Hospitals & Clinic Services
HHSC REVERTS INPATIENT REIMBURSEMENTS TO APR-DRG GROUPER 36, EFFECTIVE 9/1/2020
Note: Texas Medicaid managed care organizations (MCOs) must provide all medically necessary, Medicaid-covered services to eligible clients. Administrative procedures such as prior authorization, pre-certification, referrals, and claims/encounter data filing may differ from traditional Medicaid (fee-for-service) and from MCO to MCO. Providers should contact the client's specific MCO for details.
The Health and Human Services Commission (HHSC) Rate Analysis for Hospital Services develops reimbursement methodology rules for determining payment rates/fees for Medicaid Hospital Services. General Medicaid program rules for Hospital Services are located at Title 1 of the Texas Administrative Code, Part 15, Chapter 354, SubChapter A, Division 10, Rule §354.1121. Additional general Medicaid program rules for Hospital Services are located at Title 1 of the Texas Administrative Code, Part 15, Chapter 354, SubChapter A, Division 11, Rules 1131-1190. HHSC Rate Analysis for Hospital Services develops payment rates/fees in accordance with published rules and policy guidelines for Hospital Services.
The Families First Coronavirus Response Act, which became federal law on March 18, 2020, authorized an increase of 6.2 percentage points to the Federal medical assistance percentage (FMAP) determined for each state for each calendar quarter occurring during the emergency period. The federal government’s share of most Medicaid service costs is determined by the FMAP rate, which varies by state and is determined by a formula set in statute. An increased FMAP has the impact of increasing the amount of federal funds available for some Medicaid payments.
The Health and Human Services Commission (HHSC) received many inquiries asking how the enhanced FMAP (eFMAP) would impact supplemental and directed payment programs. Supplemental and directed payment programs are supported with a combination of federal and local funds through either certified public expenditures or intergovernmental transfers (IGT). After consultation with the Centers for Medicare and Medicaid Services (CMS) to understand how to apply the enhanced FMAP (eFMAP) to such programs, HHSC developed a plan for ensuring that funds previously transferred to the agency are applied to each applicable program in an efficient manner and with minimal administrative burden on local entities and providers.
The eFMAP will apply to state expenditures that were incurred on or after January 1, 2020, through June 30, 2020. The eFMAP may continue if the emergency period is extended beyond June 30, 2020. The eFMAP will be applied based upon the date the expenditure is incurred by the state as recorded on our CMS-64, regardless of whether the payments are made by HHSC to providers on an interim, supplemental, or per claim basis. With respect to any programs that use an interim or advanced payment methodology, the FMAP that is applied will be based upon the date the state recorded the expenditure on the CMS-64, and any reconciliations performed will be recorded as adjustments to the prior period.
Detailed information about the impacts on each supplemental and directed payment program can be found here.
If you have any questions, please contact RAD_Payments@hhsc.state.tx.us.
Section 1115 Waiver Protocol Approved by CMS
HHSC has released the final revised Texas Uncompensated Care payment protocol that was submitted approved by the Centers for Medicare and Medicaid Services (CMS) on July 26, 2018. Many stakeholders provided valuable feedback to HHSC on the preliminary on the preliminary working draft of the protocol that was released on February 23, 2018.
Texas is required by CMS to submit a revised protocol under Special Terms and Conditions (STC) for the Section 1115 Demonstration Waiver renewal. The STCs require an uncompensated care protocol that only allows for charity costs allowed under a provider’s charity policy (that that adhere to the charity care principles of the Healthcare Financial Management Association - Principles and Practices Board Statement 15: Valuation and Financial Statement Presentation of Charity Care and Bad Debts by Institutional Healthcare Providers) and also based on Medicare cost principles. The revised protocol was due to CMS no later than March 30, 2018. CMS had 90 calendar days to provide feedback to Texas, and subsequent changes were made based on that feedback. Failure to meet the March 30, 2018, deadline would have resulted in a 20% reduction in expenditure authority in the UC program.
This protocol should be read in conjunction with a number of accompanying draft Excel workbooks that are illustrative of how the procedures in the protocol are to be followed. These workbooks are for analysis purposes only and the data therein is not suitable for any other purpose. Further, these workbooks have not yet been approved by CMS and are subject to change. HHSC has posted the protocol and the draft Excel workbooks on the Rate Analysis Division website at https://rad.hhs.texas.gov/hospitals-clinic/hospital-services/uncompensated-care.
The Texas Health and Human Services Commission (HHSC) has approval from the Centers for Medicare and Medicaid Services (CMS) to implement the Uniform Hospital Rate Increase Program (UHRIP) for hospital services statewide. Further information on the UHRIP program may be obtained on our Uniform Hospital Rate Increase Program page.
SDA Add-On status verification is in process through July 27, 2017. Please review your SDA Add-On information and submit any changes on the Status Verification form.