In December 2011, Texas received federal approval of an 1115 waiver that would preserve Upper Payment Limit (UPL) funding under a new methodology, but allow for managed care expansion to additional areas of the state.
The purpose of the 1115 Healthcare Transformation waiver, supplemental payment funding, managed care savings, and negotiated funding will go into two statewide pools now worth $29 billion (all funds) over five years. Funding from the pools will be distributed to hospitals and other providers to support the following objectives: (1) an uncompensated care (UC) pool to reimburse for uncompensated care costs as reported in the annual waiver application/UC cost report; and (2) a Delivery System Reform Incentive Payment (DSRIP) pool to incentivize hospitals and other providers to transform their service delivery practices to improve quality, health status, patient experience, coordination, and cost-effectiveness.
Uncompensated Care Pool Payments are designed to help offset the costs of uncompensated care provided by the hospital or other providers.
DSRIP Pool Payments are incentive payments to hospitals and other providers that develop programs or strategies to enhance access to health care, increase the quality of care, the cost-effectiveness of care provided and the health of the patients and families served.
Under the transformation waiver, eligibility to get Uncompensated Care or DSRIP payments will require participation in a regional healthcare partnership. Within a partnership, participants include governmental entities providing public funds known as intergovernmental transfers (IGT), Medicaid providers and other stakeholders. Participants will develop a regional plan identifying partners, community needs, the proposed projects, and funding distribution. Each partnership must have one anchoring entity, which acts as a primary point of contact for HHSC in the region and is responsible for seeking regional stakeholder engagement and coordinating development of a regional plan.
1115 Waiver Annual Reports
The 1115 Waiver's Standard Terms and Conditions require HHSC to submit an annual report on the waiver to the Centers for Medicare and Medicaid Services (CMS) for each demonstration year.
- Demonstration Year 1 (December 2011 - September 2012) Annual Report (PDF)
- Demonstration Year 2 (October 2012 - September 2013) Annual Report (PDF)
- Demonstration Year 3 (October 2013 - September 2014) Annual Report (PDF)
- Demonstration Year 4 (October 2014 - September 2015) Annual Report (PDF) (8/17/16)
- Transition Plan for Funding Pools (PDF)
- Transition Plan Attachment (PDF)
- Waiver Amendment (PDF) (Version Approved by CMS on 1/19/17)
- Regional Healthcare Partnerships Roles & Responsibilities
- Federal Approval Letter and Documents (PDF)
- Overview of Texas Health Care Transformation Waiver (PDF)
- Budget Analysis (PDF)
- Frequently Asked Questions
- Texas Medicaid 1115 Waiver Proposal (PDF)
- Former Upper Payment Limit Payments and Intergovernmental Transfers, Fiscal Year 2011
Medicaid/CHIP Quality and Efficiency Improvement Website
- HHSC has launched a Medicaid and CHIP Quality and Efficiency Improvement website to increase transparency and public reporting. Please click here to view: Medicaid and CHIP Quality and Efficiency Improvement
Materials from Aug. 7-8 Regional Healthcare Partnership (RHP) Planning Summit
- Uncompensated Care Protocol, Part 1
- Uncompensated Care Protocol, Part 2
- RHP Plans, CMS Expectations, and Tool Kit Primer
- Institute for Healthcare Quality and Efficiency
- Program Funding and Mechanics Protocol
- RHP Planning Protocol
- Behavioral Health and the Waiver, Part 1
- Behavioral Health and the Waiver, Part 2
- Behavioral Health and the Waiver, Part 3
- Paying for Outcomes – not Performance
- Intergovernmental Transfers
Examples of RHP Planning Protocol sections being negotiated with CMS:
- Project 1.1 – Enhance Primary Care Access
- Project 2.1 – Expand/Enhance Medical Homes
- Behavioral Health Project Excerpt
Sample materials shared by RHPs:
These can provide ideas to regions about how to organize planning for projects and valuation. These are NOT templates of materials that RHPs are required to submit to HHSC:
- Sample Project and Measure Documentation
- Sample Project Valuation Framework, Part 1
- Sample Project Valuation Model, Part 2
- Sample Project Valuation Model, Part 3
- Sample Regional Newsletter
- Sample Summary-level Project Evaluation Tool
- Sample Category I Project Evaluation Tool
- Sample Category II Project Evaluation Tool
- California DSRIP Menu – In 2010, the federal government approved an 1115 waiver in California creating DSRIP on a smaller scale than the Texas plan.