Volume XXX, Number 3,
March 2015

Nursing facility upper payment limit / Minimum payment amount – Program Update

As anticipated (in previous issues of THCA Notes), a new “Minimum Payment Amount Program” (MPAP) System replaced the current Upper Payment Limit system (UPL) system on March 1, 2015, when nursing facilities were carved into Medicaid Managed Care.  Many facilities have opted to participate in this program due to the enhanced funding that is available.  Since non-state governmental entities must hold the license for the participating nursing facilities, these facilities must go through a change of ownership (CHOW), which in turn, has led to a backlog of CHOWs being processed by the Department of Aging and Disability Services (DADS).  (It should be noted that several of these CHOWs were submitted without all of the required documentation, further slowing the process down.) Subsequently, many facilities could not meet the February 28 deadline for CHOW processing and will be prohibited from participating in the MPA on September 1, 2015 (Eligibility Period Two).

To help address this backlog, the Health and Human Services Commission (HHSC) recently sent notifications to those in the CHOW backlog that the agency will conduct a mid-year capitation rate review for capitation rates to be effective December 1, 2015 (Eligibility Period Two-A). NFs that submitted CHOW applications by February 1, 2015, that were not processed by the February 28, 2015 cut-off date for Eligibility Period Two will be eligible to enroll in the NF MPAP effective Eligibility Period Two-A if they meet the following criteria: 

  • The NF submits all outstanding required documents pertaining to their CHOW to DADS by April 15, 2015;
  • The CHOW is resolved by DADS by May 31, 2015, with an effective date of June 1, 2015; and
  • The NF may request a change in the effective date of their CHOW to June 1, 2015, if it so desires. If the NF does not request such a change, their CHOW effective date will be retroactive to March 1, 2015.
    • If the incoming owner does not have contracts in place with its various MCOs effective March 1, 2015, the NF will receive Medicaid reimbursement at out-of-network rates from March 1, 2015 until the effective date of the incoming owner’s MCO contract(s).
    • Managed care contracts cannot have retroactive effective dates per Texas Insurance Code Chapter 1452, Subchapters, C, D, and E (and also Section of the HHSC Uniform Managed Care Contract).

Also, HHSC strongly encourages the original owners to contract with the STAR+PLUS managed care organizations (MCOs) in their service areas, if they have not done so already. Further, HHSC encourages new owners to coordinate closely with the MCOs on executing the new STAR+PLUS provider contracts, once the CHOWs become effective.

If you have questions regarding the CHOW process, contact Annie Aguirre at annie.aguirre@dads.state.tx.us If you have questions about the MPAP, contact Pam McDonald at pam.mcdonald@hhsc.state.tx.us.

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If you have suggestions for education sessions or questions about THCA education, please contact Sue Wilson at the THCA office swilson@txhca.org.