Welcome to RHP 9 – Transforming Healthcare Now

Waiver Information

  • Five-year demonstration waiver that began on September 1, 2011
  • Aligns with the Triple Aim of the Centers for Medicare and Medicaid Services (CMS): Improve the experience of care, Improve the health of populations, and Reduce the per capita costs of healthcare without compromising quality.
  • Creation of Regional Healthcare Partnerships (RHP) that support coordinated, efficient delivery of quality care, and a plan for system transformation that is driven by the needs of the community.
  • Provides incentive payments for quality improvement and healthcare delivery system reform

Quick Facts on RHP 9:

  • 3 Counties: Dallas, Denton, & Kaufman
  • 2,530 square miles
  • Population of 3.1 million
  • 40% are low income
  • 25 providers participating in Delivery System Reform Incentive Payment (DSRIP) projects
  • Needs assessment: Gaps in access, behavioral health, and overall care coordination.
  • 129 DSRIP projects
    • 46 Infrastructure Development projects (Category 1)
    • 83 Program Innovation and Redesign projects (Category 3)
    • 200 Plus Outcome Measures (Category 3)

Tuesday May 22-23, 2018:  2018 RHP 9, 10 & 18 Collaborative Connections - Impacting CareRegistration at https://2018collaborativeconnectionsimpactingcare.eventbrite.com
2018: TBD:  RHP9 Plan Submission and Updated Community Needs Assessment


Making a Difference

Waiver Update - DY7-8
  • RHP Plan Update Template has been sent via email. All documents are also posted on the DSRIP Online Reporting System bulletin board.  HHSC is updating many documents; please see the bulletin board for the latest version.  The Cat C Measure Specs (excel file), the Cat C Specifications FAQ, and the 2. Cat C Measure Specs – Hospitals and Physician Practice were all updated.  Please download from the DSRIP Online Reporting System bulletin board.  I have not attached as the files are too large. 
  • Please review the Companion Document prior to submitting questions to HHSC.
  • Category B:   Anchors requested clarification on how outpatient clinics such as labs, X-ray, physical therapy, etc., should be included in the provider’s system definition. As previously suggested by HHSC, these types of clinics may be included as optional components. This will be reflected in the next update of the Category B FAQs (not yet available).
  • Category C
    • The second round of FAQ on the Measure Specifications were sent earlier this week.  They have also been posted on the DSRIP Online Reporting System bulletin board.
    • HHSC continues to review questions regarding Measure Specifications and plan to update the FAQ every other week through the end of March.
    • Providers may submit new questions to the waiver mailbox, but please check the posted FAQs and the measure specifications (especially the Introduction) before sending additional questions.
    • Due to the volume of specifications questions received, HHSC may refer some providers back to their anchor for assistance, depending on the type of question asked.
    • Attached is the goal calculator for DY7-8.  The goal calculator allows providers to calculate DY7 and DY8 achievement goals for the standard payer-type for P4P Category C measures. The goal calculator does not currently allow for goal calculation for grandfathered LHD measures.
    • HHSC has corrected a mistake in the Cat C FAQ posted on Monday related to the use of the ANSA/CANS by CMHCs to collect data for certain measures. The FAQ posted to the waiver bulletin board has been updated, and the revised response is also posted below.
  1. Question: Can CMHCs use data from the ANSA or CANS for measures M1-261 Assessment for Substance Abuse Problems of Psychiatric Patients, M1-262 Assessment of Risk to Self/Others, and M1-263 Assessment for Psychosocial Issues of Psychiatric Patients? Can CMHCs use the data that is already being captured by the CANS/ANSA assessment tool as it is already required to be used to assess ALL of our mental health clients?
  2. Answer: The ANSA and CANS are not approved tools to use for measures M1-385 Assessment of Functional Status or QoL and M1-386 Improvement in Functional Status or QoL. HHSC has not made any recommendations regarding the use of data collected through ANSA and CANS screening to other measures. Providers are strongly encouraged to prioritize measures in need of improvement that demonstrate delivery system reform and transformation of the healthcare system.
  • HHSC has updated the Category C Measure Specifications Part 2 (Hospital and Physician Practice Measures) and the posted specifications excel file to correct a few identified errors. Please pull from bulletin board.  Most corrections are minor and corrections are detailed in the posted change log. The following significant correction was made:
    1. D1-503 -Acute Composite (PDI 91) specifications have been corrected to clarify that the age range for both the numerator and denominator is ages 3 months - 17 years.
  • HHSC is working on additional guidance related to the inclusion of incarcerated populations in the DSRIP attributed population, and the payer-type assigned to pending Medicaid.


  • Category D
    • HHSC made a technical correction to the Measure Bundle Protocol related to Category D reporting for CMHCs. Updates would allow Category D to incorporate potential changes to the measures reported by the Centers, since these measures are under internal and external review. The corrected version will be posted to the DSRIP Online Reporting System bulletin board and the waiver website.
    • HHSC is working on obtaining the data for Category D reporting.
      • PPV data will be provided the same way as the PPAs, PPCs and PPRs.
      • For LHDs, the data from the Behavioral Risk Factor Surveillance Survey (BRFSS) is based on calendar year 2016. When reporting, LHDs will provide qualitative information describing their activities in the areas included in Category D that took place any time during 2016 and through the reporting period.
      • It will be a similar approach for CMHCs, but finalization of the data is still in process.
  • Rules:  The DSRIP DY7-8 rule amendment 1 was published as proposed in the January 19, 2018, issue of the Texas Register, for an anticipated effective date of April 2018. HHSC is working on a second rule amendment to make the rules consistent with the DSRIP protocols approved by CMS.
  • Please also find attached the processes for 1) Requesting HHSC Pre-Review for Bundle I1 and Pre-Approval for Standardized Instruments, and 2) Requesting HHSC Approval of an Approximate Baseline.
  • DY7 Monitoring IGT: 
    • Attached is the estimated DY7 Monitoring IGT. The DY7 Monitoring IGT amounts are based on the total IGT funding per provider per IGT Entity applied to DY7 valuation. For example, if IGT Entity A and IGT Entity B funded Hospital Z at 60% and 40% for all DY6 Categories 1-4, then it was applied that IGT Entity A will fund 60% of Hospital Z's DY7 total provider valuation and IGT Entity B will fund the remaining 40% of Hospital Z's DY7 total provider valuation.
    • If IGT Entities change in entity or proportion funded in the RHP Plan Update submission, then HHSC will update the DY7 Monitoring IGT amounts to reflect the changes. The updated DY7 Monitoring IGT amount per IGT Entity will only decrease and will not increase based on the RHP Plan Update changes.
Waiver Negotiations Update
  • Yesterday Commissioner Smith hosted a meeting on the waiver renewal.  I have attached the documents from the meeting. 


  • UC Pool and Payment Changes
    • Pool size will be approximately $3.1 billion in DY 7 and DY 8. Pool sizes for DY 9 - 11 will be resized based on hospital charity care costs provided in Federal Fiscal Year (FFY) 2017.
    • It will be essential for all providers to accurately report charity care costs for 2017 for the resizing exercise. The UC pool size may temporarily default to a reduced amount of $2.3 billion for DY 9 - 11 until all charity costs are accurately reported. The pool will ultimately be reconciled to reflect the final charity care data and may be more or less than $2.3 billion depending on the data.
    • Charity care costs will be determined by information in Worksheet S-10 of the Medicare hospital cost report (Form CMS-2552-10). For hospitals not required to complete the S-10, which are primarily children’s, cancer, and rehabilitation hospitals, and Institutions of Mental Disease) and for non-hospital qualifying providers, an alternate methodology using CMS-approved cost reports will be used to determine charity costs.
    • Beginning in DY 9, UC pool payments will be based on charity costs incurred by qualifying providers and must exclude amounts for Medicaid shortfall as CMS prefers that reimbursement rates be adequate to cover Medicaid costs. Providers receiving both DSH and UC payments cannot be paid more than total eligible uncompensated costs.
    • The UC payment protocol must include precise definitions of eligible uncompensated provider charity care costs for each qualifying provider type.


  • UC Protocol and Rules Schedule
    • Draft UC protocol is due to CMS by March 30, 2018. Approval expected in 90 days.
    • Draft Texas Administrative Code rule on UC payments to be published by July 31, 2018.
    • Revised draft UC applications to CMS by May 1, 2019. Approval required by August 31, 2019.
    • Revised UC protocol to be implemented by October 1, 2019.
    • Final Texas Administrative Code rule on UC payments to be published by January 30, 2019, and effective by September 30, 2019.
    • Failure to meet any of these deadlines will result in a 20% reduction in expenditure authority from the UC pool for the program year. The reductions are cumulative.


    • The DSRIP funding pool has been extended four years, through September 30, 2021. Pool sizes are $3.1 billion in DY 7 and 8, $2.91 billion in DY 9, $2.49 billion in DY 10, and $0 in DY 11.
    • CMS and HHSC to finalize RHP Planning Protocol and the Program Funding and Mechanics Protocol by January 21, 2018.
    • Draft DSRIP transition plan due to CMS by October 1, 2019 to describe how the state will further develop its delivery system reform efforts when DSRIP funding is no longer available. Transition plan to be finalized by end March 2020 (DY 10).


  • Category B:   If you have outstanding questions from December related to system definitions or Category B, please feel free to resend these questions to the waiver mailbox.


  • Category C
    • The first round of FAQ on the draft Measure Specifications has been posted on the DSRIP Online Reporting System bulletin board in October.  HHSC continues to review questions. 
    • Attached are the latest Cat C Specification FAQ


  • Rules:  The DSRIP DY7-8 rules were published as adopted in the November 24, 2017, issue of the Texas Register with an effective date of December 1, 2017. HHSC is currently working to amend these rules to reflect the most recent versions of the DSRIP protocols as of December 22, 2017. HHSC anticipates that the amendments will be published as proposed in the January 19, 2018 issue of the Texas Register, for an anticipated effective date of April 2018. These rules will need to be further amended once HHSC and CMS have finished negotiating the DSRIP protocols, such as potentially narrowing the current range of distributing Category C valuation among Measure Bundles/measures and adjusting rules for P4P measures that are high performing at baseline. 
October DY6 Reporting
  • Reminder that NMI will close on 1/16/18, however an email reminder will not go out as the system will remain open for the providers impacted by Hurricane Harvey. 
  • Payment Timeline:  January 18 for the transferring hospitals and Top 14 IGT Entities;  January 31 for remaining providers and DY5 payments for all providers. 
  • QPI NMI:  Utilize the October DY6 QPI Reporting Template
  • Category 3 NMI:  There is a specific Cat 3 NMI Template that must be used for reporting NMI. If you didn’t receive an NMI, please do not rely on the NMI reporting template to confirm DY6 R2 reporting. HHSC posted an updated Summary Workbook to the online reporting system on January 11. Please rely on this information rather than the template.
Compliance Monitoring
  • MSLC Is continuing its work with Category 1 and 2 and Category 3 reviews.
  • HHSC continues finalizing results for Category 1 and 2 Round 3, and the process will continue for several weeks, depending on the resolution or need for clarification for some projects.
  • MSLC has started documentation requests and reviews for Category 3 Round 3 Performance Reviews. We anticipate that this round of reviews will be completed by May 2018 for most projects.
Waiver Renewal
  • Waiver Negotiations Update
    • Communications are still ongoing with CMS and updates will be provided as they are available, including timelines.
    • CMS is currently reviewing the proposed Program Funding and Mechanics Protocol (PFM), the Measure Bundle Protocol (MBP), and the draft Measure Specifications.
  • Category C
    • The first installment of an FAQ based on the questions and feedback submitted on the draft Measure Specifications document will be posted early this week on the online reporting system bulletin board.
    • Over 1,000 individual questions were submitted to HHSC.  Many cannot be answered without program approval by CMS.
    • Questions can continue to be submitted to the HHSC box but please do not resubmit questions. 
    • HHSC has received a number of comments regarding the administrative complexity of the measure specifications source for measure J1-222 Severe Sepsis and Septic Shock Management Bundle (NQF 0500) and will be evaluating alternative specifications sources.
  • Rules
    •  The DSRIP DY7-8 rules were published as adopted in the November 24, 2017, issue of the Texas Register with an effective date of December 1, 2017. HHSC is currently working to amend these rules to reflect the most recent versions of the DSRIP protocols as of December 22, 2017. HHSC anticipates that the amendments will be published as proposed in the Texas Register in January 2018, for an anticipated effective date of April 2018. HHSC also anticipates that the rules may need to be further amended once HHSC and CMS have finished negotiating the DSRIP protocols.