| (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.
(F) Add-on status verification.
(i) Notification. HHSC will determine a hospital's
initial add-on status by reference to the impact file available at
the time of realignment or at the time of eligibility for a new medical
education add-on as described in subparagraph (A)(iv) of this paragraph;
the Texas Department of State Health Services' list of trauma-designated
hospitals; and 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 education adjustment
factor assigned to the hospital for urban hospitals, the trauma level
designation assigned to the hospital, 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 the hospital associations
to disseminate to their member hospitals.
(ii) During 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, the HHSC
Provider Finance Department 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 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;
(III) the hospital provides documentation of its eligibility
for a different trauma designation; or
(IV) 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) Annually, HHSC will calculate a hospital's final
SDA 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) the hospital provides documentation of its eligibility
for a different trauma designation; 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.
(iv) 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) Urban hospital final SDA calculations. HHSC calculates
an urban hospital's final SDA as follows.
(A) Add all add-on amounts for which the hospital is
eligible to the base SDA. These are the fully funded final SDAs.
(B) Multiply the final SDA determined in subparagraph
(A) of this paragraph by each urban hospital's total relative weight
of the base year claims.
(C) Sum the amount calculated in subparagraph (B) of
this paragraph for all urban hospitals.
(D) Divide the total funds appropriated for reimbursing
inpatient urban hospital services under this section by the amount
determined in subparagraph (C) of this paragraph.
(E) To determine the budget-neutral final SDA:
(i) multiply the base SDA in paragraph (2) of this
subsection by the percentage determined in subparagraph (D) of this
paragraph;
(ii) multiply each of the add-ons described in paragraph
(3)(B)-(E) by the percentage determined in subparagraph (D) of this
paragraph; and
(iii) sum the results of clauses (i) and (ii) of this
subparagraph.
(F) For new urban hospitals for which HHSC has no base
year claim data, the final SDA is a base SDA plus any add-ons for
which the hospital is eligible, multiplied by the percentage determined
in subparagraph (D) of this paragraph.
(e) Rural hospital SDA calculations. HHSC will use
the methodologies described in this subsection to determine the final
SDA for each rural hospital.
(1) HHSC calculates the rural final SDA as follows.
(A) Base year cost. Calculate the total inpatient base
year cost per rural hospital.
(i) Total the inpatient charges by hospital for the
rural base year stays.
(ii) Multiply clause (i) by the hospital's inpatient
RCC and the inflation update factors to inflate the rural base year
stays to the current year of the realignment.
(B) Full-cost SDA. Calculate a hospital-specific full-cost
SDA by dividing each hospital's base year cost, calculated as described
in subparagraph (A) of this paragraph, by the sum of the relative
weights for the rural base year stays.
(C) Calculating the SDA floor and ceiling.
(i) Calculate the average adjusted hospital-specific
SDA from subparagraph (B) of this paragraph for all rural hospitals
with more than 50 claims.
(ii) Calculate the standard deviation of the hospital-specific
SDAs identified in subparagraph (B) of this paragraph for all rural
hospitals with more than 50 claims.
(iii) Calculate an SDA floor as clause (i) minus clause
(ii) multiplied by a factor, determined by HHSC to maintain budget
neutrality.
(iv) Calculate an SDA ceiling as clause (i) plus clause
(ii) multiplied by a factor, determined by HHSC to maintain budget
neutrality.
(D) Assigning a final hospital-specific SDA.
(i) If the adjusted hospital-specific SDA from subparagraph
(B) is less than the SDA floor in subparagraph (C)(iii) of this paragraph,
the hospital is assigned the SDA floor amount as the final SDA.
(ii) If the adjusted hospital-specific SDA from subparagraph
(B) is more than the SDA ceiling in subparagraph (C)(iv), the hospital
is assigned the SDA ceiling amount as the final SDA.
(iii) Assign the adjusted hospital-specific SDA as
the final SDA to each hospital not described in clauses (i) and (ii)
of this subparagraph.
(2) Alternate SDA for labor and delivery. For labor
and delivery services provided by rural hospitals on or after September
1, 2023, the final SDA is the alternate SDA for labor and delivery
stays, which is equal to the final SDA determined in paragraph (1)(D)
of this subsection plus an SDA add-on sufficient to increase paid
claims by no less than $1,500.
(3) HHSC calculates a new rural hospital's final SDA
as follows.
(A) For new rural hospitals for which HHSC has no base
year claim data, the final SDA is the mean rural SDA in paragraph
(1)(C)(i) of this subsection.
(B) The mean rural SDA assigned in subparagraph (A)
of this paragraph remains in effect until the next realignment.
(4) Minimum Fee Schedule. Effective March 1, 2021,
MCOs are required to reimburse rural hospitals based on a minimum
fee schedule. The minimum fee schedule is the rate schedule as described
above.
Cont'd... |
