| (ii) Children's base SDA plus the applicable geographic
wage add-on and the maximum teaching add-on for existing children's
hospitals. A cost settlement is required for services reimbursed under
this option. The SDA will be in effect for the hospital 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.
(d) Base urban hospital SDA calculations. HHSC will
use the methodologies described in this subsection to determine the
average statewide base SDA and the final SDA for each urban hospital.
(1) HHSC calculates the average base year cost per
claim (the universal mean) as follows.
(A) To calculate the total inpatient base year cost
per urban hospital:
(i) sum the allowable inpatient charges by hospital
for the base year claims; and
(ii) multiply clause (i) of this subparagraph by the
hospital's inpatient RCC and the inflation update factors to inflate
the base year cost to the current year.
(B) Sum the amount for all hospitals' base year costs
from subparagraph (A) of this paragraph.
(C) To derive the average base year cost per claim,
divide the result from subparagraph (B) of this paragraph by the total
number of base year claims.
(2) HHSC calculates the base urban SDA as follows.
(A) From the amount determined in paragraph (1)(B)
of this subsection for urban hospitals, HHSC sets aside an amount
for add-ons as described in paragraph (3) of this subsection. In determining
the amount to set aside, HHSC considers factors including other funding
available to reimburse high-cost hospital functions and services,
available data sources, historical costs, Medicare practices, and
feedback from hospital industry experts.
(B) The amount remaining from paragraph (1)(B) of this
subsection after HHSC sets aside the amount for add-ons in subparagraph
(A) of this paragraph is then divided by the total number of base
year claims to derive the base SDA.
(3) An urban hospital may receive increases to the
base SDA for any of the following.
(A) Add-on amounts, which will be determined or adjusted
based on the following.
(i) Impact files.
(I) HHSC will use the most recent finalized impact
file available at the time of realignment to calculate add-ons; and
(II) HHSC will use the impact file in effect at the
last realignment to calculate add-ons for new hospitals, except as
otherwise specified in this section.
(ii) Geographic wage reclassification. If a hospital
becomes eligible for the geographic wage reclassification under Medicare,
the hospital will become eligible for the adjustment upon the next
realignment.
(iii) Medical education add-on during fiscal year.
If an existing hospital has a change in its medical education operating
adjustment factor under Medicare, the hospital will become eligible
for the adjustment to its medical education add-on upon the next realignment.
(iv) New medical education add-on. If a hospital becomes
eligible for the medical education add-on after the most recent realignment:
(I) the hospital will receive a medical education add-on,
effective for claims that have a date of discharge occurring on or
after the first day of the next state fiscal year; and
(II) HHSC will calculate the add-on using the impact
file in effect at the time the hospital initially claims eligibility
for the medical education add-on; and
(III) this amount will remain fixed until the next
realignment.
(B) Geographic wage add-on.
(i) Designated impact file. Subsequent add-ons will
be based on the impact file available at the time of realignment.
(ii) Wage index. To determine an urban geographic wage
add-on, HHSC first calculates a wage index for Texas as follows.
(I) HHSC identifies the Medicare wage index factor
for each CBSA in Texas;
(II) HHSC identifies the lowest Medicare wage index
factor in Texas;
(III) HHSC divides the Medicare wage index factor identified
in subclause (I) of this clause for each CBSA by the lowest Medicare
wage index factor identified in subclause (II) of this clause and
subtracts one from each resulting quotient.
(iii) County assignment. HHSC will initially assign
a hospital to a CBSA based on the county in which the hospital is
located. A hospital that has been approved for geographic reclassification
under Medicare may request that HHSC recognize its Medicare CBSA reclassification
under the process described in subparagraph (F) of this paragraph.
(iv) Medicare labor-related percentage. HHSC uses the
Medicare labor-related percentage available at the time of realignment.
(v) Geographic wage add-on calculation. The final geographic
wage add-on is equal to the product of the base SDA calculated in
subsection (d)(2)(B) of this section, the wage index calculated in
clause (ii)(III) of this subparagraph, and the Medicare labor-related
percentage in clause (iv) of this subparagraph.
(C) Medical education add-on.
(i) Eligibility. If an urban hospital meets the definition
of a teaching hospital, as defined in subsection (b) of this section,
it is eligible for the medical education add-on. Each hospital is
required to confirm, under the process described in subparagraph (F)
of this paragraph, that HHSC's determination of the hospital's eligibility
and medical education operating adjustment factor under Medicare for
the add-on is correct.
(ii) Add-on amount. HHSC multiplies the base SDA calculated
in subsection (d)(2)(B) of this section by the hospital's Medicare
education adjustment factor to determine the hospital's medical education
add-on amount.
(D) Trauma add-on.
(i) Eligibility.
(I) If an urban hospital meets the definition of a
trauma hospital, as defined in subsection (b) of this section, it
is eligible for a trauma add-on.
(II) HHSC initially uses the trauma level designation
associated with the physical address of a hospital's TPI. A hospital
may request that HHSC, under the process described in subparagraph
(F) of this paragraph use a higher trauma level designation associated
with a physical address other than the hospital's TPI address.
(ii) Add-on amount. To determine the trauma add-on
amount, HHSC multiplies the base SDA:
(I) by 28.3 percent for hospitals with Level 1 trauma
designation;
(II) by 18.1 percent for hospitals with Level 2 trauma
designation;
(III) by 3.1 percent for hospitals with Level 3 trauma
designation; or
(IV) by 2.0 percent for hospitals with Level 4 trauma
designation.
(iii) Reconciliation with other reimbursement for uncompensated
trauma care. Subject to General Appropriations Act and other applicable
law:
(I) if a hospital's allocation from the trauma facilities
and emergency medical services account administered under Texas Health
and Safety Code Chapter 780, is greater than the total trauma add-on
amount estimated to be paid to the hospital under this section during
the state fiscal year, the Department of State Health Services will
pay the hospital the difference between the two amounts at the time
funds are disbursed from that account to eligible trauma hospitals;
and
(II) if a hospital's allocation from the trauma facilities
and emergency medical services account is less than the total trauma
add-on amount estimated to be paid to the hospital under this section
during the state fiscal year, the hospital will not receive a payment
from the trauma facilities and emergency medical services account.
(E) Safety-Net add-on.
(i) Eligibility. If an urban 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.
Cont'd... |
