Safety Net Definition
As described in the DSRIP program requirements outlined by the MRT Waiver Amendment STCs, "DSRIP funds provide incentive payments to reward safety net providers when they undertake projects designed to transform the systems of care that support Medicaid beneficiaries and low income uninsured."
The safety net definition as written in the STCs is included below. Please note that, as described below, "non-qualifying providers can participate in Performing Provider Systems. However, non-qualifying providers are eligible to receive DSRIP payments totaling no more than 5 percent of a project´s total valuation."
The definition of safety net provider for hospitals will be based on the environment in which the performing provider system operates. Below is the safety net definition:
A hospital must meet the following criteria to participate in a performing provider system:
- Must be either a public hospital, Critical Access Hospital or Sole Community Hospital, or
- Must pass two tests:
- At least 35 percent of all patient volume in their outpatient lines of business must be associated with Medicaid, uninsured and Dual Eligible individuals.
- At least 30 percent of inpatient treatment must be associated with Medicaid, uninsured and Dual Eligible individuals; or
- Must serve at least 30 percent of all Medicaid, uninsured and Dual Eligible members in the proposed county or multi-county community. The state will use Medicaid claims and encounter data as well as other sources to verify this claim. The state reserves the right to increase this percentage on a case by case basis so as to ensure that the needs of each community's Medicaid members are met.
Non-hospital based providers, not participating as part of a state-designated health home, must have at least 35 percent of all patient volume in their primary lines of business and must be associated with Medicaid, uninsured and Dual Eligible individuals.
Vital Access Provider (VAP) Exception
The state will consider exceptions to the safety net definition on a case-by-case basis if it is deemed in the best interest of Medicaid members. Any exceptions that are considered must be approved by CMS and must be posted for public comment 30 days prior to application approval. Three allowed reasons for granting an exception are:
- A community will not be served without granting the exception because no other eligible provider is willing or capable of serving the community.
- Any hospital is uniquely qualified to serve based on services provided, financial viability, relationships within the community, and/or clear track record of success in reducing avoidable hospital use.
- Any state-designated health home or group of health homes.
Non-qualifying providers can participate in Performing Providers Systems. However, non-qualifying providers are eligible to receive DSRIP payments totaling no more than 5 percent of a project's total valuation. CMS can approve payments above this amount if it is deemed in the best interest of Medicaid members attributed to the Performing Provider System.