TITLE 1. ADMINISTRATION

PART 15. TEXAS HEALTH AND HUMAN SERVICES COMMISSION

CHAPTER 353. MEDICAID MANAGED CARE

SUBCHAPTER O. DELIVERY SYSTEM AND PROVIDER PAYMENT INITIATIVES

1 TAC §353.1302, §353.1304

The Executive Commissioner of the Texas Health and Human Services Commission (HHSC) proposes amendments to §353.1302, concerning Quality Incentive Payment Program for Nursing Facilities on or after September 1, 2019; and §353.1304, concerning Quality Metrics for the Quality Incentive Payment Program for Nursing Facilities on or after September 1, 2019.

BACKGROUND AND PURPOSE

In order to continue incentivizing Texas nursing facilities (NFs) to improve quality and innovation in the provision of services, HHSC is proposing to amend the Quality Incentive Payment Program (QIPP) quality metrics that HHSC may select for each program year as well as certain component funding allocations beginning in program year five (i.e., September 1, 2021 through August 31, 2022).

Section 353.1302 would be amended to adjust QIPP Component 2 and Component 3 funding allocations as follows: increase the allocation percentage from 30 percent to 40 percent in Component 2 (paid monthly); and decrease the allocation percentage from 70 percent to 60 percent in Component 3 (paid quarterly).

The additional proposed amendments would discontinue an unnecessary requirement, provide increased clarity, and ensure that the language in this section corresponds to similar language in other sections of Subchapter O.

Section 353.1304 would be amended to remove set types of quality metrics and related performance requirements for each program year in favor of a public notice and hearing process. This proposed change allows the program to be adapted on an annual basis to ensure quality objectives are continually improved. This amendment would also clarify HHSC's validation requirements for reviews of self-reported data in the program.

SECTION-BY-SECTION SUMMARY

The proposed amendments to §353.1302 and §353.1304 replace all instances of the term "eligibility period" with "program period" to make these rules consistent with other rules regarding directed payment programs. In addition, amendments update "Rate Analysis Department" to the department's new title, "Provider Finance Department."

The proposed amendment to §353.1302(b) adds new paragraph (7) to define the term "runout period" to mean the 23 months following the end of the program period.

The proposed amendment to §353.1302(e) removes paragraph (1) and renumbers the subsection. Clarifying edits are made to new paragraph (1); text added to new paragraph (2) updates the certification requirements associated with a provider's use of QIPP funds; new paragraph (3) clarifies the requirements when a participating provider undergoes a change of ownership impacting eligibility in the program; and new paragraph (4) requires HHSC access to and provider maintenance of eligibility and enrollment records and data.

The proposed amendment to §353.1302(f) clarifies paragraphs (1), (2), and (4).

The proposed amendment to §353.1302(g) makes clarifying edits in paragraph (1) and revises the component funding allocations in paragraphs (2) and (3).

The proposed amendment to §353.1302(h) makes clarifying edits in paragraph (1) and revises subparagraph (F) to provide that no funds will be earned if a NF does not have enough data for any quality metrics to be calculated.

The proposed amendments to §353.1302(i) and §353.1302(j) make clarifying edits and update outdated references.

The proposed amendment to §353.1304(b) makes clarifying edits and removes the examples in paragraphs (1) and (2).

The proposed amendment to §353.1304(c) removes paragraphs (1) - (6) to allow HHSC to designate evidence-based quality metrics for each program period. This change will ensure the program can be adapted on an annual basis to ensure quality objectives are continually improved.

The proposed amendment to §353.1304(d) removes paragraphs (1) - (6) to allow HHSC to specify the performance requirements associated with the designated quality metrics for each program period.

The proposed amendment to §353.1304 creates a new subsection (e) related to quality assurance and the process HHSC will follow to validate provider data and documentation.

The proposed amendment to §353.1304 renumbers current subsections (e) and (f).

Current §353.1304(g) is deleted as any service delivery methodology associated with a quality metric will be provided as part of the public notice and hearing process.

FISCAL NOTE

Trey Wood, Chief Financial Officer, has determined that for each year of the first five years that the rules will be in effect, enforcing or administering the rules do not have foreseeable implications relating to costs or revenues of state or local governments.

GOVERNMENT GROWTH IMPACT STATEMENT

HHSC has determined that during the first five years that the rules will be in effect:

(1) the proposed rules will not create or eliminate a government program;

(2) implementation of the proposed rules will not affect the number of HHSC employee positions;

(3) implementation of the proposed rules will result in no assumed change in future legislative appropriations;

(4) the proposed rules will not affect fees paid to HHSC;

(5) the proposed rules will not create a new rule;

(6) the proposed rules will not expand, limit, or repeal existing rules;

(7) the proposed rules will not change the number of individuals subject to the rules; and

(8) HHSC has insufficient information to determine the proposed rules' effect on the state's economy.

SMALL BUSINESS, MICRO-BUSINESS, AND RURAL COMMUNITY IMPACT ANALYSIS

Trey Wood, Chief Financial Officer, has also determined that there will be no adverse economic effect on small businesses, micro-businesses, or rural communities. Participation in the program described in the proposed rules is optional.

LOCAL EMPLOYMENT IMPACT

The proposed rules will not affect a local economy.

COSTS TO REGULATED PERSONS

Texas Government Code §2001.0045 does not apply to these rules because the rules do not impose a cost on regulated persons.

PUBLIC BENEFIT AND COSTS

Victoria Grady, Director of Provider Finance, has determined that for each year of the first five years the rules are in effect, the public benefit will be continued incentivizing of NFs to improve quality and innovation in the provision of NF services.

Trey Wood has also determined that for the first five years the rules are in effect, there are no anticipated economic costs to persons who are required to comply with the proposed rules. Participation in the QIPP program is voluntary.

TAKINGS IMPACT ASSESSMENT

HHSC has determined that the proposal does not restrict or limit an owner's right to his or her property that would otherwise exist in the absence of government action and, therefore, does not constitute a taking under Texas Government Code §2007.043.

PUBLIC COMMENT

Written comments on the proposal may be submitted to HHSC Provider Finance Department, Mail Code H-400, P.O. Box 85200, Austin, Texas 78705-5200, or by email to QIPP@hhsc.state.tx.us.

To be considered, comments must be submitted no later than 31 days after the date of this issue of the Texas Register. Comments must be (1) postmarked or shipped before the last day of the comment period; (2) hand-delivered before 5:00 p.m. on the last working day of the comment period; or (3) emailed before midnight on the last day of the comment period. If the last day to submit comments falls on a holiday, comments must be postmarked, shipped, or emailed before midnight on the following business day to be accepted. When emailing comments, please indicate "Comments on Proposed Rules 21R069" in the subject line.

STATUTORY AUTHORITY

The amendments are authorized by Texas Government Code §531.033, which provides the Executive Commissioner of HHSC with board rulemaking authority; Texas Human Resources Code §32.021 and Texas Government Code §531.021(a), which provide HHSC with the authority to administer the federal medical assistance (Medicaid) program in Texas; Texas Government Code §531.021(b-1), which establishes HHSC as the agency responsible for adopting reasonable rules governing the determination of fees, charges, and rates for Medicaid payments under the Texas Human Resources Code, Chapter 32; and by Texas Government Code §533.002, which authorizes HHSC to implement the Medicaid managed care program.

The amendments affect Texas Human Resources Code, Chapter 32; Texas Government Code, Chapter 531; and Texas Government Code Chapter 533. No other statutes, articles, or codes are affected by the amendments.

§353.1302.Quality Incentive Payment Program for Nursing Facilities on or after September 1, 2019.

(a) (No change.)

(b) Definitions. The following definitions apply when the terms are used in this section. Terms that are used in this and other sections of this subchapter may be defined in §353.1301 (relating to General Provisions) or §353.1304 (relating to Quality Metrics for the Quality Incentive Payment Program for Nursing Facilities on or after September 1, 2019) of this subchapter.

(1) CHOW application--An application filed with HHSC for a NF change of ownership (CHOW).

(2) Program [Eligibility] period--A period of time for which an eligible and enrolled NF may receive the QIPP amounts described in this section. Each QIPP program [eligibility] period is equal to a state fiscal year (FY) beginning September 1 and ending August 31 of the following year.

(3) Network nursing facility--A NF located in the state of Texas that has a contract with a Managed Care Organization (MCO) [an MCO] for the delivery of Medicaid covered benefits to the MCO's enrollees.

(4) Non-state government-owned NF--A network nursing facility where a non-state governmental entity located in the state of Texas holds the license and is a party to the NF's Medicaid provider enrollment agreement with the state.

(5) Private NF--A network nursing facility not owned by a governmental entity located in the state of Texas, and holds a license.

(6) Regional Healthcare Partnership (RHP)--A collaboration of interested participants that work collectively to develop and submit to the state a regional plan for health care delivery system reform as defined and established under Chapter 354, Subchapter D, of this title (relating to Texas Healthcare Transformation and Quality Improvement Program).

(7) Runout Period--A period of 23 months following the end of the program period during which the MCO may make adjustments to the MCO member months.

(c) Eligibility for participation in QIPP. A NF is eligible to participate in QIPP if it complies with the requirements described in this subsection.

(1) The NF is a non-state government-owned NF.

(A) The non-state governmental entity that owns the NF must certify the following facts on a form prescribed by HHSC.

(i) That it is a non-state government-owned NF where a non-state governmental entity holds the license and is party to the facility's Medicaid contract; and

(ii) That all funds transferred to HHSC via an intergovernmental transfer (IGT) for use as the state share of payments are public funds.

(B) The NF must be located in the state of Texas in the same RHP as, or within 150 miles of, the non-state governmental entity taking ownership of the facility, be owned by the non-state governmental entity for no less than four years prior to the first day of the program [eligibility] period, or must be able to certify in connection with the enrollment application that they can demonstrate an active partnership between the NF and the non-state governmental entity that owns the NF. The following criteria demonstrate an active partnership between the NF and the non-state governmental entity that owns the NF.

(i) Monthly meetings (in-person or virtual) with NF administrative staff to review the NF's clinical and quality operations and identify areas for improvement. Meetings should include patient observations; regulatory findings; review of CASPER reports, quality measures, grievances, staffing, risk, incidents, accidents, and infection control measures; root cause analysis, if applicable; and design of performance improvement plans.

(ii) Quarterly joint trainings on topics and trends in nursing home care best practices or on needed areas of improvement.

(iii) Annual, on-site inspections of the NF by a non-state governmental entity-sponsored Quality Assurance team.

(2) The NF is a private NF. The NF must have a percentage of Medicaid NF days of service that is greater than or equal to 65 percent. For each private NF, the percentage of Medicaid NF days is calculated by summing the NF's Medicaid NF fee-for-service and managed care days of service, including dual-eligible demonstration days of service, and dividing that sum by the facility's total days of service in all licensed beds. Medicaid hospice days of service are included in the denominator but excluded from the numerator.

(A) The days of service will be annualized based on the NF's latest cost report or accountability report but from a year in which HHSC required the submission of cost reports.

(B) HHSC will exclude any calendar days that the NF was closed due to a natural or man-made disaster. In such cases, HHSC will annualize the days of service based on calendar days when the NF was open.

(d) Data sources for historical units of service. Historical units of service are used to determine an individual private NF's QIPP eligibility status and the distribution of QIPP funds across eligible and enrolled NFs.

(1) All data sources referred to in this subsection are subject to validation using HHSC auditing processes or procedures as described under §355.106 of this title (relating to Basic Objectives and Criteria for Audit and Desk Review of Cost Reports).

(2) Data sources for the determination of each private NF's QIPP eligibility status are listed in priority order below. For each program [eligibility] period, the data source must be from a cost-reporting year and must align with the NF's fiscal year.

(A) The most recently available Medicaid NF cost report for the private NF. If no Medicaid NF cost report is available, the data source in subparagraph (B) of this paragraph must be used.

(B) The most recently available Medicaid Direct Care Staff Rate Staffing and Compensation Report for the private NF. If no Medicaid Direct Care Staff Rate Staffing and Compensation Report is available, the data source in subparagraph (C) of this paragraph must be used.

(C) The most recently available Medicaid NF cost report for a prior owner of the private NF. If no Medicaid NF cost report for a prior owner of the private NF is available, the data source in subparagraph (D) of this paragraph must be used.

(D) The most recently available Medicaid Direct Care Staff Rate Staffing and Compensation Report for a prior owner of the private NF. If no Medicaid Direct Care Staff Rate Staffing and Compensation Report for a prior owner of the private NF is available, the private NF is not eligible for participation in QIPP.

(3) Data sources for determination of distribution of QIPP funds across eligible and enrolled NFs are listed in priority order below. For each program [eligibility] period, the data source must be from a cost-reporting year and must align with the NF's fiscal year.

(A) The most recently available Medicaid NF cost report for the NF. If the cost report covers less than a full year, reported values are annualized to represent a full year. If no Medicaid NF cost report is available, the data source in subparagraph (B) of this paragraph must be used.

(B) The most recently available Medicaid Direct Care Staff Rate Staffing and Compensation Report for the NF. If the Staffing and Compensation Report covers less than a full year, reported values are annualized to represent a full year. If no Staffing and Compensation Report is available, the data source in subparagraph (C) of this paragraph must be used.

(C) The most recently available Medicaid NF cost report for a prior owner of the NF. If the cost report covers less than a full year, reported values are annualized to represent a full year. If no Medicaid NF cost report for a prior owner of the NF is available, the data source in subparagraph (D) of this paragraph must be used.

(D) The most recently available Medicaid Direct Care Staff Rate Staffing and Compensation Report for a prior owner of the NF. If the Staffing and Compensation Report covers less than a full year, reported values are annualized to represent a full year.

(e) Participation requirements. As a condition of participation, all NFs participating in QIPP must do [allow for] the following.

[(1) HHSC must be able to access data for the NF from one of the data sources listed in subsection (d) of this section.]

(1) [(2)] The NF must submit a properly completed enrollment application, on a form prescribed by HHSC, by the due date determined by HHSC. The enrollment period must be no less than 30 calendar days, and the final date of the enrollment period will be at least nine days prior to the IGT notification.

(2) [(3)] The entity that owns the NF must certify, on a form prescribed by HHSC, that no part of any payment made under the QIPP will be used to pay a contingent fee; and that the entity's agreement with the nursing facility does not use a reimbursement methodology containing any type of incentive, direct or indirect, for inappropriately inflating, in any way, claims billed to Medicaid, including [, consulting fee, or legal fee associated with] the NF's receipt of QIPP funds. The [and the] certification must be received by HHSC with the enrollment application described in paragraph (1) [(2)] of this subsection.

(3) [(4)] If a provider has changed ownership in the past five years in a way that impacts eligibility for the program, the provider [The entity that owns the NF] must submit to HHSC, upon demand, copies of contracts it has with third parties with respect to the transfer of ownership or the management of the provider, and which reference the administration of, or payment from, this program [that reference the administration of, or payments from, QIPP].

(4) The NF must ensure that HHSC has access to the NF records referenced in subsection (c) of this section and the data for the NF from one of the data sources listed in subsection (d) of this section. Participating facilities must ensure that these records and data are accurate and sufficiently detailed to support legal, financial, and statistical information used to determine a NF's eligibility during the program period.

(A) The NF must maintain these records and data through the program period and until at least 90 days following the conclusion of the runout period.

(B) The NF will have 14 business days from the date of a request from HHSC to submit to HHSC the records and data.

(C) Failure to provide the records and data could result in adjustments pursuant to §353.1301(k) of this subchapter.

(f) Non-federal share of QIPP payments. The non-federal share of all QIPP payments is funded through IGTs from sponsoring non-state governmental entities. No state general revenue is available to support QIPP.

(1) HHSC will share suggested IGT responsibilities for the program [eligibility] period with all QIPP eligible and enrolled non-state government-owned NFs at least 15 days prior to the IGT declaration of intent deadline. Suggested IGT responsibilities will be based on the maximum dollars [to be] available under the QIPP program, plus eight percent, for the program [eligibility] period as determined by HHSC [, plus eight percent]; forecast STAR+PLUS NF member months for the program [eligibility] period as determined by HHSC; and the distribution of historical Medicaid days of service across non-state government-owned NFs enrolled in QIPP for the program [eligibility] period. HHSC will also share estimated maximum revenues each eligible and enrolled NF could earn under QIPP for the program [eligibility] period. Estimates are [with those estimates] based on HHSC's suggested IGT responsibilities and an assumption that all enrolled NFs will meet 100 percent of their quality metrics. The purpose of sharing this information is to provide non-state government-owned NFs with information they can use to determine the amount of IGT they wish to transfer.

(2) Sponsoring governmental entities will determine the amount of IGT they wish to transfer to HHSC for the entire program [eligibility] period and provide a declaration of intent to HHSC 15 business days before the first half of the IGT amount is transferred to HHSC.

(A) The declaration of intent is a form prescribed by HHSC that includes the total amount of IGT the sponsoring governmental entity wishes to transfer to HHSC and whether the sponsoring governmental entity intends to accept Component One payments.

(B) The declaration of intent is certified to the best knowledge and belief of a person legally authorized to sign for the sponsoring governmental entity but does not bind the sponsoring governmental entity to transfer IGT.

(3) Sponsoring governmental entities will transfer the first half of the IGT amount by a date determined by HHSC. The second half of the IGT amount will be transferred by a date determined by HHSC. The IGT deadlines and all associated dates will be published on the HHSC QIPP webpage by January 15 of each year.

(4) Reconciliation. HHSC will reconcile the actual amount of the non-federal funds [actually] expended under this section during each program [eligibility] period with the amount of funds transferred to HHSC by the sponsoring governmental entities for that same period using the methodology described in §353.1301(g) of this subchapter.

(g) QIPP capitation rate components. QIPP funds will be paid to MCOs through four components of the STAR+PLUS NF managed care per member per month (PMPM) capitation rates. The MCOs' distribution of QIPP funds to the enrolled NFs will be based on each NF's performance related to the quality metrics as described in §353.1304 of this subchapter. The NF must have had at least one Medicaid client in the care of that NF for each reporting period to be eligible for payments.

(1) Component One.

(A) The total value of Component One will be equal to 110 percent of the non-federal share of the QIPP.

(B) Interim allocation of funds across qualifying non-state government-owned NFs will be proportional, based upon historical Medicaid days of NF service.

(C) Monthly payments to non-state government-owned NFs will be triggered by achievement of performance requirements as described in §353.1304 of this subchapter.

(D) Private NFs are not eligible for payments from Component One.

(E) The interim allocation of funds across qualifying non-state government-owned NFs will be reconciled to the actual distribution of Medicaid NF days of service across these NFs during the program [eligibility] period as captured by HHSC's Medicaid contractors for fee-for-service and managed care 180 days after the last day of the program [eligibility] period. This reconciliation will only be performed if the weighted average (weighted by Medicaid NF days of service during the program [eligibility] period) of the absolute values of percentage changes between each NF's [NFs] proportion of historical Medicaid days of NF service and actual Medicaid days of NF service is greater than 18 percent.

(2) Component Two.

(A) The total value of Component Two will be equal to a percent of remaining QIPP funds after accounting for the funding of Component One and Component Four [30 percent of remaining QIPP funds after accounting for the funding of Component One and Component Four].

(i) For the program period September 1, 2019, through August 31, 2021, the percent will be equal to 30 percent.

(ii) For the program period beginning September 1, 2021, the percent will be equal to 40 percent.

(B) Allocation of funds across qualifying non-state government-owned and private NFs will be proportional, based upon historical Medicaid days of NF service.

(C) Monthly payments to NFs will be triggered by achievement of performance requirements as described in §353.1304 of this subchapter.

(3) Component Three.

(A) The total value of Component Three will be equal to a percent of remaining QIPP funds after accounting for the funding of Component One and Component Four [70 percent of remaining QIPP funds after accounting for the funding of Component One and Component Four].

(i) For the program period September 1, 2019, through August 31, 2021, the percent will be equal to 70 percent.

(ii) For the program period beginning September 1, 2021, the percent will be equal to 60 percent.

(B) Allocation of funds across qualifying non-state government-owned and private NFs will be proportional, based upon historical Medicaid days of NF service.

(C) Quarterly payments to NFs will be triggered by achievement of performance requirements as described in §353.1304 of this subchapter.

(4) Component Four.

(A) The total value of Component Four will be equal to 16 percent of the funds of the QIPP.

(B) Allocation of funds across qualifying non-state government-owned NFs will be proportional, based upon historical Medicaid days of NF service.

(C) Quarterly payments to non-state government-owned NFs will be triggered by achievement of performance requirements as described in §353.1304 of this subchapter.

(D) Private NFs are not eligible for payments from Component Four.

(5) Funds that are non-disbursed due to failure of one or more NFs to meet performance requirements will be distributed across all QIPP NFs based on each NF's proportion of total earned QIPP funds from Components One, Two, Three, and Four combined.

(h) Distribution of QIPP payments.

(1) Prior to the beginning of the program [eligibility] period, HHSC will calculate the portion of each PMPM associated with each QIPP-enrolled NF broken down by QIPP capitation rate component, quality metric, and payment period. For example, for a NF, HHSC will calculate the portion of each PMPM associated with that NF that would be paid from the MCO to the NF as follows.

(A) Monthly payments from Component One as performance requirements are met will be equal to the total value of Component One for the NF divided by twelve.

(B) Monthly payments from Component Two associated with each quality metric will be equal to the total value of Component Two associated with the quality metric divided by twelve.

(C) Quarterly payments from Component Three associated with each quality metric will be equal to the total value of Component Three associated with the quality metric divided by four.

(D) Quarterly payments from Component Four associated with each quality metric will be equal to the total value of Component Four associated with the quality metric divided by four.

(E) For purposes of the calculations described in subparagraphs (B), (C), and (D) of this paragraph, each quality metric will be allocated an equal portion of the total dollars included in the component.

(F) In situations where a NF does not have enough data for all [a] quality metrics [metric ] to be calculated, the funding associated with that metric will be evenly distributed across all remaining metrics within the component. If a NF does not have enough data for any quality metrics to be calculated, no funds will be earned.

(2) MCOs will distribute payments to enrolled NFs as they meet their reporting and quality metric requirements. Payments will be equal to the portion of the QIPP PMPM associated with the achievement for the time period in question multiplied by the number of member months for which the MCO received the QIPP PMPM. In the event of a CHOW, the MCO will distribute the payment to the owner of the NF at the time of the payment.

(i) Changes of ownership.

(1) A NF undergoing a CHOW from privately owned to non-state government owned or from non-state government owned to privately-owned will only be eligible to enroll as the new class of facility if HHSC received a completed CHOW application no later than 30 days prior to the first day of the enrollment period. All required documents pertaining to the CHOW (i.e., HHSC must have a complete application for a change of ownership license as described under 26 TAC §554.201 [40 TAC §19.201] (relating to Criteria for Licensing)[,] and 26 TAC §554.210 [40 TAC §19.210] (relating to Change of Ownership and Notice of Changes)[, and 40 TAC §19.2308 (relating to Change of Ownership)]) must be submitted in the timeframe required by HHSC.

(2) If an enrolled NF changes ownership, including to a new class of facility following the enrollment period [during the pendency of the application] or during the program [eligibility] period, the NF under the new ownership must meet the eligibility requirements described in this section for the new owner's facility class in order to continue QIPP participation during the program [eligibility] period.

(3) An enrolled NF must notify the MCOs it has contracts with of a potential CHOW at least 30 days before the anticipated date of the CHOW. [An enrolled NF must also notify the HHSC Rate Analysis Department by hand delivery, United States (U.S.) mail, or special mail delivery at least 30 days before the anticipated date of the CHOW.] Notification is considered to have occurred when the MCO [HHSC] receives the notice.

(j) Changes in operation. If an enrolled NF closes voluntarily or ceases to provide NF services in its facility, the NF must notify the HHSC Provider Finance Department by email at qipp@hhsc.state.tx.us [Rate Analysis Department by hand delivery, United States (U.S.) mail, or special mail delivery within 10 business days of closing or ceasing to provide NF services]. Notification is considered to have occurred when HHSC receives the notice.

(k) Recoupment. Payments under this section may be subject to recoupment as described in §353.1301(j) and §353.1301(k) of this subchapter.

§353.1304.Quality Metrics for the Quality Incentive Payment Program for Nursing Facilities on or after September 1, 2019.

(a) Introduction. This section establishes the quality metrics that may be used in the Quality Incentive Payment Program (QIPP) for nursing facilities (NFs) on or after September 1, 2019.

(b) Definitions. The following definitions apply when the terms are used in this section. Terms that are used in this and other sections of this subchapter may be defined in §353.1301 (relating to General Provisions) or §353.1302 (relating to Quality Incentive Payment Program for Nursing Facilities on or after September 1, 2019) of this subchapter.

(1) Baseline--A NF-specific initial standard used as a comparison against NF performance in each metric throughout the program [eligibility] period to determine progress in the QIPP quality metrics. [For example, for MDS-based measures, the facility's baselines will be set at the most recently available four-quarter average for each metric.]

(2) Benchmark--A metric-specific initial standard set prior to the start of the program [eligibility] period and used as a comparison against a NF's progress throughout the program [eligibility] period. [For example, for MDS-based measures, the benchmarks will be set at the most recently published CMS National Average for each metric.]

(c) Quality metrics. For each program [eligibility ] period, HHSC will designate one or more [of the following] quality metrics [for each QIPP capitation rate component]. Any quality metric included in QIPP will be evidence-based. HHSC may modify quality metrics from one program period to the next. The proposed quality metrics for a program period will be presented to the public for comment in accordance with subsection (f) of this section.

[(1) Quality assurance and performance improvement (QAPI) meetings. Monthly meetings in which the NF reviews its CMS-compliant plan for maintaining and improving safety and quality in the NF. QAPI meetings must contribute to a NF's ongoing development of improvement initiatives regarding clinical care, quality of life, and consumer choice. For the eligibility period beginning September 1, 2019, QAPI meetings have been designated as the quality metric for Component 1.]

[(2) MDS-based measures. Measures listed in CMS' Five-Star Quality Rating System and based on Minimum Data Set (MDS) assessment data. Within the Five-Star Quality Rating System, HHSC can select any MDS-based measure as long as there are viable data sources available for timely calculations related to the measure. For the eligibility period beginning September 1, 2019, the following five MDS-based measures may be used in Components Three and Four:]

[(A) high-risk long-stay residents with pressure ulcers;]

[(B) percent of residents who received an antipsychotic medication (long-stay);]

[(C) percent of residents with decreased independent mobility;]

[(D) percent of residents with urinary tract infections; and]

[(E) percent of residents appropriately given the pneumonia vaccine.]

[(3) Recruitment and retention program. A program that includes a plan developed by the NF to improve recruitment and retention of staff and monitor outcomes related thereto. For the eligibility period beginning September 1, 2019, the recruitment and retention plan will be used in Component Two.]

[(4) RN staffing metrics. Registered nurse (RN) hours beyond and non-concurrent with the CMS-mandated eight hours of RN on-site coverage each day. On-site hours must be met by an RN, Advanced Practice Registered Nurse (APRN), Nurse Practitioner (NP), Physician Assistant (PA), or physician (Medical Doctor (MD) or Doctor of Osteopathic Medicine (DO)). Telehealth services can be used to meet some or all of the RN staffing metrics when a NF has telehealth policies and procedures developed in accordance with subsection (g) of this section. For the eligibility period beginning September 1, 2019, the following two RN staffing metrics will be used in Component Two:]

[(A) four hours of additional RN coverage per day; and]

[(B) eight hours of additional RN coverage per day. A NF that meets the eight hours of additional RN coverage per day will automatically qualify for the metric described in subparagraph (A) of this paragraph.]

[(5) Infection control program. A program that improves antibiotic stewardship and measures outcomes through the use of infection control and data elements. For the eligibility period beginning September 1, 2019, the infection control program will be used in Component Four, and the program will consist of the following infection control and data elements:]

[(A) whether a facility:]

[(i) has identified leadership individuals for antibiotic stewardship;]

[(ii) has created written policies on antibiotic prescribing;]

[(iii) has an antibiotic use report generated by a pharmacy within last 6 months;]

[(iv) audits (monitors and documents) adherence to hand hygiene (HH);]

[(v) audits (monitors and documents) adherence to personal protective equipment (PPE) use;]

[(vi) has an infection control coordinator who has received infection control training;]

[(vii) has infection prevention policies that are evidence-based and reviewed at least annually;]

[(viii) has a current list of reportable diseases;]

[(ix) knows points of contact at local or state health departments for assistance;]

[(B) the number of:]

[(i) vaccines administered to residents and employees;]

[(ii) residents with facility acquired Clostridium difficile diagnosis;]

[(iii) residents on antibiotic medications;]

[(iv) residents with multi-drug resistant organisms; and]

[(C) select infection rates.]

[(6) Other metrics related to improving the quality of care for Texas Medicaid NF residents. HHSC may develop additional metrics for inclusion in QIPP if there is a specific systemic data-supported quality concern impacting Texas Medicaid NF residents. Any metric developed for inclusion in QIPP will be evidence-based and will be presented to the public for comment in accordance with subsection (e) of this section.]

(d) Performance requirements. For each program [eligibility] period, HHSC will specify the performance requirements [requirement that will be] associated with [the] designated quality metrics. The proposed performance requirements for a program period will be presented to the public for comment in accordance with subsection (f) of this section [metric]. Achievement of performance requirements will trigger payments for the QIPP capitation rate components as described in §353.1302 of this subchapter. [For some quality metrics, achievement is tested merely on a met versus unmet basis. Other metrics require a certain level of improvement, such as reaching a quarterly percentage goal. The following performance requirements are associated with the quality metrics described in subsection (c) of this section.]

[(1) QAPI meetings. Each month, a NF must attest on a form designated by HHSC that it convened a QAPI meeting. The NF must submit the form to HHSC by the first business day following the end of the month. Each quarter, HHSC will validate a random sample of the attestation forms. The NF that submitted the attestation form must provide the supporting documentation stated in the attestation form.]

[(2) MDS-based measures. A NF must show a five percent relative improvement on a quarterly basis over the baseline or exceed the benchmark for the selected measure.]

[(A) Baseline improvement is measured against quarterly targets determined by HHSC prior to the eligibility period.]

[(B) A NF that exceeds the benchmark for a measure qualifies for the payment from any related component. A NF that exceeds the benchmark may decline in performance and still qualify for a payment from the related component as long as the NF continues to exceed the benchmark for the measure.]

[(3) Recruitment and retention program. During the first month of the eligibility period, a NF must submit its recruitment and retention plan to HHSC. If substantive changes are made to the recruitment and retention plan, an update of the plan must be submitted to HHSC during the month in which the changes take effect.]

[(A) Failure to submit the recruitment and retention plan in the first month of the eligibility period will result in not meeting the metric for that month for the related component.]

[(B) Each subsequent month, a NF will submit to HHSC documentation produced during the development of self-direct staffing goals and in the monitoring of staffing outcomes, in accordance with the NF's recruitment and retention plan.]

[(C) Each quarter, HHSC will validate a random sample of recruitment and retention plans and outcome monitoring documentation. The NF that submitted the plan must provide supporting documentation, including policies and outcomes.]

[(4) RN staffing metrics. A NF meets the RN staffing metrics by showing that the facility was staffed at the required number of hours for at least 90 percent of the days in the reporting period.]

[(5) Infection control program. Each quarter, a NF must report:]

[(A) the presence of a number of infection control elements to exceed a quarterly benchmark. For the eligibility period beginning September 1, 2019, the NF must report the presence of seven of the nine elements in subsection (c)(5)(A) of this section to meet the metric; and]

[(B) all required data elements regarding infection control tracking in subsection (c)(5)(B) and (C) of this section.]

[(6) Other metrics related to improving the quality of care for Texas Medicaid NF residents. If HHSC develops additional metrics for inclusion in QIPP, the associated performance requirements will be presented to the public for comment in accordance with subsection (e) of this section.]

(e) Quality assurance. All data and documentation supplied to HHSC by the NF to demonstrate achievement of performance requirements is subject to validation and audit. HHSC will select a random, representative sample of participating NFs for quality assurance review each program period and will conduct reviews on one-fourth of the total sample each program quarter.

(1) If selected, the NF will have 14 business days from the date of the request from HHSC to submit to HHSC the required data and documentation.

(2) If the selected NF fails to participate in the review or to provide the required data or documentation, any payments to the provider for the quality metric or component under review may be considered an Overpayment and subject to recoupment or adjustment as described in §353.1301(k) of this subchapter.

(f) [(e)] Notice and hearing.

(1) HHSC will publish notice of the proposed metrics and their associated performance requirements no later than December 1 [31] of the calendar year that precedes the first month of the program [eligibility] period. The notice must be published either by publication on HHSC's Internet web site or in the Texas Register. The notice required under this section will include the following:

(A) instructions for interested parties to submit written comments to the HHSC regarding the proposed metrics and performance requirements; and

(B) the date, time, and location of a public hearing.

(2) Written comments will be accepted within 15 business days of publication. There will also be a public hearing within that 15-day period to allow interested persons to present comments on the proposed metrics and performance requirements.

(g) [(f)] Quality metric publication. Final quality metrics and performance requirements will be provided through the QIPP webpage on HHSC's website on or before February 1 of the calendar year that also contains the first month of the program [eligibility] period.

[(g) Telehealth. In order for a NF to use telehealth services to meet some or all of the RN staffing metric, the following requirements must be met:]

[(1) the telehealth services must be both audio and visual in nature;]

[(2) the telehealth services must be provided by an RN, APRN, NP, PA, or physician (MD or DO); and]

[(3) The NF must have policies and procedures for such services. The NF's policy must include the following:]

[(A) how the NF arranges telehealth services;]

[(B) how the NF trains staff regarding the availability of services, implementation of services, and expectations for the use of these services; and]

[(C) how the NF documents telehealth services including initiation of services, the services provided, and the outcome of services.]

The agency certifies that legal counsel has reviewed the proposal and found it to be within the state agency's legal authority to adopt.

Filed with the Office of the Secretary of State on May 14, 2021.

TRD-202101946

Karen Ray

Chief Counsel

Texas Health and Human Services Commission

Earliest possible date of adoption: June 27, 2021

For further information, please call: (512) 424-6637


CHAPTER 355. REIMBURSEMENT RATES

SUBCHAPTER J. PURCHASED HEALTH SERVICES

DIVISION 11. TEXAS HEALTHCARE TRANSFORMATION AND QUALITY IMPROVEMENT PROGRAM REIMBURSEMENT

1 TAC §355.8217

The Executive Commissioner of the Texas Health and Human Services Commission (HHSC) proposes new §355.8217, concerning Payments to Public Health Providers for Charity Care.

BACKGROUND AND PURPOSE

The purpose of the proposed new rule is to authorize HHSC to implement the Public Health Provider - Charity Care Program (PHP-CCP) payments to be available for eligible providers to help defray the uncompensated costs of charity care beginning October 1, 2022.

The PHP-CCP under the 1115 waiver reimburses certain costs for qualifying providers associated with providing care, including behavioral health, immunizations, chronic disease prevention, and other preventative services for the uninsured. This program was created as part of the 1115 waiver extension and will provide an opportunity for reimbursement of charity care costs (or Medicaid shortfall in the first year of the program).

In accordance with the Special Terms and Conditions of the 1115 waiver, to participate in the program, providers must be funded by a unit of government able to certify public expenditures. Publicly-owned and operated providers eligible to participate include:

(1) The following providers established under Texas Health and Safety Code Chapters 533 or 534 and primarily providing behavioral health services:

(a) Community Mental Health Clinics (CMHCs)

(b) Community Centers

(c) Local Behavioral Health Authorities (LBHAs)

(d) Local Mental Health Authorities (LMHAs)

(2) Local Health Departments (LHDs) and Public Health Districts (PHDs) established under the Texas Health and Safety Code Chapter 121.

SECTION-BY-SECTION SUMMARY

Proposed new §355.8217(a) establishes the transition of the PHP-CCP to reimburse for charity care costs beginning October 1, 2022.

Subsection (b) defines key terms used in the section.

Subsection (c) describes the participation requirements of the qualifying providers that wish to participate in the program, including the application and cost report process. To participate, a provider must: 1) indicate it is a qualifying provider, 2) attend annual training, 3) submit an annual uncompensated care tool for charity care costs by the due date and certify costs in a manner specified by HHSC, and 4) certify that no part of the PHP-CCP payment will be used to pay a contingency fee.

Subsection (d) describes the source of funding of the program. The non-federal share of funding for payments under this section is limited to public expenditures certified by a government entity.

Subsection (e) describes the payment frequency of the program on a schedule to be determined by HHSC and posted on HHSC's website.

Subsection (f) describes the calculation of the payment and funding limitations if the payments for charity care for the provider pool are expected to exceed the amount of funds allocated to that pool by HHSC.

Subsection (g) describes the recoupment procedures in the event of an overpayment, whether directly recouped from the provider or through HHSC withholding from future Medicaid payments.

Subsection (h) describes the notice requirements if there are changes in the operation of the provider, such as closing voluntarily or ceasing to provide Medicaid services.

Subsection (i) provides general information as to how the cost reporting guidelines will be governed using other sections of 1 TAC Chapter 355, Subchapter A.

FISCAL NOTE

Trey Wood, Chief Financial Officer, has determined that for each year of the first five years the proposed rule is in effect, there will be no cost to state government as a result of enforcing and administering the rule as proposed. For each year of the first five years the proposed rule is in effect, there will be a cost to local government.

The effect on local governments cannot be determined because HHSC lacks sufficient data to know how many providers will choose to apply for the program and at what level.

GOVERNMENT GROWTH IMPACT STATEMENT

HHSC has determined that during the first five years that the rule will be in effect:

(1) the proposed rule will not create or eliminate a government program;

(2) implementation of the proposed rule will not affect the number of HHSC employee positions;

(3) implementation of the proposed rule will not result in assumed change in future legislative appropriations;

(4) the proposed rule does not require an increase or decrease in fees paid to HHSC;

(5) the proposed rule will create a new rule;

(6) the proposed rule will not expand, limit, or repeal existing rules;

(7) the proposed rule will not change the number of individuals subject to the rule; and

(8) the proposed rule will positively affect the state's economy.

SMALL BUSINESS, MICRO-BUSINESS, AND RURAL COMMUNITY IMPACT ANALYSIS

Trey Wood has also determined that there will be no adverse economic effect on small businesses, micro businesses, or rural communities to comply with the proposed rule. Small businesses and micro businesses are not subject to the proposed rule, and because participation in the program is optional, there is no adverse economic effect on rural communities.

LOCAL EMPLOYMENT IMPACT

The proposed rule may affect a local economy as the units of local government that receive reimbursement through this program may choose to invest those funds in additional employment opportunities or other local needs.

COSTS TO REGULATED PERSONS

Texas Government Code §2001.0045 does not apply to this rule because the rule does not impose a cost on regulated persons, and the rule is necessary to receive a source of federal funds.

PUBLIC BENEFIT AND COSTS

Victoria Grady, Director of Provider Finance, has determined that for each year of the first five years the rule is in effect, the public will benefit from the adoption of the rule. The anticipated public benefit will be improved health outcomes as a result of increased funding for certain units of local government.

Trey Wood has also determined that for the first five years the rule is in effect, there are no anticipated economic costs to persons who are required to comply with the proposed rule because participation in the program is optional.

TAKINGS IMPACT ASSESSMENT

HHSC has determined that the proposal does not restrict or limit an owner's right to his or her property that would otherwise exist in the absence of government action and, therefore, does not constitute a taking under Texas Government Code §2007.043.

PUBLIC HEARING

A public hearing is scheduled for June 14, 2021, at 11:30 a.m. (Central Daylight Time) to receive public comments on the proposal. Persons requiring further information, special assistance, or accommodations should email PHP-CCP@hhs.texas.gov.

Due to the declared state of disaster stemming from COVID-19, the hearing will be conducted online only. No physical entry to the hearing will be permitted.

Persons interested in attending may register for the public hearing at: https://attendee.gotowebinar.com/register/5929398341149150992.

After registering, a confirmation email will be sent with information about joining the webinar.

HHSC will broadcast the public hearing. The broadcast will be archived for access on demand and can be accessed at https://hhs.texas.gov/about-hhs/communications-events/live-archived-meetings.

PUBLIC COMMENT

Written comments on the proposal may be submitted to HHSC, Mail Code H400, P.O. Box 13247, Austin, Texas 78711-3247, or by email to PHP-CCP@hhs.texas.gov.

During the current state of disaster due to COVID-19, physical forms of communication are checked with less frequency than during normal business operations. Therefore, please submit comments by email if possible.

To be considered, comments must be submitted no later than 31 days after the date of this issue of the Texas Register. Comments must be: (1) postmarked or shipped before the last day of the comment period; (2) hand-delivered before 5:00 p.m. on the last working day of the comment period; or (3) emailed before midnight on the last day of the comment period. If the last day to submit comments falls on a holiday, comments must be post-marked, shipped, or emailed before midnight on the following business day to be accepted. When emailing comments, please indicate "Comments on Proposed Rule 21R076" in the subject line.

STATUTORY AUTHORITY

The new rule is authorized by Texas Government Code §531.033, which authorizes the Executive Commissioner of HHSC to adopt rules necessary to carry out HHSC's duties; Texas Human Resources Code §32.021 and Texas Government Code §531.021(a), which provide HHSC with the authority to administer the federal medical assistance (Medicaid) program in Texas; and Texas Government Code §531.021(b-1), which establishes HHSC as the agency responsible for adopting reasonable rules governing the determination of fees, charges, and rates for medical assistance payments under the Texas Human Resources Code, Chapter 32.

The new rule affects Texas Human Resources Code Chapter 32 and Texas Government Code Chapter 531.

§355.8217.Payments to Public Health Providers for Charity Care.

(a) Introduction. Beginning October 1, 2022, Public Health Provider - Charity Care Program (PHP-CCP) payments are available under this section for eligible providers to help defray the uncompensated costs of charity care.

(b) Definitions. The following words and terms, when used in this section, have the following meanings, unless the context clearly indicates otherwise.

(1) Centers for Medicare and Medicaid Services (CMS)--The federal agency within the United States Department of Health and Human Services responsible for overseeing and directing Medicare and Medicaid, or its successor.

(2) Charity care--Healthcare services provided without expectation of reimbursement to uninsured patients who meet the provider's charity-care policy. The charity-care policy should adhere to the charity-care principles of the Healthcare Financial Management Association Principles and Practices Board Statement 15 (December 2019). Charity care includes full or partial discounts given to uninsured patients who meet the provider's financial assistance policy. Charity care does not include bad debt, courtesy allowances, or discounts given to patients who do not meet the provider's charity-care policy or financial assistance policy.

(3) Program period--A period of time for which eligible and enrolled providers may receive the PHP-CCP amounts described in this section. Each PHP-CCP period is equal to a Federal Fiscal Year (FFY) beginning October 1 and ending September 30 of the following year.

(4) Qualifying Providers--Publicly-owned and operated Community Mental Health Clinics (CMHCs), community centers, Local Behavioral Health Authorities (LBHAs), and Local Mental Health Authorities (LMHAs) that are established under the Texas Health & Safety Code Chapter 533 or 534 and are primarily providing behavioral health services, and publicly-owned and operated Local Health Departments (LHDs) and Public Health Districts (PHDs) that are established under the Texas Health and Safety Code Chapter 121.

(5) Total program value--The maximum amount available under PHP-CCP for a program period, as determined by the Texas Health and Human Services Commission (HHSC) and CMS.

(6) Uncompensated care payments--Payments intended to defray the charity care costs as defined in paragraph (3) of this subsection.

(7) Uncompensated care tool--A form prescribed by HHSC to identify charity care costs for Medicaid-enrolled providers and used to enroll in the program.

(8) Uninsured patient--An individual who has no health insurance or other source of third-party coverage for the services provided. The term includes an individual enrolled in Medicaid who received services that do not meet the definition of "medical assistance" in the Social Security Act §1905(a).

(9) Waiver--The Texas Healthcare Transformation and Quality Improvement Program Medicaid demonstration waiver under Social Security Act §1115.

(c) Participation requirements.

(1) Qualifying provider. A provider must indicate it is a qualifying provider as defined in subsection (b) of this section to be considered for reimbursement in the application process.

(2) PHP-CCP financial training. HHSC provides annual training to participating qualifying providers.

(A) Each primary PHP-CCP financial contact must attend and receive credit for training for each program period in which the provider chooses to participate.

(B) Training is provided for each program period and is not retroactive.

(C) A provider that does not have a trained PHP-CCP financial contact who is an employee of the provider is prohibited from submitting a PHP-CCP application. Provider-contracted vendors are not permitted to enter a provider's data into the cost report for any provider that does not have a trained PHP-CCP financial contact who is an employee of the provider.

(3) Cost reports. Qualifying providers must submit an annual uncompensated care tool for charity care costs. Uncompensated care tools must be completed for a full year based on the federal fiscal year.

(A) The uncompensated care tool format will be specified by HHSC. Qualifying providers certify through the cost report process their total actual federal and non-federal costs and expenditures for the program period. Costs must be reported in a manner that is consistent with the PHP-CCP protocol that is approved under the 1115 Waiver.

(B) The cost report is due on or before November 14 of the year of the program period ending date and must be certified in a manner specified by HHSC.

(i) If November 14 falls on a federal or state holiday or weekend, the due date is the first working day after November 14.

(ii) A provider whose cost report is not received by the due date is ineligible for PHP-CCP payment for the federal fiscal year.

(C) HHSC reserves the right to request a corrective action plan (CAP) from providers who submit incorrect cost reports or bill incorrectly. PHP-CCP payments will be withheld until the CAP is accepted by HHSC.

(D) Costs for care delivered to persons who are incarcerated at the time of the care must be excluded from the cost report.

(E) Costs for care delivered as part of an Institution of Mental Disease (IMD) must be excluded from the cost report. If a provider includes costs for Crisis Stabilization Units on their cost report, and the unit is later determined by CMS to be an IMD, associated PHP-CCP payments are subject to recoupment.

(4) Certification. The provider must certify, on a form prescribed by HHSC, that no part of any PHP-CCP payment will be used to pay a contingent fee and that the entity's agreement with a billing entity or cost report preparer does not use a reimbursement methodology that contains any type of incentive, directly or indirectly, for inappropriately inflating, in any way, claims billed to the Medicaid program, including the provider's PHP-CCP funds. The certification must be received by HHSC with the enrollment application described in paragraph (3) of this subsection.

(d) Source of funding. The non-federal share of funding for payments under this section is limited to certified public expenditures from governmental entities.

(e) Payment frequency. HHSC will distribute uncompensated care payments on a schedule to be determined by HHSC and posted on HHSC's website.

(f) Calculation of supplemental payment.

(1) Supplemental payment. A qualifying provider may be eligible to receive a supplemental payment equal to a percentage of its charity care costs for the cost reporting period.

(2) Funding limitations. Payments made under this section are limited by the amount of funds allocated to the total program value for the demonstration year. If payments for charity care for the provider pool attributable to a demonstration year are expected to exceed the amount of funds allocated to that pool by HHSC for that demonstration year, HHSC will reduce payments to providers in the pool by the same percentage as required to remain within the pool allocation amount.

(g) Recoupment.

(1) Overpayment or disallowance. In the event of an overpayment identified by HHSC or a disallowance by CMS of federal financial participation related to a provider's receipt or use of payments under this section, HHSC may recoup an amount equivalent to the amount of the overpayment or disallowance.

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

(3) Recoupment method. HHSC may recoup from any current or future PHP-CCP payments as follows:

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

(B) If, within 30 days of the provider's receipt of HHSC's written notice of recoupment, the provider has not paid the full amount of the recoupment or entered into a written agreement with HHSC to do so, HHSC may withhold any or all future PHP-CCP payments from the provider until HHSC has recovered an amount equal to the amount overpaid or disallowed. Electronic notice and electronic agreement may be used as alternative options at HHSC's discretion.

(h) Changes in operation. If an enrolled provider closes voluntarily or ceases to provide Medicaid services, the provider must notify the HHSC Provider Finance Department by hand delivery, United States (U.S.) mail, or special mail delivery within 10 business days of closing or ceasing to provide Medicaid services. Notification is considered to have occurred when the HHSC Provider Finance Department receives the notice.

(i) General information. In addition to the requirements of this section, the cost reporting guidelines will be governed by §355.101 of this chapter (relating to Introduction); §355.102 of this chapter (relating to General Principles of Allowable and Unallowable Costs); §355.103 of this chapter (relating to Specifications for Allowable and Unallowable Costs); §355.104 of this chapter (relating to Revenues); §355.105 of this chapter (relating to General Reporting and Documentation Requirements, Methods, and Procedures); §355.106 of this chapter (relating to Basic Objectives and Criteria for Audit and Desk Review of Cost Reports); §355.107 of this chapter (relating to Notification of Exclusions and Adjustments); §355.108 of this chapter (relating to Determination of Inflation Indices); §355.109 of this chapter (relating to Adjusting Reimbursement When New Legislation, Regulations, or Economic Factors Affect Costs); and §355.110 of this chapter (relating to Informal Reviews and Formal Appeals).

The agency certifies that legal counsel has reviewed the proposal and found it to be within the state agency's legal authority to adopt.

Filed with the Office of the Secretary of State on May 17, 2021.

TRD-202101955

Karen Ray

Chief Counsel

Texas Health and Human Services Commission

Earliest possible date of adoption: June 27, 2021

For further information, please call: (512) 424-6637 or (512) 462-6223