Texas § GV.542.0103 - ALTERNATIVE PAYMENT RATE OR METHODOLOGY

§ GV.542.0103. ALTERNATIVE PAYMENT RATE OR METHODOLOGY

ALTERNATIVE PAYMENT RATE OR METHODOLOGY. (a) The pilot program must be designed to test the use of innovative payment rates and methodologies for the provision of long-term services and supports to achieve the goals of the pilot program. The payment methodologies must include: (1) the payment of a bundled amount without downside risk to a comprehensive long-term services and supports provider for some or all services delivered as part of a comprehensive array of long-term services and supports; (2) enhanced incentive payments to comprehensive long-term services and supports providers based on the completion of predetermined outcomes or quality metrics; and (3) any other payment model the commission approves. (b) An alternative payment rate or methodology may be used for a managed care organization and comprehensive long-term services and supports provider only if the organization and provider agree in advance and in writing to use the rate or methodology. (c) In developing an alternative payment rate or methodology, the commission, managed care organizations, and comprehensive long-term services and supports providers shall consider: (1) the historical costs of long-term services and supports, including Medicaid fee-for-service rates; (2) reasonable cost estimates for new services under the pilot program; and (3) whether an alternative payment rate or methodology is sufficient to promote quality outcomes and ensure a provider's continued participation in the pilot program. (d) An alternative payment rate or methodology may not reduce the minimum payment a provider receives for delivering long-term services and supports under the pilot program to an amount that is less than the fee-for-service reimbursement rate the provider received for delivering those services before participating in the pilot program. Added by Acts 2023, 88th Leg., R.S., Ch. 769 (H.B. 4611 ), Sec. 1.01, eff. April 1, 2025.