Texas Register, Volume 38, Number 36, Pages 5801-5944, September 6, 2013 Page: 5,861
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hospital's DSH payment. The commenters expressed concern
that an across-the-board payment reduction could impact a few
providers where DSH payments are essential to access-to-care.
Response: HHSC agrees that the rule should address the con-
tingency described by this commenter. HHSC added language
to subsection (h)(6) that describes the methodology HHSC will
use to reduce payments under this additional allocation when
the contingency occurs. Under this methodology, if HHSC de-
termines that payments due to the additional allocation would
cause total DSH payments to exceed available DSH funds for
the payments, it will proportionally reduce the DSH payment
amounts rural public and rural public-financed hospitals are eli-
gible to receive through the additional allocation as required to
remain within the available DSH funding for the payment. HHSC
did not adopt the methodology suggested by the commenters
for two reasons. First, HHSC believes that a proportional reduc-
tion across all impacted providers is the fairest approach when
payments would otherwise exceed available DSH funding. Sec-
ond, HHSC believes that, because the commenters' proposed
reduction methodology would have a differential impact on var-
ious providers, it could not be adopted without allowing for fur-
ther comment by providers who would be disproportionately im-
pacted by the commenters' proposed methodology.
Comments in opposition to the rule:
Mandatory funding requirements
Comment: One commenter stated that as long as intergovern-
mental transfers continue, hospital districts and other public hos-
pitals should be required to provide funding for the Medicaid DSH
program as a condition for receipt of Medicaid DSH funds.
Response: Because the Texas Legislature has not appropriated
funds to HHSC to be used as the non-federal share of pay-
ments under the DSH program, HHSC agrees that public entities
may be required to provide some level funding as a condition of
their hospitals receiving DSH payments. However, HHSC is not
aware of a current basis in Texas law to require public entities to
fund DSH payments to the same level as they have in the past, or
to fund DSH payments to other providers as a condition of their
hospitals receiving DSH payments. No changes were made in
response to this comment.
Allocation of available DSH funds by Category of Hospital
Comment: Concerning 355.8065(h)(2), commenters stated
that the current methodology of allocating and funding DSH
is neither equitable nor sustainable and they do not believe
that the RHP regions are the proper basis for allocating DSH
funds. They indicated that the regions vary significantly in size
and were created for a different purpose than the allocation of
DSH funding, and while the weighting factors in the rule takes
this into account, the size of the regions still disparately impact
differing transferring hospitals.
Response: HHSC respectfully disagrees with the commenters.
The RHP regions are intended to be collaborations of inter-
ested participants that work collectively to develop and submit
to the state a regional plan for health care delivery system
reform. RHPs will support coordinated, efficient delivery of
quality care and a plan for investments in system transformation
that is driven by the needs of local hospitals, communities,
and populations. Intergovernmental transfers under the 1115
waiver are prohibited from crossing RHP boundaries unless
supported by historic patient flow patterns. HHSC believes that
it makes sense and supports regional planning and regionaltransformation to have DSH intergovernmental transfers occur
within the same RHP structure as those transfers occur under
the 1115 waiver. No changes were made in response to these
comments.
Comment: Two commenters stated that the DSH rule attempts
to obligate county tax payers for support of DSH within their RHP.
Two commenters also addressed concern that the higher level of
expected IGTs in the proposed rule for the large urban hospitals
will result in a direct loss of funds from the UC program. The com-
menters recommended that DSH be allocated between those
counties with an urban public hospital and hospitals in all other
counties. Two commenters stated that public hospitals should
be responsible for their respective counties only.
Response: As indicated above, HHSC believes that it makes
sense and supports regional planning and transformation to
have DSH intergovernmental transfers guided by the same RHP
structure as transfers made under the 1115 waiver. In each
RHP housing an urban public hospital, patient flow relationships
extend beyond the borders of the county to the various counties
comprising the RHP; provision of care to these patients by
hospitals throughout the RHP relieves the urban public hospital
within the RHP of the burden of caring for all Medicaid and
uninsured patients within their RHP. Given the relationships that
exist throughout the RHP, it makes sense to HHSC that DSH
funding should be aligned with RHP boundaries. HHSC dis-
agrees that the proposal obligates county tax payers for support
of DSH within their RHP. HHSC does not have the authority
to obligate any local taxing entity to provide intergovernmen-
tal transfers under DSH or any other supplemental payment
program. While funding of DSH IGTs reduces the total funds
urban public hospitals are eligible to receive under the state's
various supplemental payment programs, these hospitals will
still receive significantly greater combined payments under DSH
and the 1115 waiver than they did previously under DSH and
the former upper payment limit programs. No changes were
made in response to these comments.
Distribution and Payment Calculation
Comment: Some commenters proposed allocating uncompen-
sated-care payments, including DSH payments, between public
and non-public hospitals based on the proportionate amount of
uncompensated care each group provides, rather than basing it
on the source of the non-federal share of the payments.
Response: HHSC respectfully disagrees with these comments.
HHSC does not believe that the urban public hospitals' IGT con-
tributions should be used to support DSH payments to hospitals
so physically distant from the urban public hospital that there is
little to no chance of those contributions following patient flow.
HHSC believes that the most equitable solution to the funding of
the non-federal share of DSH payments for these distant hospi-
tals, at this point in time, is for the non-federal share for these
hospitals to be supported by state appropriations. No changes
were made in response to these comments.
Comment: Concerning 355.8065(h)(3) and (4), one commenter
proposed eliminating the use of weighting factors in distributing
DSH funds. Instead, for hospitals in an RHP with an urban pub-
lic hospital, the commenter proposed deducting the non-federal
share from the DSH allocation of each hospital that is not an ur-
ban public hospital and adding it to the allocation of the urban
public hospital in that RHP.
Response: HHSC does not believe that such an approach to al-
locating DSH funds would be acceptable to its federal partner,ADOPTED RULES September 6, 2013 38 TexReg 5861
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Texas. Secretary of State. Texas Register, Volume 38, Number 36, Pages 5801-5944, September 6, 2013, periodical, September 6, 2013; Austin, Texas. (https://texashistory.unt.edu/ark:/67531/metapth342081/m1/61/: accessed April 19, 2024), University of North Texas Libraries, The Portal to Texas History, https://texashistory.unt.edu; crediting UNT Libraries Government Documents Department.