1 TAC §353.3
The Health and Human Services Commission (HHSC) proposes
new §353.3 in 1 TAC Chapter 353, Medicaid Managed Care, Subchapter A,
General Provisions.
Section 353.3 describes the experience rebate policy currently contained
in the contracts between the state and health maintenance organizations (HMOs)
operating in the STAR and STAR+Plus programs. House Bill 2896 enacted by the
76th Texas Legislature requires HHSC to adopt a rule describing the policy.
Don Green, chief financial officer, has determined that for the first five-year
period the section is in effect there will be fiscal implications for state
government as a result of enforcing or administering the section. The effect
on state government for the first five-year period the section will be in
effect is an estimated loss of revenue of $996,678 in Fiscal Year 2000, $1,017,610
in Fiscal Year 2001, $1,038,960 in Fiscal Year 2002, $1,060,738 in Fiscal
Year 2003, and $1,082,516 in Fiscal Year 2004. There will be no fiscal implications
for local government as a result of enforcing or administering the section.
Mr. Green has also determined that for each year of the first five years
the proposed section is in effect the public benefit anticipated as a result
of enforcing the section will be HHSC's compliance with state law. There will
be no effect on small businesses or micro businesses and there are no anticipated
economic costs to persons who are required to comply with the proposed section.
There is no impact on local employment.
Comments on the proposal may be submitted to Barbara Tejero, Texas Health
and Human Services Commission, P. O. Box 13247, Austin, Texas 78711-3247,
within 30 days of publication of this issue of the
Texas Register
.
The new section is proposed under the Texas Government Code, §531.033,
the Texas Human Resources Code, §32.021, and the Texas Government Code, §531.021(a),
which provides the commissioner of HHSC with broad rulemaking authority, and
provides HHSC with the authority to administer the federal medical assistance
(Medicaid) program in Texas.
The amendment implements Government Code, §533.014.
§353.3.Experience Rebate in the STAR and STAR+Plus Programs.
(a)
Each health maintenance organization (HMO) participating
in the State of Texas Access Reform (STAR) and the State of Texas Access Reform
Plus (STAR+Plus) program must pay to the state an experience rebate calculated
according to the graduated rebate method described in subsection (b) of this
section. The experience rebate is based on the excess of allowable HMO revenues,
as defined by the state, over allowable HMO expenses, as defined by the state,
as reviewed and confirmed by the state.
(b)
The graduated rebate method is as follows:
(1)
The HMO retains 100% of that portion of excess allowable
revenues that falls between zero and less than or equal to 3% of total allowable
revenues.
(2)
The HMO retains 75% of that portion of excess allowable
revenues that falls between 3% and less than or equal to 7% of total allowable
revenues. The remaining 25% is paid to the state.
(3)
The HMO retains 50% of that portion of excess allowable
revenues that falls between 7% but less than or equal to 10% of total allowable
revenues. The remaining 50% is paid to the state.
(4)
The HMO retains 25% of that portion of excess allowable
revenues that falls between 10% but less than or equal to 15% of total allowable
revenues. The remaining 75% is paid to the state.
(5)
The HMO pays to the state 100% of that portion of
excess allowable revenues that is greater than 15% of total allowable revenues.
(c)
The experience rebate is based on a pre-tax basis.
(d)
Losses incurred for one contract period can only be carried
forward to the next contract period.
(e)
There are two settlements for payment of the experience
rebate and will be paid by the HMO to the state as prescribed by the state.
The state reserves the right to make corrections to the settlements based
on an audit/review by the state or other documentation acceptable to the state.
The state may also adjust the experience rebate if the state determines that
the HMO paid affiliates amounts for goods or services that are higher than
the fair market value of the goods and services in the service area.
(f)
The state has the final authority in assessing the amount
of the experience rebate.
This agency hereby certifies that the proposal has been reviewed
by legal counsel and found to be within the agency's legal authority to adopt.
Filed with the Office of
the Secretary of State, on April 10, 2000.
TRD-200002512
Marina S. Henderson
Executive Deputy Commissioner
Texas Health and Human Services Commission
Earliest possible date of adoption: May 21, 2000
For further information, please call: (512) 424-6576