Transcript Speak the Histo Lingo

 Medicaid services are established in State Medicaid
Plans and are approved by the federal Center for
Medicare and Medicaid Services (CMS).
 CMS allows for exceptions to the state plan based on a
waiver process
 Waivers are subject to CMS approval and must be
budget neutral
This expansion encroaches on the UPL, or
Upper Payment Limit payments that some
Texas healthcare facilities currently receive
and therefore suggests that a review of UPL is
necessary to ensure that changes don’t
drastically undermine these facilities.
•
• Supplemental payments made to hospitals
for inpatient and outpatient services
• Upper Payment Limit (UPL) is the difference
between what Medicaid reimbursed for the
service and what Medicare would have paid
• The non-federal portion of the UPL is funded
with local tax funds – usually through a taxing
authority or hospital district
Texas Hospital Financing FY09
19%
25%
DSH
Outpatient
17%
Inpatient
UPL
39%
• Expansion of managed care services in the
state including a pharmacy and dental services
• Allowed for the preservation of Upper
Payment Limit for hospitals in light of the fact
that the state is expanding managed care
services
• Created Regional Healthcare Partnerships or
RHP’s
• 2011 UPL payments to hospitals amounted to an estimated 2.8
billion dollars. Over the five year life of the waiver, that would
amount to almost 14 billion in funds that would be drawn down
from the federal government.
• Under the new waiver, there is an ability to drawn down nearly
29 billion in federal funds for the same time period.
• There is obvious advantages from a financial perspective for
the state to pursue this program
Year
UCC
DSRIP
2012
88%
12%
2013
80%
20%
2014
70%
30%
2015
60%
40%
2016
50%
50%
• Formed around facilities already receiving UPL
payments and a public hospital typically serves as an
anchor for a region
• Anchors coordinate the activity of the RHP and
serve as a single point of contact for the region
• Anchors serve as administrators for the RHP but do
not control the funds.
• Focus will be on improved quality, access, and
coordination.
Anchors will bring stakeholders together to
develop plans with public input.
•
• RHP participants with match funds will
choose hospitals that will receive payments
based on their incentive plans.
• Performance metrics will be established and
payments will be issued based on facility
performance against those metrics.
Public hospitals will normally serve as
anchors
•
• In regions without a public hospital, other
entities such as a hospital district, a hospital
authority, a county, or a state university with a
health science center or medical school may
serve as the anchor.
• Identification of RHP participants
• Providing a health assessment of the region
• Identifying projects by DSRIP categories
• Infrastructure development
• Program innovation and redesign
• Quality Improvements
• Population focused improvement
•
They can not require participation.
• Even if an entity starts the program in the first year,
the RHP can’t mandate participation for all four years.
• They don’t determine health policy.
• They don’t determine Medicaid program policy.
• They don’t determine regional reimbursements.
• They don’t determine manage care requirements.
Texas Health and Human Services Commission. HHSC Gets
Approval for Medicaid Improvements.
http://www.hhsc.state.tx.us/1115-waiver.shtml
Texas Association of Counties. Medicaid 1115 Waiver.
https://www.county.org/resources/legis/medicaid1115/index.asp