Quality Incentive Payment Program for Nursing Homes

The Quality Incentive Payment Program serves as a resource to help nursing facilities achieve transformation. This performance-based program encourages NFs to improve the quality and innovation of their services through implementation of program-wide improvement processes for which facilities are compensated for meeting or exceeding certain goals. Improvement is based upon several indices of success, including quality metrics that are collected by the Centers for Medicare & Medicaid Services.

Visit the QIPP Provider Finance website for more information about:

  • Nursing facility enrollment
  • Changes of ownership (CHOW)
  • Eligibility
  • Suggested inter-governmental transfer (IGT) funding
  • Published scorecards for incentive payments
  • Quick reference for due dates throughout the program

An overview of quality metrics for each program year, including associated performance and reporting requirements, are presented below.

Background

During the 83rd Legislative Session, the Texas Legislature directed that nursing facility services be included in Medicaid managed care. The Texas Health and Human Services Commission was instructed to encourage transformative efforts in the delivery of nursing facility services, including "efforts to promote a resident-centered care culture through facility design and services provided."

In 2014, HHSC established the Minimum Payment Amount Program, which became effective in 2015. MPAP established minimum payment amounts for qualified NFs in STAR+PLUS. The STAR+PLUS managed care organizations paid the minimum payment amounts to qualified NFs based on state direction. The program was intended to be a short-term program that would ultimately transition to a performance-based initiative.

HHSC Budget Rider 97 in the 2016-2017 budget directed HHSC to transition the Minimum Payment Amount Program to the Quality Incentive Payment Program. The QIPP is a Medicaid managed care delivery system and provider payment initiative in which HHSC directs expenditures through its contracts with the STAR+PLUS MCOs. Federal regulatory authority for such directed payments is contained in 42 Code of Federal Regulations §438.6(c).

QIPP Years One and Two

For QIPP Years One (Sept. 1, 2017 to Aug. 31, 2018) and Two (Sept. 1, 2018 to Aug. 31, 2019), QIPP funds were paid through three components of the STAR+PLUS nursing facility managed care per member per month capitation rates. The budget for year one was $399,333,542 and the budget for year two was $446 million.

Component One was exclusively available to non-state government-owned NFs and was triggered by the nursing facility’s submission of a monthly Quality Assurance Performance Improvement Validation Report.

Components Two and Three were available to all participating QIPP facilities and were triggered by meeting the national benchmark or by demonstrating minimum improvement (Component Two) or strong improvement (Component Three) on the following CMS long-stay nursing facility quality metrics:

  • High-risk long-stay residents with pressure ulcers.
  • Percent of residents who received an antipsychotic medication.
  • Residents experiencing one or more falls with major injury.
  • Residents who were physically restrained.

QIPP Year Three

For QIPP Year Three (Sept. 1, 2019 to Aug. 31, 2020), QIPP funds were paid through four components of the STAR+PLUS nursing facility managed care per member per month capitation rates. The budget for Year Three was $600 million. HHSC adopted a new component structure and set of quality metrics beginning with Year Three.

Component One is available for non-state government-owned NFs on a monthly basis and is triggered by the nursing facility’s submission of a monthly Quality Assurance Performance Improvement Validation Report. Facilities must demonstrate significant involvement of their partner entity in the monthly meetings.

Component Two is available to all participating QIPP facilities on a monthly basis and is triggered by demonstrating a commitment to workforce development as measured by the following three equally-weighted quality metrics:

  • NF maintains four additional hours of registered nurse staffing coverage per day, beyond the CMS mandate.
  • NF maintains eight additional hours of RN staffing coverage per day, beyond the CMS mandate.
  • NF has a staffing recruitment and retention program that includes a self-directed plan and monitoring outcomes.

Component Three is available to all participating QIPP facilities on a quarterly basis and is triggered by meeting the national benchmark or by demonstrating strong improvement on the following three equally-weighted CMS long-stay nursing facility quality metrics:

  • (CMS N015.02; NHC 453) Percent of high-risk long-stay residents with pressure ulcers, including unstageable ulcers.
  • (CMS N031.02; NHC 419) Percent of residents who received an antipsychotic medication.
  • (CMS N035.02; NHC 451) Percent of residents whose ability to move independently has worsened.

Component Four is available to non-state government-owned NFs on a quarterly basis and is triggered by meeting quality requirements for three equally-weighted quality metrics:

  • (CMS N024.01; NHC 407) Percent of residents with a urinary tract infection.
  • (Self-reported) Percent of residents whose pneumococcal vaccine is up to date.
  • Facility has an infection control program that includes antibiotic stewardship. The program incorporates policies and training as well as monitoring, documenting, and providing staff with feedback.

For more details related to QIPP Year Three metrics, reference QIPP Year Three Quality Metrics (PDF).

QIPP Year Four

For QIPP Year Four (Sept. 1, 2020 to Aug. 31, 2021), HHSC made no changes to the quality metrics or Component payment structure. Therefore, performance and submission requirements continued from Year 3. The final pool size for the eligibility period was set at $1.1 billion.

For more details related to QIPP Year Four metrics, reference QIPP Year Four Quality Metrics (PDF).

An eligibility list for Year Four participation has been posted by HHSC Provider Finance alongside change of ownership, enrollment, and inter-governmental transfer deadlines. Provider Finance also published a reference document for Year Four (PDF) that contains important dates, including data reporting deadlines and payment timeframes.

Performance and Reporting Requirement Adjustments Due to COVID-19

The U.S. Centers for Medicaid and Medicare Services (CMS) waived certain reporting requirements for nursing facilities effective March 1, 2020, including timeframe requirements for Minimum Data Set assessments and transmission.

To account for the lack of sufficient MDS data, HHSC published a notification on June 9, 2020 to waive the performance requirements connected to all MDS quality measures; i.e. Component Three and one metric under Component Four - Percent of Residents with Urinary Tract Infection (CMS ID: N024.02) effective March 1, 2020 to August 31, 2020. To help relieve the administrative burden on facilities, HHSC also waived the reporting requirement for Component One-Submission of monthly Quality Assurance and Performance Improvement Validation reports.

On December 23, 2020, to account for the lack of MDS data, HHSC published a second notification, extending the waiver effective September 1, 2020, to the rest of fiscal year 2021.

During both waivers, Non-state government-owned NFs were required to continue holding monthly QAPI meetings according to the performance requirements set forth in TAC §353.1304(d)(1). HHSC clarified that only the reporting requirement for Component One was suspended. If a facility was randomly selected for a QA review, HHSC will require supporting documentation for all monthly meetings.

QIPP Year Three funds dedicated to Component Three were disbursed in monthly payments to all enrolled NFs to support responses to COVID-19, such as workforce recruitment and retention and infection control. The changes to the Component Three payment schedule were implemented from the May 2020 and included retroactive Component Three payments for March and April 2020.

The changes to QIPP Year Four payment schedule for Component Three was reflected in the December 2020 scorecard and included all retroactive Component payments for September through November 2020.

Note: If CMS reinstates MDS reporting requirements, HHSC may reinstate QIPP MDS-related performance requirements no earlier than three months after the CMS requirements are effective.

QIPP Year Five

On December 30, 2020, HHSC proposed changes to the quality metrics for QIPP Year Five (Sept. 1, 2021 to Aug. 31, 2022). The final pool size for the eligibility period has not yet been determined.

For more details related to QIPP Year Five proposed quality metrics and their associated performance requirements, reference QIPP Year Five Proposed Quality Metrics (PDF). HHSC conducted an online public hearing on January 15, 2021 to allow public comment on the proposal. A recording of the public hearing is available here. HHSC continued to accept written comments until 5 p.m. CST on Jan. 25, 2021.

Prior to proposal, HHSC met with stakeholders during workgroup meetings held between September 2020 and January 2021. Recommendations received in 2020 from CMS and Office of the U.S. Department of Health and Human Services Office of Inspector General, were also considered.

In accordance with 1 TAC §353.1304, the final quality metrics and performance requirements (PDF)  will be submitted to CMS as part of the approval of QIPP Year Five .

Contact Information

If you have questions for HHSC, email: QIPP@hhsc.state.tx.us.

Managed Care Organization Contacts

Amerigroup
Jessica McFarlin
TXQIPP@amerigroup.com
817-456-6720

United
Sandi Howard
Senior Provider Relations Manager
sandi.howard@optum.com
952-202-3559

Superior
Alaine Heselmeyer
Sr. Director of Finance
QIPP@superiorhealthplan.com
(512) 406-7236

Molina
Bob Kalin
VP Long Term Care Operations
robert.kalin@molinahealthcare.com
713-824-1664

Cigna-HealthSpring
Cynthia Forester
Senior Director of Provider Operations – Medicaid
State_Compliance@cigna.com
817.554.5627