existing funding
levels. HHSC feels it has been open in its discussions; the conversation with CMS as HHSC
worked through the various negotiation points, included a conversation around the full five-
year renewal. While the formal request that HHSC sent to CMS is around a 21 month
extension; the more recent discussions have been around of a full five-year renewal.
Regarding Dr. Handal’s questions about the DSRIP program, Ms. Snyder deferred to John
Scott who is presenting Agenda Item 5 to include a discussion around the plan going forward
as well as the mechanics of the program.
The final update the MCAC requested was outcomes of the special session. Ms. Snyder
noted that when the governor initially issued a statement around the special session, HHSC
did not contemplate there would be a lot of activity on the Medicaid front because the items
on the call didn't relate to Medicaid specifically. HHSC was, however, very active during the
special session around a couple of issues, one of which addressed the deferral of MCO
payments in order to fund salary increases for teachers. The other area addressed what are
known as deemed preferred provider arrangements, involving new expectations HHSC has
within the Medicaid program to increase the amount of value-based purchasing activity
occurring within the program. As of contractor year 2018 which begins on September 1,
2017, HHSC is setting a threshold for health plans, mandating that 25percent of all payments
to providers for any health plan across all product lines be governed by some sort of value-
based purchasing or alternative payment model. As such, HHSC has seen an increase in the
activity on the part of MCOs to form preferred provider arrangements, which are really
arrangements with providers that MCOs feel are interested in partnering with them around a
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value based model which seeks to enhance quality and drive down costs.
This is a shift away from where HHSC has been and there are providers and stakeholders in
the community that have concerns about how those preferred provider arrangements are
established. HHSC worked very closely with legislators throughout the special session and
provided testimony to explain the value of reimbursement arrangements which really seek to
enhance quality. The preferred provider arrangement is one tool in that process of enhancing
quality and reducing costs.
Dr. Handal noted there are several big hits here. MCOs have been cut by 62.5 million dollars
for the biennium and are asked at the same time to develop new strategies to eliminate waste
at 25 percent levels beginning this year. MCOs will not have freedom in contracting with
providers, typically MCOs use what room they have to contract with providers and get into
value-based alternative payments or quality improvement programs. Secondly, there is the
fact that there is $300 million dollars loaned to the educational system, this comes from
Medicaid as well and has a big impact, over 150 million dollars a year for the biennium.
Thirdly, Medicaid has been cut over 400 million dollars. How will the commissioner come
up with a solution to three cuts at the same time that HHSC is trying to impose a value based
program? Value based systems are not cost savers in the beginning, perhaps after they are
mature and established they may cut costs somewhat, but in the very beginning they are more
expensive. There are some unrealistic expectations here.
Ed Walsh stated at the pharmacy level, pharmacies are already losing money filling Medicaid
prescriptions in the state. Nationally, pharmacists are working on programs to put more
money into pharmacy so that we can develop programs that are going to reduce the problems
with non-adherence to medications or adverse reactions to medications. Mr. Walsh stated he
feels that we are going in the wrong direction.
Ms. Snyder: you make really good points. HHSC certainly understands we have our work cut
out for us in terms of looking at the levers that we have available to us as we seek to contain
costs. As part of the 85th Regular Session HHSC has a number of cost-containment
initiatives that emerged that we’ll be pursuing to ensure that we are able to stay within the
budgetary limitations that have been established. To the point about pharmacy in particular,
one of the things we are focused on as we look at this value based work is ensuring that the
MCOs that are working with providers are really at the front end of their negotiations with
providers around value based work; that the MCOs are doing their due diligence in terms of
assessing providers interests and aptitude in participating in value-based purchasing
arrangements. To the point specifically about factors which can play into pharmacy benefits,
there are various kinds of quality metrics that could be integrated into those arrangements
where the MCO could incentivize a provider for their willingness to work on things like
medication adherence. Dr. Handal is right that these types of arrangements do not reduce
cost immediately, there has to be investment up front. There has to be a commitment on the
part of HHSC as a regulator to recognize that investment on the part of MCOS and providers.
HHSC’s hope is that health plans will work closely with providers to develop arrangements
where they're recognizing the provider’s commitment to quality through various kind of
incentives that are available connected to those different quality metrics.
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Ed Walsh stated, nationally, almost 25 percent of the money spent on taking care of chronic
care management is going to pay for bad outcomes due to pharmacy. It is showing that we
need to spend money in pharmacy to hold down costs on the bad outcomes that are due to not
spending enough on pharmacy. There is a product involved, once you say okay we're going
to put this person on medication, that's not the end, it is just the beginning of the treatment.
There is a lot of money to be saved if we invest in the proper programs that will help create
better outcomes.
Ms. Snyder replied, that is absolutely the intent of value-based purchasing work in our
system; to incentivize providers in a way that is going to lead to optimal health outcomes for
members. What HHSC would like to see is real incentive alignment so members are
accessing the right care, at the right place, at the right time in a way that's more cost-effective
as well. Mr. Walsh replied, the problem that pharmacies have seen in the national area is
there have been Pharmacy Benefit Managers (PBMs) who, as CMS has pushed incentives on
Medicare Part D, have come up with ways to offset risk by the way they handle pharmacy
reimbursement. This was not the purpose CMS initiated; laws exist now to roll that back.
Ms. Horton stated there were cost containment measures included in the regular budget, also
a rider that said that HHSC had to develop additional cost containment in the Medicaid
program. Has HHSC identified where the additional 400 plus million will come from?
Ms. Snyder noted HHSC has a variety of cost containment measures underway. Value-based
purchasing is one vehicle in the HHSC system being used to realize additional savings. The
legislature identified a number of cost containment opportunities, some of which have been
around in the HHSC system for some time; some of which of which are new. HHSC has
been using data to inform its evaluation of cost-containment opportunities, looking at
utilization data and opportunities for cost containment in that area. The HHSC Rate Analysis
team is always looking at reimbursement but also remaining cognizant of where the system is
at and the challenges that stakeholders in the system face as that cost containment work is
pursued.
Ms. Horton noted, you spoke about rates and utilization, then we hear about people losing
services through utilization management and about inadequate provider networks because the
rates are so low and the administrative costs are so high. When the rubber hits the road
people get hurt and 450 million dollars is a lot of money to take away from an already
stressed system. It would be beneficial for this committee to have a little bit more detail.
Ms. Snyder stated she would be happy to bring to the next MCAC meeting a more detailed
description of what HHSC is doing in regard to cost containment across the board across the
legislatively mandated cost containment items as well as the other items that HHSC has been
discussing. It is not about reduced utilization; it's about appropriate utilization that is the
conversation HHSC has been having with MCOs as to how to ensure individuals are
obtaining the preventive services they need on the front end so they are not having to access
services, for instance, in the emergency department.
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Ms. Horton replied, for families it is not a matter of reduced utilization when there are
children who have been in the medically dependent children's program for years because they
have significant disabilities and suddenly they are either not eligible for the program or they
are receiving minimal hours of services. This is very real and it impacts people and is not
just a utilization management number, it is a very real impact on families. If that is the
direction the state is going to take, then HHSC needs to be honest and transparent about it
and let the public know; people can't fight back if they don't know what's happening.
Ms. Horton questioned the 1115 Waiver projects; HHSC was receiving a significant influx of
money on behavioral health through House Bill 13, the community collaboratives and Senate
Bill 292. There are over 400 behavioral health 1115 Waiver projects; is there any effort to
really look at what we've been doing and what we plan to do and coordinate the two or are
we just going to add projects on top of projects.
John Scott noted, in the revised DSRIP proposal, HHSC is shifting away from past projects
to focus on measures and measure bundles. There is a shift from the project idea to give more
flexibility to providers in the DSRIP program to identify measures and measure bundles they
want to improve upon. HHSC is moving beyond the projects and focusing on system-level
outcomes.
Ms. Horton noted the results would depend on the quality of the measures, specifically
around behavioral health and mental health. There is focus on people served numbers but no
real focus on recovery outcomes. If we're moving to an outcome-focused system, we need to
really look at the quality of the outcomes, using measures which actually measure
improvement in the quality of life for people; just measuring outcomes is not enough.
Dr. Webster asked, regarding the outcomes with the provider groups, who vets the outcomes,
who looks to say there is value to members from those outcomes. How would that happen?
Mr. Scott replied, HHSC went through a stakeholder process with clinicians to identify the
measures that would be most appropriate. In Spring 2017, HHSC had over one hundred
clinicians on bundle advisory teams. The teams went through an iterative prioritization
process to identify measures, discuss the measures and refine them and went through
multiple votes to prioritize and select. HHSC ended up with 144 measures through the
process with the clinicians; this was used as a starting point, looking at the areas which were
already being measured under DSRIP to see which ones were successful project areas. They
also looked at commonly used national measures; CMS, the federal approval authority, is
very concerned with measuring the same things across states. The clinicians on these teams
were also able to propose measures if there was anything they thought wasn't being captured.
HHSC does have a few innovative measures that are not necessarily well tested yet. These
measures had value to clinicians who were on the committees.
Dr. Handal noted that Ms. Snyder offered to send the MCAC Committee a package for the
November 16, 2017 meeting to inform the committee of several items HHSC is working on.
The HHSC Executive Commissioner has until December, 2017, to present to the legislature
where the cuts will take place. The cuts are a mandate from the legislature. The same is true
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with the 1115 Waiver; it is a negotiation. HHSC is trying to obtain a full five-year renewal
instead of a 21 month extension.
Dr. Handal stated that he sent a letter to the Executive Commissioner in accordance with the
request from the MCAC members at the June 15, 2017, meeting. Dr. Handal expressed to
the Executive Commissioner the concerns the MCAC has regarding input in the rulemaking
process for Medicaid funded programs.
Ms. Snyder noted that subsequent to the June 15, 2017, meeting, Dr. Handal sent a letter to
the Executive Commissioner expressing his concern about the number of items that are
coming to the MCAC as information only versus action items. HHSC has started a
conversation about ways to address that issue while understanding the number of expedited
rule packages HHSC has to process, some of which are due to legislative direction and other
variables. One of the options is to increase the frequency of the MCAC meetings. HHSC
also has created an internal work group to investigate what other options might be available
to provide an opportunity for the MCAC to weigh in on regulatory changes during the public
comment period. Ms. Snyder stated the commentary the MCAC provides is incredibly
valuable to HHSC, even if it is outside of the public comment period, in terms of how HHSC
operationalizes the rules. HHSC understands the committee's concern in regard to the
number of items that are now coming to the MCAC as informational only items and realizes
that there needs to be a better solution to help the committee engage in the process. HHSC is
working through the mechanics and hopefully will have a proposal to the MCAC before the
next meeting.
NOTICE OF INFORMATIONAL ITEMS:
4. Texas Medicaid Fee-for-Service Access Monitoring Review Plan.
State Medicaid programs must comply with federal rules at 42 C.F.R. §§ 447.203-204
intended to establish a standardized, transparent, data-driven process for states to document
that fee-for-service provider payment rates are consistent with Social Security Act §
1902(a)(30)(A), 42 U.S.C.A. § 1396(a)(30)(A). This section of the Act requires states to have
methods and procedures to assure payments to providers are “sufficient to enlist enough
providers so that care and services are available under the plan at least to the extent that such
care and services are available to the general population in the geographic area.” In its initial
plan submitted to the Centers for Medicare & Medicaid Services (CMS) in October 2016,
HHSC indicated a follow-up plan in 2017 was necessary to address the requirement of rate
comparisons and to present data pertaining to children with disabilities. HHSC presents a
draft of the 2017 Texas Medicaid Fee-For-Service Access Monitoring Review Plan to the
Committee as an informational item and is prepared to take questions the Committee has
about the plan.
- Brian Dees, Senior Policy Advisor, Program and Policy Section, Medicaid and CHIP
Services Department, HHSC
- Michelle Long, Program Specialist, Medical and Social Services Division, HHSC
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Brian Dees: This plan is required by federal regulation. States are required to submit a plan
to CMS every three years detailing how access and rates are monitored to ensure sufficient
access to care within the Fee-For-Service components of a Medicaid program. Texas
submitted its initial report in October, 2016. In that report, HHSC notified CMS that we
would be submitting a subsequent, follow-up report off-cycle in 2017 to add additional
components; one of the components being a rate comparison between Medicare and
Medicaid rates, and the other being additional data to take into account the proportion of the
Medicaid population that is children with disabilities, primarily Supplemental Security
Income (SSI) and children on waiver programs. This report is solely on the Fee-For-Service
part of the program and does not include any of the large proportion of the population that is
in managed care. The data in the report presented to the MCAC is for Fiscal Year 2016. One
of the changes that has happened to the program and will be accounted for in the 2019 report,
is the transition of a large part of the existing Fee-For-Service population from Fee-For-
Service into the STAR Kids Program in November, 2016, and subsequent to that, in Calendar
Year 2017, HHSC will be transitioning the Adoption Assistance and the Medicaid for Breast
and Cervical Cancer populations into managed care.
The report is available for public comment until December 7, 2017, through GovDelivery
and HHSC websites.
Dr. Handal noted three areas where he has concerns:
- The first issue is when you strive to improve quality of care, you must compensate the
physicians and the providers at all levels.
- The second issue is that Medicaid pays specialty care the same as it pays pediatric care;
this is unfair and inappropriate. If you want quality, you have to pay for quality; you
cannot compensate specialists at the same level you compensate primary care physicians.
- The third issue is that patient-time must be included in the payment calculation for
physician compensation. The amount of time a physician spends with a special needs
patient far exceeds the amount of time needed to be spent with a well child.
Ms. Snyder: Brian mentioned that this report is focused only on Fee-For-Service. The
National Association of Medicaid Directors has been discussing approaching CMS around
some flexibility the new administration may offer to Medicaid programs; specifically, the
National Association has asked that for states like Texas, where a large percentage of the
population are served in managed care, that they be relieved of the responsibility of
producing this report because it is not as meaningful and will become less meaningful.
Another tactic may be approaching CMS about the creation of a report that is really reflective
of the service system as a whole, in particular for those states which are largely managed care
focused states, having a report that looks at access to care on both sides of the system may be
a more meaningful representation of access to care.
Ms. Horton: When I look at the enrolled providers versus the active providers, I would ask if
when you conducted your survey, were you asking the question, managed care versus Fee-
For-Service. Hopefully if we go into a new type of reporting, we look not only at the
managed care side but that we ask questions that will really delineate if people are getting the
services they need and if they have access to the providers they need.
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Mr. Dees: For this report it is solely quantitative as we are looking at claims data, that is
essentially how we are identifying if a provider is active, it is not based on the survey yet.
Public Comment - Sarah Mills, Director of Public Policy and Government Relations, Texas
Association for Home Care and Hospice, testified neutral to the plan.
Mr. Dees: This report does highlight some of the things that have always been problematic
about Fee-For-Service and some of the ways in which the levers we have to really impact the
quality of care and to really enhance outcomes for our clients are somewhat limited in a Fee-
For-Service environment. This report highlights some of the limitations the program has
always had.
Dr. Handal: In Austin only 10 to 12 percent of the private providers take Medicaid.
In El Paso 62 percent of the children are on Medicaid, 8 per cent more are on CHIP. What
works in Austin or in Houston is much different than what works in a border town. It takes a
lot more time and a physician is paid much less. We have to be very careful how we put data
together.
Dr. Deshpande: It is important that we understand what the underlying rationale is for
determining whether we have met or not met an access standard. Even though there has been
a lot of work put into place to come up with geographic and time based access standards, at
the end of the day, there may still be patient who cannot get in to see a doctor. That is really
what matters. Is there any other venue or reporting that enumerates complaints and
resolutions.
Ms. Snyder: HHSC has several avenues that members, providers and stakeholders can use to
issue complaints, the complaints are tracked through all of those avenues as well. At the
Agency level, there is the Ombudsman’s office, our Health Plan Management Team
maintains a complaint email address where individuals can issue written complaints, and
MCOs collect data on complaints that are issued through the MCO and that is supplied to the
Agency. HHSC has routine reporting for the MCOs and we have internal reports that reflect
complaints issued to the Ombudsman or to the Health Plan Management (HPM) email box.
That data has been historically shared in various venues. Integration of that data into the
report is merited. We feel complaint data is one of the key indicators of system performance.
HHSC routinely meets to discuss trends being seen in the complaint data and use that to form
interventions across the system
Mr. Dees: For particular initiatives, HHSC does specifically track complaints both received
at the HPM level, the Ombudsman level and the MCO level.
5. Delivery System Reform Incentive Payment (DSRIP) Program Demonstration
Years 7-8.
HHSC proposes new rules to Texas Administrative Code (TAC), Title 1, Part 15, Chapter
354, Subchapter D, Division 7, relating to DSRIP Program Demonstration Years 7-8,
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including §354.1691, relating to Definitions; §354.1693, relating to Regional Healthcare
Partnerships (RHPs); §354.1695, relating to Participants; §354.1697, relating to RHP Plan
Update; §354.1699, relating to RHP Plan Update Review; §354.1701, relating to RHP Plan
Update Modifications; §354.1703, relating to Independent Assessor; §354.1705, relating to
Categories; §354.1707, relating to Performer Valuations; §354.1709, relating to Category A
Requirements for Performers; §354.1711, relating to Category B Requirements for
Performers; §354.1713, relating to Category C Requirements for Performers; §354.1715,
relating to Category D Requirements for Performers; §354.1717, relating to Uncompensated
Care (UC) Hospital Requirements; §354.1719, relating to Disbursement of Funds; and
§354.1721, relating to Remaining Funds for Demonstration Years 7-8; Chapter 355,
Subchapter J, Division 11, §355.8205, relating to DSRIP for Demonstration Years 7-8; and
§355.8206, relating to Funding for DSRIP Monitoring Program for Demonstration Years 7-8.
On December 12, 2011, the CMS approved Texas's request for a new Medicaid
demonstration waiver entitled “Texas Healthcare Transformation and Quality Improvement
Program” in accordance with section 1115 of the Social Security Act. The DSRIP program is
one of the three main components of this waiver. The initial waiver was approved through
September 30, 2016, and an initial extension was granted through December 31, 2017.
HHSC has requested an additional 21 months that would extend the waiver through
September 30, 2019. The framework for DSRIP payments is governed by the Program
Funding and Mechanics (PFM) protocol that is referenced in the waiver’s Special Terms and
Conditions. HHSC developed the draft PFM protocol proposal for the requested additional
21 months (demonstration years 7-8) and submitted it to CMS on May 17, 2017. These
proposed new rules closely mirror the PFM protocol proposal that HHSC submitted to CMS.
- John Scott, Director of Operations, Texas Healthcare Transformation Waiver, HHSC
John Scott: HHSC went through a stakeholder process with the Program Funding and
Mechanics (PFM) protocol; it originally posted in January 2017 and received over 170
comments that were closely reviewed. HHSC incorporated some changes and then had
another draft that was sent to CMS in May, 2017. Since then there have been additional
updates based on additional input from the public. We now have a draft that was sent to
CMS on August 4, 2017; the PFM may have additional changes. This proposal for
demonstration years (DY) 7 and 8 moves us from the historical project level reporting to
provider system-level reporting. Originally HHSC had about 1400 separate projects with ten
thousand or more metrics that were reported annually. In our proposal for the future, HHSC
proposes to move to system level reporting with 300 providers that will report data system
level. For the most part, providers will keep their same valuation in the future assuming that
the DSRIP pool size remains constant. HHSC has four provider types, the first thing that
they'll do is define what will be their system. This is their clinics, hospitals, the places where
they serve individuals. Once they define their system, they will begin looking at data to
report under four different categories, A, B, C, and D.
Category A is qualitative reporting where providers will describe the various activities they
have to make improvements, they will also describe progress toward alternative payment
methodologies, they'll do a cost and savings analysis on one of their key activities and they'll
describe any collaborative activities that they're doing with other providers. Category A is
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required reporting but there's not a payment associated with it, it is just required in order to
receive their other payments.
Category B is patient population by provider. This is where providers will state how many
individuals their system serves as a whole and will also provide information regarding how
many individuals they serve are Medicaid-eligible or low income or uninsured. The target
population for the 1115 Waiver is Medicaid and Low Income Uninsured (MLIU). This
category B is a way for HHSC to see where providers are in terms of numbers of MLIU
served and then continue that level as they go into the subsequent years of the waiver. If
their number of MLIU individuals drops too significantly, the payment associated with
category B would be reduced as well. Category B is HHSC’s attempt to ensure that the
target population remains served.
Category C is where the measure bundles and measures are; this is the heart of the program.
This is the step that providers would take after they define their system. They would identify
measure bundles or measures that they want to improve upon. Measure bundles and
measures have certain point values and providers are given a minimum point threshold that
they must achieve. For example, a provider might have a minimum point threshold of 20;
they need to select measure bundles or measures that would add up to at least 20 points.
Different types of providers have different minimum point threshold maximums, a hospital
or physician practice would have a maximum point threshold of 75, a community mental
health center would have a maximum threshold of 40 and a local health department would
have a maximum point threshold of 20. The formula we use to determine these point
thresholds for providers results in providers having approximately the same number of
measures in the future years as they've had previously under Category 3 which is where
they've measured outcome measures. HHSC went through a process to identify the measure
bundles and measures with bundle advisory teams. The focus was on using common existing
measures as well as national measures from CMS consensus and core sets, Medicare Access
and CHIP Reauthorization Act (MACRA) Payment System, Merit-Based Incentive Payment
System (MIPS) and Quality Payment Program (QPP) measures as well as other measure
submitted by advisory team members. Once the providers have defined their systems and
selected measures to meet their point threshold, they will report their base lines for their
measures based on Calendar Year 17. They can then report their achievement based on
Calendar Year 18 and 19. The payments then that result from reporting are divided among
categories B, C and D which have specific payment amounts.
Category D is Pay-for-Reporting of population health measures. These measures are
statewide; for example, population health for hospitals would be potentially preventable
admissions, readmissions, complications and ED visits. HHSC would ask providers to report
this data; the payment for this is just pay for reporting.
For DY7, providers will receive 20 percent of their evaluation payment for participating in
the Regional Healthcare Partnership (RHP) plan update process and defining systems and
selecting measures and submitting that with their RHP. Category B would have a 10 percent
of the valuation payment, category C, the measure bundles, would be either 55 or 65 percent
and category D would be 15 or 5 percent. The reason for the variation in category C and D
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payments is that HHSC has tried to incentivize continuing the level of private hospital
participation by allowing regions which maintain their private hospital participation to shift
some of their payment into category D which is pay for reporting. In DY8, the 20 percent for
the RHP plan update would no longer be paid because that would already have been
accomplished; the 20 percent shifts into category C and then there is quite a lot at stake in
pay-for-performance, 75 to 85 percent under category C.
HHSC has had various stakeholder processes and we've had a few stakeholder concerns...
One concern was ensuring that we had sufficient incentive for private hospital participation
and that is why we have percentages for category C and D to incentivize private hospital
participation. We also had comments related to allocating remaining DSRIP funds. Certain
regions did not allocate their full amount for DY 5 so under the proposal those regions that
did not allocate all of their dollars will have a chance to allocate dollars under this new
planning process. Concerns have also been raised about the formula for calculating the
minimum threshold; HHSC worked with the formula to make sure that providers have
approximately the same number of measures going forward as they've had in the past.
Dr. Deshpande asked if the dollar allocation is happening by taking the existing project
valuations and then re-attributing those to the new groupings of providers. John Scott
replied, as an example, a provider may now have five projects going on under DSRIP and
those five projects would each have a valuation. HHSC would add those valuations together
and the provider would have that lump sum valuation under this new structure.
Dr. Deshpande asked if is it correct to say that HHSC does not really care what the provider
is doing going forward but only cares about what outcomes they achieve. John Scott replied,
we do care about what they're doing; under their category A reporting we are asking them to
tell us what core activities they're doing to achieve the measures they focused on. Also,
when they submit their RHP plan updates as a first step, they'll be mapping their current
projects into the new structure and they'll be able to tell us at that time if they look at if they
plan to continue the activities under existing projects. They also will have the flexibility to
decide at this point that activities under a specific project now could end because they're
refocusing on a different set of measures. Dr. Deshpande responded, would you retain the
privilege of reallocating the dollars? John Scott: They would still keep their overall lump-
sum valuation, they will tell us what activities they're going to be doing to support the
measures that they've chosen with that valuation. Dr. Deshpande replied, I think there's a
potential risk there for systems getting something for not doing a whole lot. I understand that
at the end of the day we want outcomes but if the activities that are designed to achieve those
outcomes are fairly simple they may not necessarily warrant the investment.
Dr. Deshpande asked for more background around the desire to ensure the participation of
the private hospital systems and how HHSC decided to allocate certain categories
differentially to incentivize them to participate. John Scott responded, in our first waiver
when the regional health care partnerships were formed and providers were identified to
participate, there was recognition that private hospitals were an important part of the safety
net for the MLIU population. CMS encouraged us and wanted us to find a way to ensure that
private hospitals would be included in the planning and implementation of DSRIP which is
why they were included originally. As we've looked at this proposal going forward there
12
were concerns that there was a point in time when private hospitals were included, there
would be a temptation for the Intergovernmental Transfer (IGT) entities that fund the DSRIP
activities to drop the private hospitals and no longer provide the IGT for them to be part of
the program. HHSC wanted to ensure there were some incentives to maintain that IGT which
supports the private hospital participation. Dr. Deshpande asked, how did you decide to do
that? John Scott replied, the incentive is built into the payment amounts that are possible
under category C and D. Category C is the pay- for- performance on those measures that that
providers are choosing; because category C is pay-for-performance, those dollars are more
difficult to earn. Category D is pay for reporting of data and is within the provider’s control
to provide data and get a payment. If a region is able to maintain their private hospital
participation, all the providers in that region can shift a percentage of their payments into
category D, which is easier to earn, out of category C. Dr. Deshpande asked categories A
and D are just reporting related? John Scott: yes and category D has a payment attached but
category A does not have a payment attached, but category A is required as a type of
prerequisite.
Dr. Handal commented, theoretically this is going to be a continuance of the same projects
that are already approved. The question is will there be an opportunity to shift gears for
people on regular health partnership who don't have any funding to develop new projects?
John Scott: because of the way the financing is set up requiring the IGT source, it is
essential that the providers have an IGT source to move forward in the program; however, as
the providers look at their measures and look at community needs they certainly do have
flexibility to work with community partners and others outside of a direct DSRIP provider
roll. There is more flexibility in this model than there was in our previous DSRIP program.
Dr. Deshpande asked if the dollar allocation is happening by taking the existing project
valuations and then re-attributing those to the new groupings of providers. John Scott
replied, as an example, a provider may now have five projects going on under DSRIP and
those five projects would each have a valuation. HHSC would add those valuations together
and the provider would have that lump sum valuation under this new structure.
Dr. Deshpande asked if is it correct to say that HHSC does not really care what the provider
is doing going forward but only cares about what outcomes they achieve. John Scott replied,
we do care about what they're doing; under their category A reporting we are asking them to
tell us what core activities they're doing to achieve the measures they focused on. Also,
when they submit their RHP plan updates as a first step, they'll be mapping their current
projects into the new structure and they'll be able to tell us at that time if they look at if they
plan to continue the activities under existing projects. They also will have the flexibility to
decide at this point that activities under a specific project now could end because they're
refocusing on a different set of measures. Dr. Deshpande responded, would you retain the
privilege of reallocating the dollars. John Scott: They would still keep their overall lump-
sum valuation, they will tell us what activities they're going to be doing to support the
measures that they've chosen with that valuation. Dr. Deshpande replied, I think there's a
potential risk there for systems getting something for not doing a whole lot. I understand that
at the end of the day we want outcomes but if the activities that are designed to achieve those
outcomes are fairly simple they may not necessarily warrant the investment.
13
Dr. Deshpande asked for more background around the desire to ensure the participation of
the private hospital systems and how HHSC decided to allocate certain categories
differentially to incentivize them to participate. John Scott responded, in our first waiver
when the regional health care partnerships were formed and providers were identified to
participate, there was recognition that private hospitals were an important part of the safety
net for the MLIU population. CMS encouraged us and wanted us to find a way to ensure that
private hospitals would be included in the planning and implementation of DSRIP which is
why they were included originally. As we've looked at this proposal going forward there
were concerns that there was a point in time when private hospitals were included, there
would be a temptation for the Intergovernmental Transfer (IGT) entities that fund the DSRIP
activities to drop the private hospitals and no longer provide the IGT for them to be part of
the program. HHSC wanted to ensure there were some incentives to maintain that IGT which
supports the private hospital participation. Dr. Deshpande asked, how did you decide to do
that. John Scott replied, the incentive is built into the payment amounts that are possible
under category C and D. Category C is the pay for performance on those measures that that
providers are choosing, because category C is pay-for-performance those dollars are more
difficult to earn. Category D is pay for reporting of data and is within the provider’s control
to provide data and get a payment. If a region is able to maintain their private hospital
participation, all the providers in that region can shift a percentage of their payments into
category D, which is easier to earn, out of category C. Dr. Deshpande asked are A and D are
just reporting related? John Scott: yes and D has a payment attached but A does not have a
payment attached, but A is required as a type of prerequisite.
Dr. Handal commented, theoretically this is going to be a continuance of the same projects
that are already approved. The question is will there be an opportunity to shift gears for
people on regular health partnership who don't have any funding to develop new projects.
John Scott responded, because of the way the financing is set up requiring the IGT source, it
is essential that the providers have an IGT source to move forward in the program; however,
as the providers look at their measures and look at community needs they certainly do have
flexibility to work with community partners and others outside of a direct DSRIP provider
roll. There is more flexibility in this model than there was in our previous DSRIP program.
Dr. Deshpande asked do you have any specific ways in which you would envision that would
happen in this next phase. John Scott: yes, there are things going on at HHSC that are even
broader in scope than just DSRIP. We are trying to link into those and one way is through
our category A reporting of progress toward alternative payment models. We will be asking
providers to tell us their progress in working with MCOs on alternative payment models;
they may have had a successful DSRIP project which is saving money and so they would
have a reason to approach an MCO and try to get an enhanced payment of some kind if
they're able to save the MCO money. CMS has pressed us on how can we look at DSRIP
moving into a more integrated system with MCOs. Dr. Handal noted that of HHSC’s 1400 +
current projects, not very many have them have MCOs involved. Most of them really are
individual endeavors. Dr. Handal questioned, will there be opportunity to shift gears and shift
programs and put resources into new projects that would allow through transformation to
value based programs?
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Dr. Deshpande questioned, if the provider system is already receiving a significant
supplemental payment through this IGT, it's not readily apparent why the MCO would pay
them some additional fee through some alternative payment model for doing the same thing
for which they have already drawn down money.
John Scott replied, it would be, for example, if a project that they've done historically, maybe
in the future model they are choosing certain measures where that project may not directly
feed into a new measure they've chosen but they want to continue it anyway. HHSC has
tried to make sure providers know that DSRIP is a temporary program. We've had MCOs in
our statewide learning collaboratives; our regional health care partnerships have also had
regional meetings where the topic is specifically around matching MCO interests with
DSRIP type projects and making those connections. This gives us a foundation for providers
and MCOs to work together.
Dr. Deshpande replied, I agree with what Dr Handal was saying, it probably would have been
a better idea to follow some of that money through the health plans because they are
ultimately going to be the people who will take over as it were when the current DSRIP
funding goes away, then we would have had a very definitive system of operational
interaction between the MCOs and the providers to build upon and that is not necessarily
what we're going to have. John Scott: your point is well taken because CMS has encouraged
that as well; we've seen the obstacles that need to be worked out because the IGT is the
source of payment. Dr Handal responded, to continue funding the same proposals that have
made very little transformation in health care will be a big error, we have to shift gears and
look into how, with the actual managed care system we can include providers and the
community-at-large to really work in a value system supported by 1115 monies and DSRIP
monies.
6. Reimbursement Methodology for Certified Registered Nurse Anesthetists.
HHSC proposes an amendment to TAC Title 1, Part 15, Chapter 355, Subchapter J, Division
12, §355.8221 relating to Reimbursement Methodology for Certified Registered Nurse
Anesthetists.
The proposed amendment adds Anesthesiologist Assistants (AAs) to the reimbursement
methodology and adjusts the percentage payment for a supervised anesthesia service for both
Certified Registered Nurse Anesthetists (CRNAs) and AAs. CRNAs and AAs will be
reimbursed the lesser of the CRNA's or AA's billed charges or 50 percent of the calculated
payment for a supervised anesthesia service. For example, if the calculated payment for a
supervised anesthesia service is $100, the payment to the CRNA or AA would be $50.
Previously, both CRNAs and AAs were reimbursed at the lesser of billed charges or 92
percent of the solo physician's reimbursement. CRNA's and AA's will not receive a 42
percent decrease as a result of this proposed rule. In Texas, CRNAs and AAs may not
practice independently and must provide services under the supervision of a physician.
There is an estimated fiscal impact for the proposed rule change. Additional rate adjustments
related to anesthesia conversion factors are anticipated to be effective October 1, 2017.
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- Megan Wolfe, Senior Rate Analyst, HHSC Rate Analysis
Ed Walsh questioned, how do you not get that 42 percent reduction. Ms. Wolfe replied,
there will be additional adjustments made in the calculation of the total rate. Currently a
CRNA or anesthesiologist assistant receives 92 percent of the calculated fee for an
anesthesiologist’s service, in order to maintain cost neutrality, that calculated
anesthesiologist fee would be increased so that 50 percent would not be the same number as
the 92 percent.
Public Comment - Margot Cardwell, Texas Association of Nurse Anesthesiologists testified
in opposition to the rule.
7. Reimbursement Methodology for Preadmission Screening and Resident Review
(PASRR) Specialized Services.
HHSC proposes a new rule to TAC Title 1, Part 15, Chapter 355, Subchapter C, §355.315,
relating to Reimbursement Methodology for Preadmission Screening and Resident Review
(PASRR) Specialized Services. Effective December 1, 2017, HHSC plans to implement an
array of PASRR Specialized Services for Medicaid clients that reside in nursing facilities as
required by the CMS under 42 C.F.R. §§ 483.100 to 483.138. This rule project proposes the
reimbursement methodology for those services. HHSC will develop the payment rates for
PASRR Specialized Services based upon rates for other programs that provide similar
services. If payment rates are not available from other programs that provide similar
services, payment rates will be determined using a pro forma approach.
- Victor Perez, Director, HHSC Rate Analysis
The rule being presented is going to create the methodology needed to develop the rates for a
group of specialized services under the Pre-Admission Screening and Resident Review
(PASRR) services for clients residing in nursing facilities. The rule will be effective
December 1, 2017. The PASRR specialized services that we are developing rates for are
required by federal law for a nursing facility resident with mental illness or an intellectual
disability. HHSC has currently been providing these services using General Revenue
funding. The list or the group of services for PASRR specialized services will consist of
employment services, supported employment and employment assistance, independent living
skills training, behavioral support, debilitation coordination and day habilitation. These rules
were published just recently so we have not received any comments to date.
Ms. Horton asked, this is just stating that you are going to create rates but you haven't created
any yet. Mr. Perez replied, the rule must be adopted before we can move ahead with the
development of rates. Once we get the rule adopted, we will move forward with the rate
approval process. Mr. Galinsky asked, if you don't know what the rates are going to be how
can you determine the fiscal impact? Mr. Perez replied, there are a number of tasks that we
have to do - a state plan amendment had to be submitted to CMS earlier than the normal
process, along with the rate rule. Our plan is to use the Home and Community-based
Services program (HCS) rates that we use for the consolidated budget which is using the
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most recently audited HCS cost reports; this played into how we developed the fiscal impact.
Before we move with a formal rate adoption process we have to have the methodology set.
8. Amendments to Disallowance Provisions in Directed Payment General Provisions.
HHSC proposes amendments to TAC Title 1, Part 15, Chapter 353, Subchapter O,
§353.1301, relating to General Provisions. In March of 2017, HHSC adopted a series of
rules governing delivery system and provider payment initiatives through Medicaid managed
care organizations (MCOs). These initiatives are, generally, funded through
intergovernmental transfers (IGTs) from local governmental entities. Given that these
programs are not funded with state general revenue, HHSC must ensure, to the greatest
extent possible, that no state dollars are at risk through the operation of these programs. A
disallowance by CMS is one potential risk to general revenue, unless HHSC can ensure that
funds from another source are available.
Section 353.1301(j) describes the procedure HHSC would use in the case of a disallowance.
The rule delineates between a disallowance for impermissible provider-related donations and
all other disallowances. At present, if there is a disallowance for impermissible provider-
related donations, the rule requires HHSC to recover the disallowed amount from
transferring governmental entities responsible for the non-federal share of the disallowed
payments. If there is a disallowance for reasons other than an impermissible provider-related
donation, HHSC reserves the right to recoup the disallowed amount from MCOs, providers,
or governmental entities.
In an effort to provide HHSC more flexibility when determining the appropriate entity from
which to recoup, HHSC proposes to amend §353.1301 to remove the requirement that it
recover only from governmental entities in the case of a disallowance for impermissible
provider-related donations. Instead, HHSC will reserve the right to recoup from MCOs,
providers, or governmental entities in any disallowance. In order to ensure that there is no
risk to general revenue, to the greatest extent possible, HHSC will require that if a
recoupment for a disallowance results in a subsequent disallowance, the entity that HHSC
initially recouped against will face a recoupment for the subsequent disallowance.
In addition, HHSC will clarify the heading for §353.1301(k) by changing the name from
“Recoupment” to “Overpayment.”
- Charles Greenberg, Director of Policy, Office of Chief Counsel, HHSC
As of now this rule only applies to two separate programs, one of which is Uniform Hospital
Rate Increase Program (UHRIP), the other is a Quality Incentive Payment Program (QIPP).
It is important to distinguish between those two programs and other supplemental payment
programs that we have such as Uncompensated Care Program (UC) and DSRIP. This rule
does not apply to UC or to DSRIP. One of the facets of this rule is it discusses HHSC’s
policies in the case of federal disallowance. A federal disallowance is when basically CMS
says you, state, did something wrong or there's a problem so we are going to take back in the
next quarter some of the federal share of our money. There are number of ways in which
17
you can have such a disallowance; in most cases and historically, HHSC would approach the
entity most responsible for the disallowance to recoup from them the amount of federal or
share that was withheld from HHSC. In this particular rule we chose to do that for almost all
disallowances except for disallowances in the case of provider-related donations, which is a
very specific area of federal law. For disallowance for a provider-related donation, HHSC
chose, at the time in March, 2017, to fill that budget hole by getting that amount of money
from the governmental entity that provided the non-federal share of the payment at issue.
UHRIP, QIPP and the directed payment models are funded through local dollars from
typically hospital districts and counties, just like UC and DSRIP and non-federal shares are
funded through local dollars. Because of that HHSC must very zealously guard its General
Revenue. If there is a disallowance, we don't have the appropriation authority to cover those
dollars; which is why we chose to be very strict in this one particular instance, to say we will
go to the governmental entity that IGT’d initially to get those dollars back. We continue to
receive feedback from stakeholders about this policy and we decided to sit down again with
stakeholders to have more discussions and we had discussions with CMS about possible
alternatives. This amendment is the result of those discussions. We're proposing to remove
the requirement that the IGT and governmental entity be responsible for filling the budget
hole in the case of a disallowance for provider related donations. So in essence we're going
back to the way things are in UC and DSRIP where in any type of disallowance, HHSC will
determine who is the most appropriate entity to recoup against. This provides HHSC
flexibility to negotiate with CMS to find a better solution for all parties involved. There is
one caveat however; we are proposing that if a disallowance and the recoupment from that
disallowance were to result in yet another disallowance, which is theoretically possible, the
entity that HHSC recouped against in the first case will be recouped against for the
subsequent disallowance. This has to do with the provider-related donation issue that I
brought up earlier. If we require that the initial entity that was recouped against in the first
disallowance is recouped against in all the subsequent disallowances that were caused by
that, HHSC can maintain that we will ultimately repay the entire amount of federal share at
issue while keeping HHSC’s General Revenue safe.
Dr. Handal asked how much money has been disallowed so far in DSRIP. Mr. Greenberg
replied, the only disallowance we have right now is in the UC context. It is about 26 million
dollars, it is for one quarter in Tarrant and Dallas County. HHSC is currently fighting that in
front of the HHS Department of Appeals Board; there have been no other disallowances in
these types of programs.
Dr. Handal: The system looks complicated; will it lead to finger-pointing from the MCOs
and the providers and the IGT organization; how will you control that? Mr. Greenberg
replied, going back to the issue of the UC disallowance however that gets answered will
answer a lot of questions here. In the future with UHRIP and QIPP, we're going to have to
navigate this as best we can. It is difficult for me to think of a situation in which an MCO
would be on the hook for a disallowed amount, but we can’t say that for sure. It is not clear
that CMS can disallow a portion of a managed care payment, and I say this because in the
preamble to the most recent massive overhaul of federal regulation regarding MCOs, it
specifically says that CMS does not believe it has the authority to disallow only portions of
capitated payments. It can either disallow the entire contract amount or nothing. I'm not
18
exceedingly worried that there could be a disallowance in these types of programs because of
that language; however we can't take the chance that there's some change in belief at CMS;
however we think that between this rule and negotiating with CMS and our relationships
with stakeholders, we can come to a good outcome.
Dr. Handal noted that John Scott’s presentation about the points feels like a preventive way
of disallowance, resulting in less possibility of disallowance.
Mr. Greenberg replied, HHSC requires in UC and DSRIP, certifications of participation that
list out do's and don'ts for the entities providing us IGT. We do have some preventive
measures to some extent. One of the issues that we always end up having on the finance side
is we don't know everything going on the background. We accept IGT and we can tell
people these are generally do's and don'ts but it is impossible for anyone to know everything
that's going on in the background. We lay out the law as best we can and then tell everyone
think about what you're doing, talk with your attorneys and just make sure that you're doing
everything that you're supposed to. Dr. Handal replied, you cannot look into just the legal
issue or the financial issue or the governmental issue, you have to look at the whole picture.
9. Amendments to Uniform Hospital Rate Increase Program.
HHSC proposes amendments to TAC Title 1, Part 15, Chapter 353, Subchapter O,
§353.1305, relating to the Uniform Hospital Rate Increase Program.
In March of 2017, HHSC adopted rules governing a provider payment initiative through
Medicaid managed care organizations (MCOs) called the Uniform Hospital Rate Increase
Program (UHRIP) (42 TexReg 13). Under the UHRIP initiative, a service delivery area
(SDA) may apply to receive an increase in certain hospital rates which would vary by class
of hospital. Although UHRIP was supposed to begin in September 2017 and be available to
any SDA, operational issues necessitated a delay. Such issues included lack of readiness by
MCOs, lack of program understanding among providers, and incomplete approvals from the
CMS. HHSC proposes to amend the UHRIP rules in three ways.
First, HHSC proposes to amend §353.1305(b)(7) and (8), the definitions of “rural private
hospital” and “rural public hospital” to be consistent with a revised definition of “rural
hospital” that was adopted earlier this year in §355.8052 (relating to Inpatient Hospital
Reimbursement). The definitions in this rule would now refer to the definition of “rural
hospital” in §355.8052.
Second, HHSC proposes to add §353.1305(k) which would allow for a limited December 1,
2017, entry into UHRIP for a subset of SDAs. Specifically, if HHSC received an approval
from CMS for any particular SDA by April 15, 2017, that SDA would be able to participate
in UHRIP for dates of service beginning December 1, 2017.
Third, HHSC standardizes references to SDAs throughout the section.
- Selvadas Govind, Director for Hospitals, HHSC Rate Analysis
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In May, 2016, CMS finalized a federal rule that allows states to direct expenditures under
contracts with MCOs under certain limited circumstances. Based on Federal rule, a state
may direct an MCO to raise rates for a class of providers for a particular service, by a
uniform dollar amount or percentage subject to contract approvals by CMS.
Dr. Webster: it appears this implementation may possibly start December 1, 2017; earlier
you listed the challenges that precluded it being started earlier; have all of those challenges
been resolved in such a way to facilitate a smooth beginning of this on December 1, 2017?
Mr. Govind: This is a new and complicated program. This is the first time it is being
implemented in Texas and is also the first time CMS is approving the program across
various states. It requires a lot of education and understanding and appreciation of the
impact this program and the methodologies for reimbursement this program might have on
new MCOs, hospitals and accounting systems. It is not a smooth road but we are making
good progress; we are still aiming for the December 1, 2017 rollout for Bexar and El Paso
SDAs.
Dr. Deshpande: About a week ago, Jami Snyder indicated HHSC had not yet determined
what the hospital rate increases would be in those two SDAs; has that happened at this time?
Mr. Govind: We are still working out the rates which are based on certain guidelines that
the Executive Commissioner has instructed us to use. Among the considerations in working
out the rates are costs and the availability of IGTs from the SDAs. The Executive
Commissioner has instructed us not to allow rate increases to be more than 95 percent of
Medicaid shortfall and we have to keep it in the budget neutrality limitations of the program.
Dr. Handal: This is IGT dependent, is there a limit to the amount of money, will it be
dependent on the IGT only? Mr. Govind: The Executive Commissioner had instructed us
to use 800 million dollars on an annual basis for the roll-out of this program in
terms of budget neutrality; that would be the total amount in All Funds. Since we are
looking at a roll out for two SDAs for the first of December for three months, we will
prorate it accordingly. We also intend to do a state wide roll out for March 1, 2018, and
since that will be for six months for the balance of the state fiscal year, the budget neutrality
cap for the March 1, 2018 rollout will be 400 million dollars.
Mr. Galinsky: Why would we want to limit the amount available to the hospitals and
prorate it out when it is an annual amount that’s available and if we compressed it into six
months we still could access the full amount rather than prorate it. This is not a matter of
fiscal impact to the state because there is no fiscal impact due to the fact that it is funded by
IGTs; I am curious as to why we would trim back and prorate half the year off, other than
the two SDAs that are going live December 1, 2017. Why would we want to limit ourselves
to accessing federal funds to only half of the available annual amount. Mr. Govind: I am
not aware of all of the considerations the Executive Commissioner had in mind; however, I
can suggest that first of all it is a new and very complicated program, attempting to roll it
out with a large amount of money may not be the most prudent strategy; secondly, there is a
potential for some disruption when hospitals might be dependent on certain cash flows in a
short period of time as opposed to over an entire fiscal year.
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Dr. Handal: to work on a six month timeframe is not appropriate, planning must be done
well ahead of time. Mr. Govind: Under the terms of the UHRIP program these programs
have to be reauthorized by CMS on an annual basis. For this particular program we had
intended to roll it out September 1, 2017; however, there were certain obstacles and
operational issues with regard to rolling it out, not on the part of HHSC but on the part of
the stakeholder community. There is a great deal of interest among the hospitals for this
program to be rolled out, and in response to representations by hospitals, the Executive
Commissioner agreed to roll it out for six months from March 1, 2018. In response to
representations by the hospitals from Bexar and El Paso SDAs, he agreed to this pilot
program due to the fact they were the two SDAs in the state which appeared to be the most
eager to implement the program. Ideally we would have an annual planning process.
Mr. Galinsky: regarding the two SDAs which are potentially going live December 1, 2017,
will they receive a 9 month allocation or will they take the 6 month allocation, divide by 9
and spread it out over 9 months to achieve the full amount of their payment? Mr. Govind:
this is a pilot program, it will be for three months and we will allocate a portion of the
budget neutrality those two SDAs would have cost. They will not receive anything more
than they would have if all the other SDAs participated on December 1, 2017. Mr.
Galinsky: but if all the SDAs participated on December 1, 2017 then presumably they would
receive 600 million dollars spread over the nine months equaling three quarters of a year
versus half a year. Being a pilot in that scenario would have its benefits of having an
additional one quarter of a year in funding. Mr. Govind: yes, because it is a pilot program.
Mr. Galinsky: this goes back to my point earlier as to why we are limiting the money out to
six months whether it is a pilot program or not, the pot of money shouldn’t change, if it
does, more SDAs should have been given the opportunity to participate in the pilot.
Mr. Govind: It would have been beneficial to the hospitals if all of the SDAs had been ready
to participate by December 1, 2017. We were not able to be ready by September 1, 2017,
due to differences in viewpoint between MCOs and the hospitals and even within the SDAs.
Mr. Galinsky: I have voiced my opinion that I believe the full amount should have been
allocated for the year, not prorated out. On the March 1, 2018, rollout, is the entire state
being rolled out or will any SDAs be held back. Mr. Govind: HHSC has approval from
CMS on all the SDAs; we anticipate that all of the SDAs will participate.
ACTION ITEMS:
10. Nursing Facility Applications and Informal Reviews.
The Department of Aging and Disability Services (DADS) proposes to amend TAC Title 40,
Part 1, Chapter 19, Subchapter C, §19.212, relating to Time Periods for Processing License
Applications; and Subchapter X, §19.2322, relating to Medicaid Bed Allocation
Requirements.
The proposed amendments clarify the deadline for HHSC to receive a nursing facility license
application. The proposed amendments also allow HHSC to pend an application for up to six
21
months to allow an applicant to comply with licensure requirements. The proposed
amendments further enable HHSC to pend an application for renewal if the facility is subject
to a proposed denial or pending licensure revocation.
In addition, the proposed amendments also allow an existing nursing facility to request an
informal review when the nursing facility has been denied an increase in Medicaid bed
allocations or was subject to decertification or de-allocation of Medicaid beds.
- Bobby Schmidt, Manager, DADS Regulatory Services
The proposed rule amendments are the result of an HHSC Medicaid Bed Allocation Audit
and an HHSC internal audit requested by Department of Aging Disability Services
(DADS) Regulatory Services Licensing and Credentialing Section.
There are 3 items in the proposal; first, all references to DADS will be changed to HHSC.
Second, new rules regarding timeframes for processing licensing applications and additional
circumstances for pending an application for renewal will be added. Third, we will be
proposing amendments to rules to allow nursing facilities to request an informal review
regarding decisions related to Medicaid bed allocations. Specifically in Section 19.212
Time Periods for Processing License Applications; there is language that will change “within
60 days” to “at least 60 days” for an application to be received for review. Language will be
retained in that section which allows HHSC to pend an application for up to six months
to allow license application applicants to comply with licensure requirements. In the
proposed amendment in Section 19.2322K Informal Review Procedures, in the
Medicaid Bed Allocation Section, this will allow an existing nursing facility to request an
informal review when it has been denied an increase in Medicaid bed allocations, or when it
was the subject to decertification or deallocation of Medicaid beds.
Interested stakeholders were provided a copy of these rules, via email and GovDelivery on
April 3, 2017. In addition a public meeting was held on April 10, 2017. We received no
comments on these rules.
Colleen Horton motioned for approval of the rule
Dr. Deshpande seconded the motion
The motion to approve the rule passed unanimously
10. Public Comment.
No additional Public Comment was received.
11. Proposed next meeting: February 15, 2018, at 9 a.m.
12. Meeting Adjourned.