Section 354.1729 - DefinitionsThe following words and terms, when used in this division, have the following meanings unless the context clearly indicates otherwise.
(1) Core activity--An activity implemented by a performer to improve patient health or quality of care. It may be implemented by a performer to achieve the performer's Category C measure goals or it may be connected to the mission of the performer's organization.(2) Delivery System Reform Incentive Payment (DSRIP) pool--Funds available to DSRIP performers under the waiver for their efforts to enhance access to health care, the quality of care, and the health of patients and families they serve.(3) Demonstration Year (DY) 6--Federal fiscal year 2017 (October 1, 2016 - September 30, 2017).(4) Demonstration Year (DY) 7--Federal fiscal year 2018 (October 1, 2017 - September 30, 2018).(5) Demonstration Year (DY) 8--Federal fiscal year 2019 (October 1, 2018 - September 30, 2019).(6) Demonstration Year (DY) 9--Federal fiscal year 2020 (October 1, 2019 - September 30, 2020).(7) Demonstration Year (DY) 10--Federal fiscal year 2021 (October 1, 2020 - September 30, 2021).(8) Demonstration Year (DY) 11--Federal fiscal year 2022 (October 1, 2021 - September 30, 2022).(9) Denominator--As it relates to a Category C measure's volume: (A) the number of Medicaid and low-income or uninsured (MLIU) cases; or(B) one of the following, which the performer receives approval from HHSC to use for the measure: (i) the number of all-payer cases;(ii) the number of Medicaid cases; or(iii) the number of low-income or uninsured (LIU) cases.(10) Encounter--An encounter, for the purposes of Patient Population by Provider, is any physical or virtual contact between a performer and a patient during which an assessment or clinical activity is performed, with exceptions including those in subparagraph (B) of this definition. (A) An encounter must be documented by the performer.(B) An email, phone call, or text message is not considered an encounter.(11) Federal poverty level (FPL)--The household income guidelines issued annually and published in the Federal Register by the United States Department of Health and Human Services.(12) Initial demonstration period--The first five demonstration years (DYs) of the waiver, or December 12, 2011 through September 30, 2016.(13) Innovative measure--F1-T03 (Preventative Care & Screening: Oral Cancer Screening).(14) Insignificant volume--For most Category C measures, the denominator is considered to have insignificant volume if its volume is greater than zero but less than 30.(15) Low-income or Uninsured (LIU)--An individual who is not enrolled in Medicaid or the Children's Health Insurance Program who meets one of the following criteria: (A) is at or below 200 percent of the FPL; or(B) does not have health insurance.(16) Measure--A mechanism to assign a quantity to an attribute by comparison to a criterion. As it relates to Category C, a measure is a standardized tool to measure or quantify healthcare processes, outcomes, patient perceptions, organizational structure, or systems that are associated with the ability to provide high-quality health care.(17) Measure Bundle--A grouping of measures under Category C that share a unified theme, apply to a similar population, and are impacted by similar activities. Measure Bundles are selected by hospitals and physician practices. All Measure Bundles include required measures, and some Measure Bundles also include optional measures.(18) Measure Bundle Protocol--A master list of potential Category C Measure Bundles and measures, as well as Category D Statewide Reporting Measure Bundles and measures.(19) Medicaid and low-income or uninsured (MLIU)--An individual who: (A) is enrolled in Medicaid;(B) is enrolled in the Children's Health Insurance Program;(C) is at or below 200 percent of the FPL; or(D) does not have health insurance.(20) Milestone--An objective of DSRIP performance on which DSRIP payments are based.(21) Minimum point threshold (MPT)--The minimum number of points that a performer must meet in selecting its Category C Measure Bundles or measures, as described in §354.1753 of this division (relating to Category C Requirements for Performers).(22) No volume--For Category C measures, the denominator is considered to have no volume if its volume is equal to zero. For a Category C population-based clinical outcome measure, the numerator is considered to have no volume if the volume is equal to zero.(23) Patient Population by Provider (PPP)--The number of individuals in a performer's system for which there was an encounter during the applicable DY.(24) Patient Population by Provider Goal (PPP Goal)--The target number of individuals in a performer's system for which there will be an encounter during the applicable DY.(25) Performer--A provider enrolled in Texas Medicaid that participates in DSRIP and receives DSRIP payments.(26) Population-based clinical outcome measure--A Category C clinical outcome measure that measures emergency department utilization or admissions for select conditions for all individuals in the Measure Bundle's target population. It may be required as pay-for-performance (P4P) or pay-for-reporting (P4R) based on the Measure Bundle and the hospital's or physician practice's MPT as specified in the Measure Bundle Protocol.(27) Regional Healthcare Partnership (RHP) plan update--An RHP plan update for DY7-8 that is further updated for DY9-10, as further described in §354.1737 of this division (relating to RHP Plan Update).(28) Related strategy--A strategy employed by a performer to improve performance on a measure.(29) Significant volume--For most Category C measures, the denominator is considered to have significant volume if its volume is greater than or equal to 30.(30) Statewide hospital factor (SHF)--A factor used to determine the MPT that takes into account a hospital's MLIU inpatient days and MLIU outpatient costs compared to all hospitals, as described in §354.1753 of this division.(31) Statewide hospital ratio (SHR)--A factor used to determine the MPT that takes into account whether a hospital's DY7 DSRIP valuation is higher or lower than would be expected based on the hospital's MLIU inpatient days and MLIU outpatient costs compared to other hospitals, as described in §354.1753 of this division.(32) System--A performer's patient care landscape, as defined by the performer, in accordance with the Program Funding and Mechanics Protocol and Measure Bundle Protocol. Essential functions or departments of a performer's provider type are required components that must be included in a performer's system definition.(33) Target population--For a Category C Measure Bundle, the pool of individuals to be included in a measure denominator for which a hospital or physician practice is accountable for improvement.(34) Volume--For Category C measure denominators, the total number of measured units in the denominator. Volume is used to determine the size of the population for which improvement is being measured.1 Tex. Admin. Code § 354.1729
Adopted by Texas Register, Volume 44, Number 45, November 8, 2019, TexReg 6856, eff. 11/12/2019; Amended by Texas Register, Volume 45, Number 48, November 27, 2020, TexReg 8514, eff. 12/2/2020