| (II) that are also urban RRCs, for DY 7 only, determine
the private urban RRC set-aside amount by multiplying by 54% the sum
of the interim hospital specific limits from subsection (g)(2)(A)
of this section for all private urban RRCs that are eligible to receive
uncompensated-care payments under this section and that meet the definition
of an urban RRC from subsection (b)(26) of this section. Truncate
the resulting value to zero decimal places.
(iii) Determine the total set-aside amount by summing
the results of subclauses (i)(I), (i)(II), (ii)(I), and (ii)(II) of
this subparagraph.
(C) Non-state-owned provider pools. HHSC will allocate
the remaining available uncompensated-care funds, if any, and the
set-aside amount among the non-state-owned provider pools as described
in this subparagraph. The remaining available uncompensated-care funds
equal the amount of funds approved by CMS for uncompensated-care payments
for the demonstration year less the sum of funds allocated to the
state-owned hospital pool under subparagraph (A) of this paragraph
and the set-aside amount from subparagraph (B) of this paragraph.
(i) HHSC will allocate the funds among non-state-owned
provider pools based on the following amounts:
(I) Large public hospitals:
(-a-) The sum of the interim hospital specific limits
from subsection (g)(2)(A) of this section for all large public hospitals,
as defined in subsection (b)(14) of this section, eligible to receive
uncompensated-care payments under this section; plus
(-b-) An amount equal to the IGTs transferred to HHSC
by large public hospitals to support DSH payments to themselves and
private hospitals for the same demonstration year.
(II) Small public hospitals:
(-a-) The sum of the interim hospital specific limits
from subsection (g)(2)(A) of this section for all non-rural and non-urban
RRC small public hospitals, as defined in subsection (b)(21) of this
section, eligible to receive uncompensated-care payments under this
section; plus
(-b-) An amount equal to the IGTs transferred to HHSC
by small public hospitals to support DSH payments to themselves for
Pass One and Pass Two payments for the same demonstration year.
(III) Private hospitals: The sum of the interim hospital
specific limits from subsection (g)(2)(A) of this section for all
non-rural and non-urban RRC private hospitals, as defined in subsection
(b)(16) of this section, eligible to receive uncompensated-care payments
under this section.
(IV) Physician group practices: The sum of the unreimbursed
uninsured costs and Medicaid shortfall for physician group practices,
as described in §355.8202(g)(2)(A) of this title (relating to
Waiver Payments to Physician Group Practices for Uncompensated Care).
(V) Governmental ambulance providers: The sum of the
uncompensated care costs multiplied by the federal medical assistance
percentage (FMAP) in effect during the cost reporting period for governmental
ambulance providers, as described in §355.8600 of this title
(relating to Reimbursement Methodology for Ambulance Services). Estimated
amounts may be used if actual data is not available at the time calculations
are performed.
(VI) Publicly-owned dental providers: The sum of the
total allowable cost minus any payments for publicly owned dental
providers, as described in §355.8441 of this title (relating
to Reimbursement Methodologies for Early and Periodic Screening, Diagnosis,
and Treatment (EPSDT) Services). Estimated amounts may be used if
actual data is not available at the time calculations are performed.
(ii) HHSC will sum the amounts calculated in clause
(i) of this subparagraph.
(iii) HHSC will calculate the aggregate limit for each
non-state-owned provider pool as follows:
(I) To determine the large public hospital pool aggregate
limit:
(-a-) multiply the remaining available uncompensated-care
funds, from this subparagraph, by the amount calculated in clause
(i)(I) of this subparagraph; and
(-b-) divide the result from item (-a-) of this subclause
by the amount calculated in clause (ii) of this subparagraph and truncate
to zero decimal places.
(II) To determine the small public hospital pool aggregate
limit:
(-a-) multiply the remaining available uncompensated-care
funds from this subparagraph by the amount calculated in clause (i)(II)
of this subparagraph;
(-b-) divide the result from item (-a-) of this subclause
by the amount calculated in clause (ii) of this subparagraph and truncate
to zero decimal places; and
(-c-) add the result from item (-b-) of this subclause
to the amount calculated in subparagraph (B)(ii) of this paragraph.
(III) To determine the private hospital pool aggregate
limit:
(-a-) multiply the remaining available uncompensated-care
funds from this subparagraph by the amount calculated in clause (i)(III)
of this subparagraph;
(-b-) divide the result from item (-a-) of this subclause
by the amount calculated in clause (ii) of this subparagraph and truncate
to zero decimal places; and
(-c-) add the result from item (-b-) of this subclause
to the amount calculated in subparagraph (B)(iii) of this paragraph.
(IV) To determine the physician group practice pool
aggregate limit:
(-a-) multiply the remaining available uncompensated-care
funds from this subparagraph by the amount calculated in clause (i)(IV)
of this subparagraph; and
(-b-) divide the result from item (-a-) of this subclause
by the amount calculated in clause (ii) of this subparagraph and truncate
to zero decimal places.
(V) To determine the maximum aggregate amount of the
estimated uncompensated care costs for all governmental ambulance
providers:
(-a-) multiply the remaining available uncompensated-care
funds from this subparagraph by the amount calculated in clause (i)(V)
of this subparagraph; and
(-b-) divide the result from item (-a-) of this subclause
by the amount calculated in clause (ii) of this subparagraph and truncate
to zero decimal places.
(VI) To determine the publicly owned dental providers
pool aggregate limit:
(-a-) multiply the remaining available uncompensated-care
funds from this subparagraph by the amount calculated in clause (i)(VI)
of this subparagraph; and
(-b-) divide the result from item (-a-) of this subclause
by the amount calculated in clause (ii) of this subparagraph and truncate
to zero decimal places.
(3) Payments made under this section are limited by
the availability of funds identified in subsection (d) of this section.
If sufficient funds are not available for all payments for which a
hospital is eligible, HHSC will reduce payments as described in subsection
(h)(2) of this section.
(g) Uncompensated-care payment amount.
(1) Application.
(A) Cost and payment data reported by the hospital
in the uncompensated-care application is used to calculate the annual
maximum uncompensated-care payment amount for the applicable demonstration
year, as described in paragraph (2) of this subsection.
(B) Unless otherwise instructed in the application,
the hospital must base the cost and payment data reported in the application
on its applicable as-filed CMS 2552 Cost Report(s) For Electronic
Filing Of Hospitals corresponding to the data year and must comply
with the application instructions or other guidance issued by HHSC.
(i) When the application requests data or information
outside of the as-filed cost report(s), the hospital must provide
all requested documentation to support the reported data or information.
(ii) For a new hospital, the cost and payment data
period may differ from the data year, resulting in the eligible uncompensated
costs based only on services provided after the hospital's Medicaid
enrollment date. HHSC will determine the data period in such situations.
(2) Calculation. A hospital's annual maximum uncompensated-care
payment amount is the sum of the components below. In no case can
the sum of payments made to a hospital for a demonstration year for
DSH and uncompensated-care payments, less the payments described in
paragraph (3) of this subsection, exceed a hospital's specific limit
as determined in §355.8066 of this title after modifications
to reflect the adjustments described in paragraph (4) of this subsection.
(A) The interim hospital specific limit, calculated
as described in §355.8066 of this title, except that an IMD may
not report cost and payment data in the uncompensated-care application
for services provided during the data year to Medicaid-eligible and
uninsured patients ages 21 through 64, less any payments to be made
under the DSH program for the same demonstration year, calculated
as described in §355.8065 of this title;
Cont'd... |
