| (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
(-b-) the difference between the capped payment amount
from subclause (I) or (II) of this clause and the prior period payments
from subparagraph (B)(i) of this paragraph.
(IV) HHSC will allocate to each non-state-owned hospital
the revised maximum uncompensated-care payment amount from subclause
(III) of this clause.
(7) Non-state-owned hospital SDA sub-pools. After HHSC
completes the calculations described in paragraph (6) of this subsection,
HHSC will place each non-state-owned hospital into a sub-pool based
on the hospital's geographic location in a designated Medicaid SDA
for purposes of the calculations described in subsection (h) of this
section.
(8) Prohibition on duplication of costs. Eligible uncompensated-care
costs cannot be reported on multiple uncompensated-care applications,
including uncompensated-care applications for other programs. Reporting
on multiple uncompensated-care applications is duplication of costs.
(9) Advance payments.
(A) In a demonstration year in which uncompensated-care
payments will be delayed pending data submission or for other reasons,
HHSC may make advance payments to hospitals that meet the eligibility
requirements described in subsection (c)(2) of this section and submitted
an acceptable uncompensated-care application for the preceding demonstration
year from which HHSC calculated an annual maximum uncompensated-care
payment amount for that year.
(B) The amount of the advance payments will:
(i) in demonstration year nine, be based on uninsured
charity-care costs reported by the hospital on schedule S-10 of the
CMS 2552-10 cost report used for purposes of sizing the UC pool, or
on documentation submitted for that purpose by each hospital not required
to submit schedule S-10 with their cost report; and
(ii) in demonstration years ten and after, be a percentage,
to be determined by HHSC, of the annual maximum uncompensated-care
payment amount calculated by HHSC for the preceding demonstration
year.
(C) Advance payments are considered to be prior period
payments as described in paragraph (6)(B)(i) of this subsection.
(D) A hospital that did not submit an acceptable uncompensated-care
application for the preceding demonstration year is not eligible for
an advance payment.
(E) If a partial year uncompensated-care application
was used to determine the preceding demonstration year's payments,
data from that application may be annualized for use in computation
of an advance payment amount.
(h) Payment methodology.
(1) Notice. Prior to making any payment described in
subsection (g) of this section, HHSC will give notice of the following
information:
(A) the payment amount for each hospital in a pool
or sub-pool for the payment period (based on whether the payment is
made quarterly, semi-annually, or annually);
(B) the maximum IGT amount necessary for hospitals
in a pool or sub-pool to receive the amounts described in subparagraph
(A) of this paragraph; and
(C) the deadline for completing the IGT.
(2) Payment amount. The amount of the payment to hospitals
in each pool or sub-pool will be determined based on the amount of
funds transferred by the affiliated governmental entities as follows:
(A) If the governmental entities transfer the maximum
amount referenced in paragraph (1) of this subsection, the hospitals
in the pool or sub-pool will receive the full payment amount calculated
for that payment period.
(B) If the governmental entities do not transfer the
maximum amount referenced in paragraph (1) of this subsection, each
hospital in the pool or sub-pool will receive a portion of its payment
amount for that period, based on the hospital's percentage of the
total payment amounts for all hospitals in the pool or sub-pool.
(3) Final payment opportunity. Within payments described
in this section, governmental entities that do not transfer the maximum
IGT amount described in paragraph (1) of this subsection during a
demonstration year will be allowed to fund the remaining payments
to hospitals in the pool or sub-pool at the time of the final payment
for that demonstration year. The IGT will be applied in the following
order:
(A) to the final payments up to the maximum amount;
and
Cont'd... |
