HHSC

Health and Human Services Commission (HHSC)

Provider Finance Department

Texas Hospital Disproportionate Share (DSH) and Uncompensated Care (UC)

Application Request Form
HHSC is currently accepting application requests for Federal Fiscal Year (FFY) 2023 Disproportionate Share Hospitals (DSH) and Demonstration Year (DY) 12 Uncompensated Care (UC) Program Payments.

Providers may find eligibility, qualification, the conditions to participate, and payment allocation methodology in the DSH program in 1 Texas Administrative Code (TAC) Part 15, Sec. §355.8065, and the criteria for calculating the Hospital Specific Limit (HSL) used in the DSH program in Sec. §355.8066.

Providers may find eligibility and payment allocation methodology for the DY 12 UC program in 1 TAC Part 15, Sec. §355.8212 for hospitals and §355.8214 for physician groups.  Effective in FFY 2020/DY 9, UC will reimburse for uncompensated uninsured charity care costs instead of Medicaid and uninsured costs.

An application fee will be required with the submission of the UC application for all non-public providers. The application fee will be determined annually based upon an estimate of the amount equal to the estimated costs necessary to administer the program. Please refer to Texas Administrative Code § 355.8200 for more information regarding the UC application fee.

HHSC will collect the data for FFY 2023 DSH and DY 12 UC in one DSH/UC Application. The data for the FFY 2023/DY 12 program year is FFY 2021.

Due Date for submission: September 30, 2022   

Please complete the following form if the Hospital wishes to participate in the FFY 2023 DSH program and/or DY 12 UC.

The form must include the name and all contact information of the person requesting the DSH/UC Application, the person preparing the application, and up to three additional contracts the hospital wishes to receive DSH/UC correspondence from HHSC.

HHSC will send hospital applications to the contracts provided on or around the week of October 24, 2022. Providers will have 30 days to complete with the option to request a 15-day extension starting on November 18, 2022. The physician applications will not be sent until January 2023.

The Medicaid Appeals Period to submit an HSL/Medicaid claims appeals to TMHP starting on October 29, 2022 and has a deadline of November 30, 2022 by 5:00 PM.

For questions regarding the content of the form, please send an email to the PFD Hospitals mailbox.

For technical questions regarding the website, please contact the Provider Finance Department Help Desk.
 
Hospital Medicare Number (CCN)
Hospital TPI Number
Hospital TPI Number (related to data year, if different from current year)
Hospital NPI Number
 
Provider Ownership Type








Hospital Name
Hospital DBA Name (if any)
Hospital System Name (if applicable)
Hospital Physical Address
City
TX
Zip
 
County

     
Hospital Mailing Address
City
Zip
Hospital Telephone

Would the hospital like to participate in the FFY 2023 DSH program?

Would the hospital like to participate in the DY12 UC program?
 

Note: The Primary Application Contact and Primary Hospital Contact MUST be a different individual.

The Primary Application Contact, this person is authorized to act as a liaison between the hospital and HHSC.   (This person can be a contractor.)
Primary Application Contact Name
Primary Application Contact Telephone
Primary Application Contact Email
 example: first.last@hosp.com

Note: The Secondary Application Contact and Primary Hospital Contact MUST be a different individual.

Secondary Application Contact, the person designated to complete the DSH/UC Application on behalf of the Primary Hospital Contact.   (This person can be a contractor.)
Secondary Application Contact Name
Secondary Application Contact Telephone
Secondary Application Contact Email
 example: first.last@hosp.com
Is the hospital primary contact a CEO or CFO?

Primary Hospital Contact, the person requesting the DSH/UC Application and that can make decisions on the hospital's behalf (this person cannot be a contractor and is usually the hospital's CEO or CFO.)
Hospital CEO Name
Hospital CEO Telephone
Hospital CEO Email

Primary Hospital Contact, the person requesting the DSH/UC Application and that can make decisions on the hospital's behalf (this person cannot be a contractor and is usually the hospital's CEO or CFO.)
Hospital CFO Name
Hospital CFO Telephone
Hospital CFO Email


Additional Contacts 1-3 please include representatives related to qualification and/or people who interact with HHSC during the Payments Cycle.
Contact 1 Name
Contact 1 Email
Contact 2 Name
Contact 2 Email
Contact 3 Name
Contact 3 Email






Please verify all data before submitting.