| (a) Introduction. The Texas Health and Human Services
Commission (HHSC) uses the methodology described in this section to
calculate reimbursement for a covered inpatient hospital service.
(b) Definitions.
(1) Add-on--An amount that is added to the base Standard
Dollar Amount (SDA) to reflect high-cost functions and services or
regional cost differences.
(2) Adjudicated--The approval or denial of an inpatient
hospital claim by HHSC.
(3) Base standard dollar amount (base SDA)--A standardized
payment amount calculated by HHSC, as described in subsections (c)
and (d) of this section, for the costs incurred by prospectively paid
hospitals in Texas for furnishing covered inpatient hospital services.
(4) Base year--For the purpose of this section, the
base year is a state fiscal year (September through August) to be
determined by HHSC.
(5) Base year claims--For the purposes of rate setting
(including Diagnosis-related group (DRG) relative weights, Mean length
of stay (MLOS) and Days Thresholds, and rebasing or realignment of
base rates) effective September 1, 2021, and after HHSC includes Medicaid
inpatient fee-for-service (FFS) and Managed Care Organization (MCO)
encounters that meet the criteria in subparagraphs (A) - (F) of this
paragraph in the Base Year claims data. For base rates set prior to
September 1, 2021, individual sets of base year claims are compiled
for children's hospitals and urban hospitals for the purposes of rate
setting and realignment. All Medicaid inpatient fee-for-service (FFS)
and Primary Care Case Management (PCCM) inpatient hospital claims
for reimbursement filed by an urban or children's hospital that:
(A) had a date of admission occurring within the base
year;
(B) were adjudicated and approved for payment during
the base year and the six-month grace period that immediately followed
the base year, except for such claims that had zero inpatient days;
(C) were not claims for patients who are covered by
Medicare;
(D) were not Medicaid spend-down claims;
(E) were not claims associated with military hospitals,
out-of-state hospitals, state-owned teaching hospitals, and freestanding
psychiatric hospitals; and
(F) individual sets of base year claims are compiled
for children's hospitals and urban hospitals for the purposes of rate
setting and rebasing.
(6) Children's hospital--A Medicaid hospital designated
by Medicare as a children's hospital and exempted by Centers for Medicare
and Medicaid Services (CMS) from the Medicare prospective payment
system.
(7) Cost outlier payment adjustment--A payment adjustment
for a claim with extraordinarily high costs.
(8) Cost outlier threshold--One factor used in determining
the cost outlier payment adjustment.
(9) Day outlier payment adjustment--A payment adjustment
for a claim with an extended length of stay.
(10) Day outlier threshold--One factor used in determining
the day outlier payment adjustment.
(11) Diagnosis-related group (DRG)--The classification
of medical diagnoses as defined in the 3MTM All
Patient Refined Diagnosis Related Group (APR-DRG) system or as otherwise
specified by HHSC. Each DRG has four digits. The last digit of the
Diagnosis-Related Group is the Severity of Illness (SOI). SOI indicates
the seriousness of the condition on a scale of one to four: minor,
moderate, major, or extreme. SOI may increase if secondary diagnoses
are present, in addition to the primary diagnosis.
(12) Final settlement--Reconciliation of Medicaid cost
in the CMS form 2552-10 hospital fiscal year end cost report performed
by HHSC within six months after HHSC receives the cost report audited
by a Medicare intermediary, or HHSC.
(13) Final standard dollar amount (final SDA)--The
rate assigned to a hospital after HHSC applies the add-ons and other
adjustments described in this section.
(14) Geographic wage add-on--An adjustment to a hospital's
base SDA to reflect geographical differences in hospital wage levels.
Hospital geographical areas correspond to the Core-Based Statistical
Areas (CBSAs) established by the federal Office of Management and
Budget in 2003.
(15) HHSC--The Texas Health and Human Services Commission,
or its designee.
(16) Impact file--The Inpatient Prospective Payment
System (IPPS) Final Rule Impact File that contains data elements by
provider used by the CMS in calculating Medicare rates and impacts.
The impact file is publicly available on the CMS website.
(17) Inflation update factor--Cost of living index
based on the annual CMS Prospective Payment System Hospital Market
Basket Index.
(18) Inpatient Ratio of cost-to-charge (RCC)--A ratio
that covers all applicable Medicaid hospital costs and charges relating
to inpatient care.
(19) In-state children's hospital--A hospital located
within Texas that is recognized by Medicare as a children's hospital
and is exempted by Medicare from the Medicare prospective payment
system.
(20) Interim payment--An initial payment made to a
hospital that is later settled to Medicaid-allowable costs, for hospitals
reimbursed under methods and procedures in the Tax Equity and Fiscal
Responsibility Act of 1982 (TEFRA).
(21) Interim rate--The ratio of Medicaid allowed inpatient
costs to Medicaid allowed inpatient charges filed on a hospital's
cost report, expressed as a percentage. The interim rate established
during a cost report settlement for an urban hospital or a rural hospital
reimbursed under this section excludes the application of TEFRA target
caps and the resulting incentive and penalty payments.
(22) Managed Care Organization (MCO) Adjustment Factor--Factor
used to estimate managed care premium tax, risk margin, and administrative
costs related to contracting with HHSC. The estimated amounts are
subtracted from appropriations.
(23) Mean length of stay (MLOS)--One factor used in
determining the payment amount calculated for each DRG; the average
number of inpatient days per DRG.
(24) Medical education add-on--An adjustment to the
base SDA for an urban teaching hospital to reflect higher patient
care costs relative to non-teaching urban hospitals.
(25) Military hospital--A hospital operated by the
armed forces of the United States.
(26) New Hospital--A hospital that was enrolled as
a Medicaid provider after the end of the base year and has no base
year claims data.
(27) Out-of-state children's hospital--A hospital located
outside of Texas that is recognized by Medicare as a children's hospital
and is exempted by Medicare from the Medicare prospective payment
system.
(28) Realignment--Recalculation of the base SDA and
add-ons using current RCCs, inflation factors, and base year claims
as specified by HHSC, or its designee, for one or more hospital types.
Realignment will occur based on legislative direction.
(29) Rebasing--Calculation of all SDAs and add-ons,
DRG relative weights, MLOS, and day outlier thresholds for all hospitals
using a base period as specified by HHSC, or its designee. Rebasing
will occur based on legislative direction.
(30) Relative weight--The weighting factor HHSC assigns
to a DRG representing the time and resources associated with providing
services for that DRG.
(31) Rural base year stays--An individual set of base
year stays is compiled for rural hospitals for the purposes of rate
setting and realignment. All inpatient FFS claims and inpatient managed
care encounters for reimbursement filed by a rural hospital that:
(A) had a date of admission occurring within the base
year;
(B) were adjudicated and approved for payment during
the base year or the six-month period that immediately followed the
base year, except for such stays that had zero inpatient days;
(C) were not stays for patients who are covered by
Medicare; and
(D) were not Medicaid spend-down stays; and were not
stays associated with military hospitals, out-of-state hospitals,
state-owned teaching hospitals, and freestanding psychiatric hospitals.
(32) Rural hospital--A hospital enrolled as a Medicaid
provider that:
(A) is located in a county with 68,750 or fewer persons
according to the 2020 U.S. Census;
(B) is designated by Medicare as a Critical Access
Hospital (CAH), a Sole Community Hospital (SCH), or a Rural Referral
Center (RRC) that is not located in a Metropolitan Statistical Area
(MSA), as defined by the U.S. Office of Management and Budget; or
(C) meets all of the following:
(i) has 100 or fewer beds;
(ii) is designated by Medicare as a CAH, a SCH, or
a RRC; and
Cont'd... |
