| (I) For each children's hospital, identify the total
hospital medical education cost from each hospital cost report or
reports that cross over the base year.
(II) For each children's hospital, sum the amounts
identified in subclause (I) of this clause to calculate the total
medical education cost.
(III) For each children's hospital, calculate the average
medical education cost by dividing the amount from subclause (II)
of this clause by the number of cost reports that cross over the base
year.
(IV) Sum the average medical education cost per hospital
to determine a total average medical education cost for all hospitals.
(V) For each children's hospital, divide the average
medical education cost for the hospital from subclause (III) of this
clause by the total average medical education cost for all hospitals
from subclause (IV) of this clause to calculate a percentage for the
hospital.
(VI) Divide the total average medical education cost
for all hospitals from subclause (IV) of this clause by the total
base year cost for all children's hospitals from subsection (c)(1)(B)
of this section to determine the overall teaching percentage of Medicaid
cost.
(VII) For each children's hospital, multiply the percentage
from subclause (V) of this clause by the percentage from subclause
(VI) of this clause to determine the teaching percentage for the hospital.
(VIII) For each children's hospital, multiply the hospital's
teaching percentage by the base SDA amount to determine the teaching
medical education add-on amount.
(D) Safety-Net add-on.
(i) Eligibility. If a children's hospital meets the
definition of a "safety-net hospital" as defined in subsection (b)
of this section, it is eligible for a safety-net add-on.
(ii) Add-on amount. HHSC calculates the safety-net
add-on amounts annually or at the time of realignment as follows.
(I) For each eligible hospital, determine the following
amounts for a period of 12 contiguous months specified by HHSC:
(-a-) total allowable Medicaid inpatient days for fee-for-service
claims;
(-b-) total allowable Medicaid inpatient days for managed
care encounters;
(-c-) total relative weights for fee-for-service claims;
and
(-d-) total relative weights for managed care encounters.
(II) Determine the total allowable days for eligible
safety-net hospitals by summing the amounts in items (-a-) and (-b-)
of this subclause.
(III) Determine the hospital's percentage of total
allowable days to the total in subclause (II) of this clause.
(IV) Determine the hospital's portion of appropriated
safety-net funds before the MCO adjustment factor is applied by multiplying
the amount in subclause (III) of this clause for each hospital by
the total safety-net funds deflated to the data year.
(V) For each hospital, multiply item (-d-) of this
subclause by the relevant MCO adjustment factor.
(VI) Sum the amounts in item (-c-) of this subclause
and subclause (V) of this clause for each hospital.
(VII) To calculate the safety-net add-on, divide the
amount in subclause (IV) of this clause by the amount in subclause
(VI) of this clause for each hospital. The result is the safety-net
add-on.
(iii) Reconciliation. Effective for costs and revenues
accrued on or after September 1, 2015, HHSC may perform a reconciliation
for each hospital that received the safety-net add-on to identify
any such hospitals with total Medicaid reimbursements for inpatient
and outpatient services in excess of their total Medicaid and uncompensated
care inpatient and outpatient costs. For hospitals with total Medicaid
reimbursements in excess of total Medicaid and uncompensated care
costs, HHSC may recoup the difference.
(E) Add-on status verification.
(i) Notification. HHSC will determine a hospital's
initial add-on status by reference to the impact file at the time
of realignment, Medicaid days, and relative weight information from
HHSC's fiscal intermediary. HHSC will notify the hospital of the CBSA
to which the hospital is assigned, the Medicare teaching hospital
designation for children's hospitals as applicable, and any other
related information determined relevant by HHSC. For state fiscal
years 2017 and after, HHSC will also notify eligible hospitals of
the data used to calculate the safety-net add-on. HHSC may post the
information on its website, send the information through the established
Medicaid notification procedures used by HHSC's fiscal intermediary,
send through other direct mailing, or provide the information to hospital
associations to disseminate to their member hospitals.
(ii) Rate realignment. HHSC will calculate a hospital's
final SDA using the add-on status initially determined by HHSC unless,
within 14 calendar days after the date of the notification, HHSC receives
notification in writing from the hospital, in a format determined
by HHSC, that any add-on status determined by HHSC is incorrect and:
(I) the hospital provides documentation of its eligibility
for a different teaching medical education add-on or teaching hospital
designation;
(II) the hospital provides documentation that it is
approved by Medicare for reclassification to a different CBSA; or
(III) for state fiscal years 2017 and after, the hospital
provides documentation of different data and demonstrates to HHSC's
satisfaction that the different data should be used to calculate the
safety-net add-on.
(iii) Annual SDA calculation. HHSC will calculate a
hospital's final SDA annually using the add-on status initially determined
during realignment by HHSC unless, within 14 calendar days after the
date of the notification, HHSC receives notification in writing from
the hospital, in a format determined by HHSC, that any add-on status
determined by HHSC is incorrect and:
(I) the hospital provides documentation of a new teaching
program or new teaching hospital designation; or
(II) for state fiscal years 2017 and after, the hospital
provides documentation of different data and demonstrates to HHSC's
satisfaction that the different data should be used to calculate the
safety-net add-on.
(iv) Failure to notify. If a hospital fails to notify
HHSC within 14 calendar days after the date of the notification that
the add-on status as initially determined by HHSC includes one or
more add-ons for which the hospital is not eligible, resulting in
an overpayment, HHSC will recoup such overpayment and will prospectively
reduce the SDA accordingly.
(4) Final children's hospital SDA calculations. HHSC
calculates a children's hospital's final SDA as follows.
(A) Add all add-on amounts for which the hospital is
eligible to the base SDA.
(B) For labor and delivery services provided to adults
age 18 or older in a children's hospital, the final SDA is equal to
the base SDA for urban hospitals without add-ons, calculated as described
in subsection (d)(4)(E)(i) of this section plus the urban hospital
geographic wage add-on for an urban hospital located in the same CBSA
as the children's hospital providing the service.
(C) For new children's hospitals that are not teaching
hospitals, for which HHSC has no base year claim data, the final SDA
is the base SDA plus the hospital's geographic wage add-on. The SDA
will be inflated from the base year to the current period at the time
of enrollment or to state fiscal year 2015, whichever is earlier.
(D) For new children's hospitals that qualify for the
teaching medical education add-on, as defined in subsection (b) of
this section, for which HHSC has no base year claim data, the final
SDA is calculated based on one of the following options until realignment
is performed with base year claim data for the hospital. A new children's
hospital must notify the HHSC Provider Finance Department of its selected
option within 60 days from the date the hospital is notified of its
provider activation by HHSC's fiscal intermediary. If the HHSC Provider
Finance Department does not receive timely notice of the option, HHSC
will assign the hospital the SDA calculated as described in clause
(i) of this subparagraph. The SDA calculated based on the selected
option will be effective retroactive to the first day of the provider's
enrollment.
(i) Children's hospital base SDA plus the applicable
geographic wage add-on and the minimum teaching add-on for existing
children's hospitals. No settlement of costs is required for services
reimbursed under this option. The SDA will be in effect until the
next realignment when a new SDA will be determined. The SDA will be
inflated from the base year to the current period at the time of enrollment
or to state fiscal year 2015, whichever is earlier.
Cont'd... |
