Section 354.1713 - Category C Requirements for Performers(a) Requirements for hospitals and physician practices.(1) Measure Bundle and measure selection.(A) A hospital or physician practice, with the exception of those described in subparagraph (J) of this paragraph, must select Measure Bundles from the Hospital and Physician Practice Measure Bundle Menu of the Measure Bundle Protocol in accordance with the requirements in subparagraphs (B) - (I) of this paragraph in the RHP plan update for its RHP.(B) Each Measure Bundle is assigned a point value as described in the Measure Bundle Protocol.(C) A hospital or physician practice is assigned a minimum point threshold (MPT) for Measure Bundle selection as described in paragraphs (6) and (7) of this subsection.(D) A hospital or physician practice must select Measure Bundles worth enough points to meet its MPT in order to maintain its total valuation for DY7 and DY8. If a hospital or physician practice does not select Measure Bundles worth enough points to meet its MPT, its total DY7 valuation will be reduced proportionately across its RHP Plan Update and Categories B-D funds for DY7, and its total DY8 valuation will be reduced proportionately across its Categories B-D funds for DY8, based on the point values of the Measure Bundles it selects.(E) A hospital or physician practice may only select a Measure Bundle for which its denominators for the baseline measurement period for at least half of the required measures in the Measure Bundle have significant volume.(F) A hospital or physician practice with a valuation greater than $2,500,000 per demonstration year (DY) for DY7-8 must: (i) select at least one Measure Bundle with at least one required three-point measure for which its denominator for the baseline measurement period has significant volume; or(ii) select at least one Measure Bundle with at least one optional three-point measure for which its denominator for the baseline measurement period has significant volume, and select at least one optional three-point measure in that Measure Bundle for which its denominator for the baseline measurement period has significant volume.(G) A hospital or physician practice with an MPT of 75 must select at least one Measure Bundle with at least one population-based clinical outcome measure as specified in the Measure Bundle Protocol.(H) A hospital or physician practice may only select an optional measure in a selected Measure Bundle for which its denominator for the baseline measurement period has significant volume.(I) Only a hospital with a valuation less than or equal to $2,500,000 per DY for DY7-8 may select a Measure Bundle identified as a rural Measure Bundle in accordance with the requirements in the Measure Bundle Protocol.(J) If a hospital or physician practice has a limited scope of practice, cannot reasonably report on at least half of the required measures in the Measure Bundle(s) appropriate for it based on its scope of practice and community partnerships, and consequently cannot meet its MPT for Measure Bundle selection, the hospital or physician practice may request HHSC approval to select measures, rather than Measure Bundles, from the Measure Bundle Protocol. The hospital or physician practice must submit a request for such approval to HHSC prior to the RHP plan update submission, by a date determined by HHSC. Such a request may be subject to review by the Centers for Medicare and Medicaid Services (CMS). If HHSC and CMS, as appropriate, approve such a request, the following requirements apply: (i) the hospital's or physician practice's total valuation for DY7 and DY8 may be reduced;(ii) the hospital or physician practice must select measures from the following menus of the Measure Bundle Protocol in accordance with the requirements in clauses (iii) - (v) of this subparagraph in the RHP plan update for its RHP: (I) the Measure Bundles on the Hospital and Physician Practice Measure Bundle Menu;(II) the Community Mental Health Center Measure Menu; or(III) the Local Health Department Measure Menu;(iii) each measure in a Measure Bundle on the Hospital and Physician Practice Measure Bundle Menu, and each measure on the Community Mental Health Center Measure Menu and the Local Health Department Measure Menu, is assigned a point value as described in the Measure Bundle Protocol;(iv) the hospital or physician practice is assigned an MPT for measure selection as described in paragraphs (5) and (6) of this subsection; and(v) the hospital or physician practice must select measures worth enough points to meet its MPT in order to maintain its total valuation for DY7 and DY8. If the hospital or physician practice does not select measures worth enough points to meet its MPT, its total DY7 valuation will be reduced proportionately across its RHP Plan Update and Categories B-D funds for DY7, and its total DY8 valuation will be reduced proportionately across its Categories B-D funds for DY8, based on the point values of the measures it selects.(2) DSRIP-attributed population. A hospital or physician practice must determine its DSRIP-attributed population to be applied to its selected Measure Bundles and measures as specified in the Measure Bundle Protocol.(3) Measure Bundle valuation. A hospital or physician practice may allocate its Category C valuation among its selected Measure Bundles in the RHP plan update for its RHP as it chooses, provided the following requirements are met: (A) The valuation for each selected Measure Bundle must be greater than or equal to (the Measure Bundle point value divided by the sum of all the selected Measure Bundles' point values) multiplied by 0.75 multiplied by the Category C valuation.(B) The valuation for each selected Measure Bundle without any required or selected optional three-point measures must be less than or equal to (the Measure Bundle point value divided by the sum of all the selected Measure Bundles' point values) multiplied by the Category C valuation.(C) The valuation for each selected Measure Bundle with a required or selected optional three-point measure must be less than or equal to (the Measure Bundle point value divided by the sum of all the selected Measure Bundles' point values) multiplied by 1.25 multiplied by the Category C valuation.(D) If a hospital or physician practice allocates to a Measure Bundle a percentage of its Category C valuation that is one percent greater than the Measure Bundle's point value as a percentage of all the selected Measure Bundles' point values, the hospital or physician practice must provide sufficient justification as specified in the Program Funding and Mechanics Protocol.(4) Measure valuation. The valuation for each measure in a selected Measure Bundle is equal to the Measure Bundle valuation divided by the number of measures in the selected Measure Bundle, so that the valuations of the measures in the selected Measure Bundle are equal, with the following exceptions:(A) If a Measure Bundle includes an innovative measure: (i) the valuation for each innovative measure in the Measure Bundle is equal to the Measure Bundle valuation divided by the number of the measures in the Measure Bundle subtracted by 0.5 for each innovative measure and divided by 2; and(ii) the valuation for each measure in the Measure Bundle that is not an innovative measure is equal to the Measure Bundle valuation divided by the number of measures in the Measure Bundle subtracted by 0.5 for each innovative measure.(B) If a hospital's or physician practice's denominator for a required measure or numerator for a population-based clinical outcome measure in a selected Measure Bundle for the baseline measurement period or a performance year has no volume, the measure is removed from the Measure Bundle, and its valuation for the applicable DY is redistributed among the remaining measures in the Measure Bundle for which the hospital's or physician practice's denominator for the baseline measurement period or performance year has significant volume for the applicable DY. The valuation for the applicable DY for each of the remaining measures in the Measure Bundle for which the hospital's or physician practice's denominator for the baseline measurement period or performance year has significant volume is equal to the valuation for the Measure Bundle for the applicable DY divided by the number of measures for which the hospital's or physician practice's denominator for the baseline measurement period or performance year has significant volume, so that the valuations for the applicable DY for the measures in the Measure Bundle for which the hospital's or physician practice's denominator for the baseline measurement period or performance year has significant volume are equal.(C) If a hospital's or physician practice's denominator for a required measure or numerator for a P4R population-based clinical outcome measure in a selected Measure Bundle for the baseline measurement period or a performance year has insignificant volume, the measure's milestone valuations are adjusted in accordance with subsection (e)(2) of this section.(5) Milestone valuation. The measure milestones and corresponding valuations for DY7-8 are as described in subsection (e) of this section.(6) MPTs for hospitals.(A) The MPT for hospitals, with the exception of those described in subparagraphs (B) and (C) of this paragraph, is calculated as follows: (i) First, the hospital's statewide hospital factor (SHF) is equal to (.64 multiplied by (the hospital's Medicaid and uninsured inpatient days divided by the sum of all hospitals' Medicaid and uninsured inpatient days)) plus (.36 multiplied by (the hospital's Medicaid and uninsured outpatient costs divided by the sum of all hospitals' Medicaid and uninsured outpatient costs)).(ii) Second, the hospital's statewide hospital ratio (SHR) is equal to (the hospital's DY7 valuation divided by the sum of all hospitals' DY7 valuations) divided by the SHF.(iii) Third, the hospital's MPT is determined as follows:(I) If the SHR is less than or equal to 3, the MPT is the lesser of: (-a-) the DY7 valuation divided by $500,000; or(II) If the SHR is greater than 3 but less than or equal to 10, the MPT is the lesser of: (-a-) (the DY7 valuation divided by $500,000 multiplied by (the SHR divided by 3); or(III) If the SHR is greater than 10 and the DY7 valuation is less than or equal to $15 million, the MPT is the lesser of: (-a-) (the DY7 valuation divided by $500,000 multiplied by (the SHR divided by 3); or(IV) If the SHR is greater than 10 and the DY7 valuation is greater than $15 million, the MPT is the lesser of: (-a-) (the DY7 valuation divided by $500,000 multiplied by (the SHR divided by 3); or(B) If a hospital does not have the data needed for the SHF calculation in paragraph (5)(A)(i) of this subsection, or if a hospital did not participate in DSRIP during the initial demonstration period or DY6, its MPT is the lesser of: (i) the hospital's DY7 valuation divided by $500,000; or(C) If a hospital has a limited scope of practice, cannot reasonably report on at least half of the required measures in the Measure Bundle(s) appropriate for it based on its scope of practice and community partnerships, and consequently cannot meet its MPT for Measure Bundle selection, the hospital may request HHSC approval for a reduced MPT equal to the sum of the points for all the Measure Bundles for which the hospital could reasonably report on at least half of the required measures in the Measure Bundle. The hospital must submit a request for such approval to HHSC prior to the RHP plan update submission, by a date determined by HHSC. Such a request may be subject to review by the Centers for Medicare and Medicaid Services (CMS). If HHSC and CMS, as appropriate, approve such a request, the hospital's total valuation for DY7 and DY8 may be reduced.(7) MPTs for physician practices. (A) The MPT for physician practices, with the exception of those described in subparagraph (B) of this paragraph, is the lesser of: (i) the physician practice's DY7 valuation divided by $500,000; or(B) If a physician practice has a limited scope of practice, cannot reasonably report on at least half of the required measures in the Measure Bundles appropriate for it based on its scope of practice and community partnerships, and consequently cannot meet its MPT for Measure Bundle selection, the physician practice may request HHSC approval for a reduced MPT equal to the sum of the points for all the Measure Bundles for which the physician practice could reasonably report on at least half of the required measures in the Measure Bundle. The physician practice must submit a request for such approval to HHSC prior to the RHP plan update submission, by a date determined by HHSC. Such a request may be subject to review by CMS. If HHSC and CMS, as appropriate, approve such a request, the physician practice's total valuation for DY7 and DY8 may be reduced.(b) Requirements for community mental health centers (CMHCs).(1) Measure selection. (A) A CMHC must select measures from the Community Mental Health Center Measure Menu of the Measure Bundle Protocol.(B) Each measure is assigned a point value as described in the Measure Bundle Protocol.(C) A CMHC is assigned an MPT for measure selection as described in paragraph (3) of this subsection.(D) A CMHC must select measures worth enough points to meet its MPT in order to maintain its total valuation for DY7 and DY8. If a CMHC does not select measures worth enough points to meet its MPT, its total DY7 valuation will be reduced proportionately across its RHP Plan Update and Categories B-D funds for DY7, and its total DY8 valuation will be reduced proportionately across its Categories B-D funds for DY8, based on the point values of the measures it selects.(E) A CMHC may only select a measure for which its denominator for the baseline measurement period has significant volume.(F) A CMHC must select at least two measures.(G) A CMHC with a valuation greater than $2,500,000 per DY for DY7-8 must select at least one three-point measure.(2) DSRIP-attributed population. A CMHC must determine its DSRIP-attributed population to be applied to its selected measures as specified in the Measure Bundle Protocol.(3) Measure valuation. A CMHC may allocate its Category C valuation among its selected measures, provided the following requirements are met: (A) The valuation for each selected measure must be greater than or equal to (the Category C valuation divided by the number of selected measures) multiplied by 0.75.(B) The valuation for each selected one-point measure must be less than or equal to the Category C valuation divided by the number of selected measures.(C) The valuation for each selected three-point or four-point measure must be less than or equal to (the Category C valuation divided by the number of selected measures) multiplied by 1.25.(D) If a CMHC allocates to a measure a percentage of its Category C valuation that is one percent greater than the Category C valuation divided by the number of selected measures, the CMHC must provide sufficient justification as specified in the Program Funding and Mechanics Protocol.(4) Milestone valuation. The measure milestones and corresponding valuations for DY7-8 are as described in subsection (e) of this section.(5) MPTs. A CMHC's MPT is the lesser of:(A) the CMHC's DY7 valuation divided by the standard point valuation ($500,000); or(c) Requirements for local health departments (LHDs).(1) Measure selection. (A) An LHD must select measures from: (i) the Local Health Department Measure Menu of the Measure Bundle Protocol; or(ii) its DY6 Category 3 pay-for-performance (P4P) measures.(B) An LHD may not select the same measure from both the Local Health Department Measure Menu of the Measure Bundle Protocol and its DY6 Category 3 P4P measures.(C) If an LHD's DY6 Category 3 P4P measures include multiple versions of the same measure, the LHD may select multiple versions of that measure, but the points associated with that measure will only count once toward the LHD's MPT.(D) Each measure on the Local Health Department Measure Menu is assigned a point value as described in the Measure Bundle Protocol.(E) Each LHD DY6 Category 3 P4P measure is assigned a point value as described in the Measure Bundle Protocol.(F) An LHD is assigned an MPT for measure selection as described in paragraph (4) of this subsection.(G) An LHD must select measures worth enough points to meet its MPT in order to maintain its total valuation for DY7 and DY8. If an LHD does not select measures worth enough points to meet its MPT, its total DY7 valuation will be reduced proportionately across its RHP Plan Update and Categories B-D funds for DY7, and its total DY8 valuation will be reduced proportionately across its Categories B-D funds for DY8, based on the point values of the measures it selects.(H) An LHD may only select a measure for which its denominator for the baseline measurement period has significant volume.(I) An LHD must select at least two measures.(J) An LHD with a valuation of more than $2,500,000 per DY for DY7-8 must select at least one three-point measure.(2) DSRIP-attributed population. An LHD must determine its DSRIP-attributed population to be applied to its selected measures as specified in the Measure Bundle Protocol.(3) Measure valuation. An LHD may allocate its Category C valuation among its selected measures, provided the following requirements are met: (A) The valuation for each selected measure must be greater than or equal to (the Category C valuation divided by the number of selected measures) multiplied by 0.75.(B) The valuation for each selected one-point measure must be less than or equal to the Category C valuation divided by the number of selected measures.(C) The valuation for each selected three-point or four-point measure must be less than or equal to (the Category C valuation divided by the number of selected measures) multiplied by 1.25.(D) If an LHD allocates to a measure a percentage of its Category C valuation that is one percent greater than the Category C valuation divided by the number of selected measures, the LHD must provide sufficient justification as specified in the Program Funding and Mechanics Protocol.(4) Milestone valuation. The measure milestones and corresponding valuations for DY7-8 are as described in subsection (e) of this section.(5) MPTs. An LHD's MPT is the lesser of:(A) the LHD's DY7 valuation divided by the standard point valuation ($500,000); or(d) Measurement periods. (1) Baseline measurement periods. The baseline measurement period for a measure is calendar year 2017 with the following exceptions:(A) the baseline measurement period for a DY6 Category 3 P4P measure selected by a LHD is DY6;(B) a performer that demonstrates good cause may request for a measure to have a shorter baseline measurement period consisting of no fewer than six months as specified in the Program Funding and Mechanics Protocol and HHSC guidance;(C) a performer that demonstrates good cause may request for a measure to have a delayed baseline measurement period that ends no later than September 30, 2018, as specified in the Program Funding and Mechanics Protocol and HHSC guidance; and(D) any other exception specified in the Measure Bundle Protocol or one of its appendices.(2) Performance measurement periods. The performance measurement periods for a P4P measure are as follows: (A) Performance Year (PY) 1 for a measure is calendar year 2018 unless otherwise specified in the Measure Bundle Protocol or one of its appendices.(B) PY2 for a measure is calendar year 2019 unless otherwise specified in the Measure Bundle Protocol or one of its appendices.(C) PY3 for a measure is calendar year 2020 unless otherwise specified in the Measure Bundle Protocol or one of its appendices.(3) Reporting measurement periods. The reporting measurement periods for a pay-for-reporting (P4R) measure are as follows unless otherwise specified in the Measure Bundle Protocol:(A) Reporting Year (RY) 1 for a measure is DY7; and(B) RY 2 for a measure is DY8.(e) Measure milestones. (1) The milestones and corresponding valuations for DY7-8 are as follows, with the exceptions specified in paragraphs (2) and (3) of this subsection: Attached Graphic
(2) If a hospital's or physician practice's denominator for a required measure in a selected Measure Bundle for the baseline measurement period or a performance measurement period has insignificant volume, the valuation for the measure's goal achievement milestone for the DY is redistributed among the goal achievement milestones for the measures in the Measure Bundle for which the hospital's or physician practice's denominator for the baseline measurement period or performance measurement period has significant volume for the applicable DY. The valuations for the goal achievement milestones for the measures in the Measure Bundle for which the hospital's or physician practice's denominator has significant volume for the DY are calculated as follows: (A) the valuation for the DY7 goal achievement milestone is equal to 50 percent of the valuation for the Measure Bundle divided by the number of measures in the Measure Bundle for which the hospital's or physician practice's denominator has significant volume, so that the valuations for the DY7 goal achievement milestones for the measures in the Measure Bundle for which the hospital's or physician practice's denominator has significant volume are equal; and(B) the valuation for the DY8 goal achievement milestone is equal to 75 percent of the valuation for the Measure Bundle divided by the number of measures in the Measure Bundle for which the hospital's or physician practice's denominator has significant volume, so that the valuations for the DY8 goal achievement milestones for the measures in the Measure Bundle for which the hospital's or physician practice's denominator has significant volume are equal.(3) Measures with multiple parts. Some P4P measures have multiple parts, as described in the Program Funding and Mechanics Protocol and Measure Bundle Protocol. (A) A measure with multiple parts has one baseline reporting milestone per DY, one PY reporting milestone per DY, and multiple goal achievement milestones per DY.(B) The valuation for each measure part's goal achievement milestone is equal to the measure's total goal achievement milestone valuation divided by the number of measure parts so that the measure parts' goal achievement milestone valuations are equal.(C) All measure parts' baseline reporting milestones must be reported during the same reporting period.(D) All measure parts' PY reporting milestones must be reported during the same reporting period.(E) Each measure part's goal achievement milestone will have its own goal. Therefore, the percent of goal achieved, as described in §RSA 354.1719 of this division (relating to Disbursement of Funds) will be determined for a measure part's goal achievement milestone independently of the percent of goal achieved for the other measure parts' goal achievement milestones.(4) A performer must report a baseline for a measure, and HHSC must approve the reported baseline for reporting purposes, before a performer can report PY1 (or PY2 if HHSC approved the use of a delayed baseline measurement period for the measure). (A) A performer must adhere to measure specifications and maintain a record of any variances approved by HHSC prior to reporting a baseline for a measure.(B) HHSC's approval of a reported baseline for reporting purposes does not constitute approval for a performer to report a measure outside measure specifications. If at any point HHSC or the independent assessor finds that a performer is reporting a measure outside measure specifications, reporting milestone payment and goal achievement milestone payment may be withheld or recouped while the performer works to bring reporting into compliance with measure specifications.(5) A performer must report a P4P measure's reporting milestone and goal achievement milestone for a given PY during the same reporting period, with exceptions for P4P measures with a delayed baseline measurement period.(f) Measure eligible denominator population. (1) Each Measure Bundle for hospitals and physician practices has a target population as specified in the Measure Bundle Protocol.(2) A measure's eligible denominator population must include all individuals served by the performer's system during a given measurement period that are included in the performer's DSRIP-attributed population and the target population for a measure for hospitals and physician practices, and that meet the measure's specifications as specified in the Measure Bundle Protocol.(3) A performer may not use a performer-specific facility, co-morbid condition, age, gender, or race/ethnicity subset not otherwise specified in the Measure Bundle Protocol.(4) Reporting milestones. A performer must report its performance on a measure for the all-payer, Medicaid-only, and Low-income Uninsured-only (LIU-only) payer types to be eligible for payment of the measure's reporting milestones. (A) A performer that demonstrates good cause may request in the RHP plan update submission to be exempted from reporting its performance on a measure for the Medicaid-only payer type or the LIU-only payer type as specified in the Program Funding and Mechanics Protocol.(B) A performer that demonstrates good cause may submit a RHP plan update modification request to HHSC to be exempted from reporting its performance on a measure for the Medicaid-only payer type or the LIU-only payer type as specified in the Program Funding and Mechanics Protocol.(5) Goal achievement milestones. Payment for a P4P measure's goal achievement milestone is based on the performer's performance on the measure for the MLIU payer type. (A) A performer that demonstrates good cause may request in the RHP plan update submission that payment for a P4P measure's goal achievement milestone be based on the performer's performance on the measure for the all-payer, Medicaid-only, or LIU-only payer type as specified in the Program Funding and Mechanics Protocol.(B) A performer that demonstrates good cause may submit a RHP plan update modification request to HHSC to change the payer type on which payment for a P4P measure's goal achievement milestone is based as specified in the Program Funding and Mechanics Protocol.(g) Methodology for P4P measure goal setting.(1) A P4P measure's goals are set as an improvement over the baseline.(2) A P4P measure is designated as either Quality Improvement System for Managed Care (QISMC) or Improvement over Self (IOS) as specified in the Measure Bundle Protocol. A P4P measure designated as QISMC has a defined High Performance Level (HPL) and Minimum Performance Level (MPL) based on national or state benchmarks.(3) A P4P measure's goals for its goal achievement milestones are set as follows: Attached Graphic
(4) A performer may request HHSC approval in the RHP plan update to use a numerator of zero for certain P4P measures for the baseline measurement period, as described in the Program Funding and Mechanics Protocol and Measure Bundle Protocol. If a performer receives HHSC approval to use a numerator of zero for a P4P measure for the baseline measurement period, the goal for the DY7 goal achievement milestone will be equal to the 75th percentile, and the goal for the DY8 goal achievement milestone will be equal to a 10% gap closure between the 75th percentile and the HPL, as described in the Measure Bundle Protocol.(h) Carry forward policy.(1) Carry forward of reporting. If a performer does not report a measure's baseline reporting milestone or performance year reporting milestone during the first reporting period after the end of the milestone's measurement period, the performer may request to carry forward reporting of the milestone to the next reporting period.(2) Carry forward of achievement. (A) A performer may request to carry forward achievement of a measure's goal achievement milestone so that the DY7 goal achievement milestone may be achieved in PY1 or PY2, and the DY8 goal achievement milestone may be achieved in PY2 or PY3, with the exception described in subparagraph (B) of this paragraph.(B) If a measure has a delayed baseline measurement period, a performer will carry forward achievement of its goal achievement milestone so that the DY7 goal achievement milestone may be achieved in PY2.(C) The performer must report the carried forward achievement of a measure's goal achievement milestone during the first reporting period after the end of the milestone's carried forward measurement period.1 Tex. Admin. Code § 354.1713
Adopted by Texas Register, Volume 42, Number 47, November 24, 2017, TexReg 6609, eff. 12/1/2017; Amended by Texas Register, Volume 43, Number 16, April 20, 2018, TexReg 2393, eff. 4/26/2018; Amended by Texas Register, Volume 43, Number 34, August 24, 2018, TexReg 5497, eff. 9/1/2018