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The Quality Incentive Payment Program (QIPP) is a state directed payment program (DPP) which serves as a performance-based initiative to help nursing facilities achieve transformation in the quality of their services through implementation of innovative program-wide improvement processes. Facilities may earn incentive payments 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 (CMS).
Two classes of Nursing Facility (NF) Provider types are eligible to participate:
Non-state owned governmental entities (NSGO): A non-state governmental entity includes nursing facilities operated by a hospital authority, hospital district, health district, city, or county.
Privately-owned facilities: Current eligibility criteria requires 65% Medicaid utilization by a privately-owned facility.
QIPP is governed by the General Provisions in Title 1 of the Texas Administrative Code, Part 15, Chapter 353, Subchapter O, Rule §353.1301. Additional information on QIPP for Nursing Facilities on or after September 1, 2019 are explained in 1 TAC §353.1302; before September 1, 2019 are explained in 1 TAC § 353.1303, and Quality Metrics for the Quality Incentive Payment Program for Nursing Facilities on or after September 1, 2019 are explained in 1 TAC §353.1304.
Visit the QIPP Provider Finance website for more information about:
- Nursing facility enrollment
- Changes of ownership (CHOW)
- 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.
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 Years Three and Four
For QIPP Year Three (Sept. 1, 2019 to Aug. 31, 2020) and QIPP Year Four (Sept. 1, 2020 to Aug. 31, 2021) 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 and the budget for Year Four was $1.1 billion. HHSC adopted a new component structure and set of quality metrics beginning with Year Three.
Component One was available for non-state government-owned NFs on a monthly basis and was 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 was available to all participating QIPP facilities on a monthly basis and was 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 was available to all participating QIPP facilities on a quarterly basis and was 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 was available to non-state government-owned NFs on a quarterly basis and was 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 had an infection control program that included antibiotic stewardship. The program incorporated 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).
For more details related to QIPP Year Four metrics, reference QIPP Year Four Quality Metrics (PDF).
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 (MDS) 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. The adjustments continued through the first three quarters of Year Four. When CMS reinstated MDS reporting requirements effective May 10, 2021, HHSC followed suit by reinstating QIPP reporting requirements effective June 1, 2021. Performance requirements for MDS-based quality measures were reinstated for the fourth quarter, which ends on August 31, 2021.
QIPP Year Five
HHSC facilitated stakeholder workgroup meetings between September 2020 and January 2021 and reviewed recommendations received from CMS and the U.S. Department of Health and Human Services Office of Inspector General in 2020. Changes were proposed to the quality metrics for QIPP Year Five State Fiscal Year (SFY) 2022 covering the program period of Sept. 1, 2021 to Aug. 31, 2022.
HHSC conducted an online public hearing on January 15, 2021 to allow public comments on the proposed quality metrics and their associated performance requirements for QIPP Year Five. A recording of the public hearing is available here.
Pursuant to 42 C.F.R. § 438.6(c) Preprint process, HHSC submitted proposed quality metrics and performance requirements (PDF) to CMS for review.
On November 15, 2021, CMS approved the Quality Improvement Payment Program (QIPP)[PDF] for SFY2022.
The final pool size for the program year has been set at $1.1 billion.
Final performance requirements, reporting templates, timelines and other provider resources are available on the QIPP Resources webpage.
QIPP Year Six
HHSC facilitated stakeholder workgroup meetings in August and September 2021 to garner feedback on proposed changes to the quality metrics for QIPP Year Six (SFY2023) covering program period of Sept. 1, 2022 to Aug. 31, 2023.
- Download Proposed Quality Metrics for SFY2023 (PDF)
- Written comments regarding the proposed quality metrics may be submitted instead of, or in addition to, oral comments until 5 p.m. on December 23, 2021. Written comments may be sent by U.S. mail or email.
- U.S. Mail: Texas Health and Human Services Commission, Quality Monitoring Program, Attention: Erin Cibrone, Mail Code W510, John H. Winters Bldg., 701 West 51st St., Austin, TX 78751.
- Email: QIPP@hhs.texas.gov
- HHSC conducted an online public hearing on December 20, 2021 to allow public comments on the proposed quality metrics and their associated performance requirements for QIPP Year Six.
- Final quality metrics and performance requirements to be submitted to CMS, pursuant to 42 C.F.R. § 438.6(c) Preprint review will be published here on or before February 1, 2023.
If you have questions for HHSC, email: QIPP@hhsc.state.tx.us.
Managed Care Organization Contacts
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Senior Director of Provider Operations – Medicaid