| (B) For each hospital not required by Medicare to submit
schedule S-10 of the CMS 2552-10 cost report, the hospital must report
its hospital charity-care charges for services provided to uninsured
patients for the hospital's cost reporting period ending in the calendar
year two years before the demonstration year on the uncompensated-care
application described in paragraph (1) of this subsection.
(i) The instructions for reporting eligible charity-care
costs in the application will be consistent with instructions contained
in schedule S-10.
(ii) An IMD may not report charity-care charges for
services provided during the data year to patients aged 21 through
64.
(4) Other eligible costs.
(A) In addition to inpatient and outpatient charity-care
costs, a hospital may also claim reimbursement under this section
for uncompensated charity care, as specified in the uncompensated-care
application, that is related to the following services provided to
uninsured patients who meet the hospital's charity-care policy:
(i) direct patient-care services of physicians and
mid-level professionals; and
(ii) certain pharmacy services.
(B) A payment under this section for the costs described
in subparagraph (A) of this paragraph are not considered inpatient
or outpatient Medicaid payments for the purpose of the DSH audit described
in §355.8065 of this subchapter.
(5) Adjustments. When submitting the uncompensated-care
application, a hospital may request that cost and payment data from
the data year be adjusted to reflect increases or decreases in costs
resulting from changes in operations or circumstances.
(A) A hospital:
(i) may request that costs not reflected on the as-filed
cost report, but which would be incurred for the demonstration year,
be included when calculating payment amounts; and
(ii) may request that costs reflected on the as-filed
cost report, but which would not be incurred for the demonstration
year, be excluded when calculating payment amounts.
(B) Documentation supporting the request must accompany
the application, and provide sufficient information for HHSC to verify
the link between the changes to the hospital's operations or circumstances
and the specified numbers used to calculate the amount of the adjustment.
(i) Such supporting documentation must include:
(I) a detailed description of the specific changes
to the hospital's operations or circumstances;
(II) verifiable information from the hospital's general
ledger, financial statements, patient accounting records or other
relevant sources that support the numbers used to calculate the adjustment;
and
(III) if applicable, a copy of any relevant contracts,
financial assistance policies or other policies/procedures that verify
the change to the hospital's operations or circumstances.
(ii) HHSC will deny a request if it cannot verify that
costs not reflected on the as-filed cost report will be incurred for
the demonstration year.
(C) Notwithstanding the availability of adjustments
impacting the cost and payment data described in this section, no
adjustments to the state payment cap will be considered for purposes
of Medicaid DSH payment calculations described in §355.8065 of
this subchapter.
(6) Reduction to stay within uncompensated-care pool
allocation amounts. Prior to processing uncompensated-care payments
for any payment period within a waiver demonstration year for any
uncompensated-care pool described in subsection (f)(2) of this section,
HHSC will determine if such a payment would cause total uncompensated-care
payments for the demonstration year for the pool to exceed the allocation
amount for the pool and will reduce the maximum uncompensated-care
payment amounts providers in the pool are eligible to receive for
that period as required to remain within the pool allocation amount.
(A) Calculations in this paragraph will be applied
to each of the uncompensated-care pools separately.
(B) HHSC will calculate the following data points:
(i) For each provider, prior period payments to equal
prior period uncompensated-care payments for the demonstration year.
(ii) For each provider, a maximum uncompensated-care
payment for the payment period to equal the sum of:
(I) the portion of the annual maximum uncompensated-care
payment amount calculated for that provider (as described in this
section and the sections referenced in subsection (f)(2)(B) of this
section) that is attributable to the payment period; and
(II) the difference, if any, between the portions of
the annual maximum uncompensated-care payment amounts attributable
to prior periods and the prior period payments calculated in clause
(i) of this subparagraph.
(iii) The cumulative maximum payment amount to equal
the sum of prior period payments from clause (i) of this subparagraph
and the maximum uncompensated-care payment for the payment period
from clause (ii) of this subparagraph for all members of the pool
combined.
(iv) A pool-wide total maximum uncompensated-care payment
for the demonstration year to equal the sum of all pool members' annual
maximum uncompensated-care payment amounts for the demonstration year
from paragraph (2) of this subsection.
(v) A pool-wide ratio calculated as the pool allocation
amount from subsection (f)(2) of this section divided by the pool-wide
total maximum uncompensated-care payment amount for the demonstration
year from clause (iv) of this subparagraph.
(C) If the cumulative maximum payment amount for the
pool from subparagraph (B)(iii) of this paragraph is less than the
allocation amount for the pool, each provider in the pool is eligible
to receive its maximum uncompensated-care payment for the payment
period from subparagraph (B)(ii) of this paragraph without any reduction
to remain within the pool allocation amount.
(D) If the cumulative maximum payment amount for the
pool from subparagraph (B)(iii) of this paragraph is more than the
allocation amount for the pool, HHSC will calculate a revised maximum
uncompensated-care payment for the payment period for each provider
in the pool as follows:
(i) The physician group practice pool, the governmental
ambulance provider pool, and the publicly owned dental provider pool.
HHSC will calculate a capped payment amount equal to the product of
each provider's annual maximum uncompensated-care payment amount for
the demonstration year from paragraph (2) of this subsection and the
pool-wide ratio calculated in subparagraph (B)(v) of this paragraph.
(ii) The non-state-owned hospital pool.
(I) For rural hospitals, HHSC will:
(-a-) sum the annual maximum uncompensated-care payment
amounts from paragraph (2) of this subsection for all rural hospitals
in the pool;
(-b-) in demonstration year:
(-1-) nine, set aside for rural hospitals the amount
calculated in item (-a-) of this subclause; or
(-2-) ten and after, set aside for rural hospitals
the lesser of the amount calculated in item (-a-) of this subclause
or the amount set aside for rural hospitals in demonstration year
nine;
(-c-) calculate a ratio to equal the rural hospital
set-aside amount from item (-b-) of this subclause divided by the
total annual maximum uncompensated-care payment amount for rural hospitals
from item (-a-) of this subclause; and
(-d-) calculate a capped payment amount equal to the
product of each rural hospital's annual maximum uncompensated-care
payment amount for the demonstration year from paragraph (2) of this
subsection and the ratio calculated in item (-c-) of this subclause.
(II) For non-rural hospitals, HHSC will:
(-a-) sum the annual maximum uncompensated-care payment
amounts from paragraph (2) of this subsection for all non-rural hospitals
in the pool;
(-b-) calculate an amount to equal the difference between
the pool allocation amount from subsection (f)(2) of this section
and the set-aside amount from subclause (I)(-b-) of this clause;
(-c-) calculate a ratio to equal the result from item
(-b-) of this subclause divided by the total annual maximum uncompensated-care
payment amount for non-rural hospitals from item (-a-) of this subclause;
and
(-d-) calculate a capped payment amount equal to the
product of each non-rural hospital's annual maximum uncompensated-care
payment amount for the demonstration year from paragraph (2) of this
subsection and the ratio calculated in item (-c-) of this subclause.
(III) The revised maximum uncompensated-care payment
for the payment period equals the lesser of:
(-a-) the maximum uncompensated-care payment for the
payment period from subparagraph (B)(ii) of this paragraph; or
Cont'd... |
