| (II) Inpatient routine cost center cost. For each Medicaid
payor type and the uninsured, HHSC will multiply the Medicaid inpatient
cost per day for each routine cost center from subclause (I) of this
clause times the number of inpatient days for each routine cost center
from the data year to determine the inpatient routine cost for each
cost center.
(III) Total inpatient routine cost. For each Medicaid
payor type and the uninsured, HHSC will sum the inpatient routine
costs for the various routine cost centers from subclause (II) of
this clause to determine the total inpatient routine cost.
(iii) Determining inpatient and outpatient ancillary
costs.
(I) Inpatient and outpatient Medicaid cost-to-charge
ratio for ancillary cost centers. Using data from the Medicaid cost
report, HHSC will divide the allowable ancillary cost by the sum of
the inpatient and outpatient charges for each ancillary cost center
to determine a Medicaid cost-to-charge ratio for each ancillary cost
center.
(II) Inpatient and outpatient ancillary cost center
cost. For each Medicaid payor type and the uninsured, HHSC will multiply
the cost-to-charge ratio for each ancillary cost center from subclause
(I) of this clause by the ancillary charges for inpatient claims and
the ancillary charges for outpatient claims from the data year to
determine the inpatient and outpatient ancillary cost for each cost
center.
(III) Total inpatient and outpatient ancillary cost.
For each Medicaid payor type and the uninsured, HHSC will sum the
ancillary inpatient and outpatient costs for the various ancillary
cost centers from subclause (II) of this clause to determine the total
ancillary cost.
(iv) Determining total Medicaid and uninsured cost.
For each Medicaid payor type and the uninsured, HHSC will sum the
result of clause (ii)(III) of this subparagraph and the result of
clause (iii)(III) of this subparagraph plus organ acquisition costs
to determine the total cost.
(D) Calculation of the state payment cap.
(i) Total hospital cost. HHSC will sum the total cost
by Medicaid payor type and the uninsured from subparagraph (C)(iv)
of this paragraph to determine the total hospital cost for Medicaid
and the uninsured.
(ii) State payment cap.
(I) HHSC will reduce the total hospital cost under
clause (i) of this subparagraph by total payments as follows:
(-a-) For program periods beginning on or after October
1, 2019, from all payor sources, including graduate medical services
and out-of-state payments.
(-b-) For program periods beginning on or after October
1, 2017, and ending on or before September 30, 2019, payments for
inpatient and outpatient claims, under Title XIX of the Social Security
Act, including graduate medical services and out-of-state payments,
and payments on behalf of the uninsured; and
(-c-) For program periods beginning on or after October
1, 2013 and ending on or before September 30, 2017, from all payor
sources, including graduate medical services and out-of-state payments,
excluding third-party commercial insurance payors for inpatient and
outpatient claims.
(II) HHSC will not reduce the total hospital cost under
clause (i) of this subparagraph by supplemental payments (including
upper payment limit payments), or uncompensated-care waiver payments
for the data year to determine the state payment cap. HHSC may reduce
the total hospital cost by supplemental payments or uncompensated-care
waiver payments (excluding payments associated with pharmacies, clinics,
and physicians) attributed to the hospital for the program year if
necessary to prevent total interim payments to a hospital for the
program year from exceeding the state payment cap for that program
year.
(E) Inflation adjustment.
(i) HHSC will trend each hospital's state payment cap
using the inflation update factor.
(ii) HHSC will trend each hospital's state payment
cap from the midpoint of the data year to the midpoint of the program
year.
(2) Hospital-specific limit.
(A) HHSC will calculate the individual components of
a hospital's hospital-specific limit using the calculation set out
in paragraph (1)(A) - (D)(ii)(I)(-a-) of this subsection, except that
HHSC will:
(i) use information from the hospital's Medicaid cost
report(s) that cover the program year and from cost settlement payment
or recoupment amounts attributable to the program year for the calculations
described in paragraphs (1)(C)(ii)(I) and (1)(C)(iii)(I) of this subsection.
If a hospital has two or more Medicaid cost reports that cover the
program year, the data from each cost report will be pro-rated based
on the number of months from each cost report period that fall within
the program year;
(ii) include supplemental payments (including upper
payment limit payments) and uncompensated-care waiver payments (excluding
payments associated with pharmacies, clinics, and physicians) attributable
to the hospital for the program year when calculating the total payments
to be subtracted from total costs as described in paragraph (1)(D)(ii)(I)(-a-)
of this subsection;
(iii) use the hospital's actual charges and payments
for services described in paragraph (1)(A) and (B) of this subsection
provided to Medicaid-eligible and uninsured patients during the program
year; and
(iv) include charges and payments for claims submitted
after the 95-day filing deadline for Medicaid-allowable services provided
during the program year unless such claims were submitted after the
Medicare filing deadline.
(B) For payments to a hospital under the DSH program,
the hospital-specific limit will be calculated at the time of the
independent audit conducted under §355.8065(o) of this title.
(d) Due date for DSH or non-DSH survey.
(1) HHSC Rate Analysis must receive a hospital's completed
survey no later than 30 calendar days from the date of HHSC's written
request to the hospital for the completion of the survey, unless an
extension is granted as described in paragraph (2) of this subsection.
(2) HHSC Rate Analysis will extend this deadline provided
that HHSC receives a written request for the extension by email no
later than 30 calendar days from the date of the request for the completion
of the survey.
(3) The extension gives the requester a total of 45
calendar days from the date of the written request for completion
of the survey.
(4) If a deadline described in paragraph (1) or (3)
of this subsection is a weekend day, national holiday, or state holiday,
then the deadline for submission of the completed survey is the next
business day.
(5) HHSC will not accept a survey or request for an
extension that is not received by the stated deadline. A hospital
whose survey or request for extension is not received by the stated
deadline will be ineligible for DSH or uncompensated-care waiver payments
for that program year.
(e) Verification and right to request a review of data.
This subsection applies to calculations under this section beginning
with calculations for program year 2014.
(1) Claim adjudication. Medicaid participating hospitals
are responsible for resolving disputes regarding adjudication of Medicaid
claims directly with the appropriate Medicaid contractors as claims
are adjudicated. The review of data described under paragraph (2)
of this subsection is not the appropriate venue for resolving disputes
regarding adjudication of claims.
(2) Request for review of data.
(A) HHSC will pre-populate certain fields in the DSH
or non-DSH survey, including data from its Medicaid contractors.
(i) A hospital may request that HHSC review any data
in the hospital's DSH or non-DSH survey that is pre-populated by HHSC.
(ii) A hospital may not request that HHSC review self-reported
data included in the DSH or non-DSH survey by the hospital.
(B) A hospital must submit via email a written request
for review and all supporting documentation to HHSC Hospital Rate
Analysis within 30 days following the distribution of the pre-populated
DSH or non-DSH survey to the hospital by HHSC. The request must allege
the specific data omissions or errors that, if corrected, would result
in a more accurate HSL.
(3) HHSC's review.
(A) HHSC will review the data that is the subject of
a hospital's request. The review is:
(i) limited to the hospital's allegations that data
is incomplete or incorrect;
(ii) supported by documentation submitted by the hospital
or by the Medicaid contractor;
(iii) solely a data review; and
(iv) not an adversarial hearing.
(B) HHSC will notify the hospital of the results of
the review.
Cont'd... |
