| (-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;
(B) Other eligible costs for the data year, as described
in paragraph (3) of this subsection;
(C) Cost and payment adjustments, if any, as described
in paragraph (4) of this subsection; and
(D) For each hospital eligible for payments under subsection
(f)(2)(C)(i)(I) of this section, the amount transferred to HHSC by
that hospital's affiliated governmental entity to support DSH payments
for the same demonstration year.
(3) Other eligible costs.
(A) In addition to cost and payment data that is used
to calculate the hospital-specific limit, as described in §355.8066
of this title, a hospital may also claim reimbursement under this
section for uncompensated care, as specified in the uncompensated-care
application, that is related to the following services provided to
Medicaid-eligible and uninsured patients:
(i) direct patient-care services of physicians and
mid-level professionals;
(ii) pharmacy services; and
(iii) clinics.
(B) The 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 title.
(4) Adjustments. When submitting the uncompensated-care
application, hospitals 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;
(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. 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) In addition to being subject to the reconciliation
described in subsection (i)(1) of this section which applies to all
uncompensated-care payments for all hospitals, uncompensated-care
payments for hospitals that submitted a request as described in subparagraph
(A)(i) of this paragraph that impacted the interim hospital-specific
limit described in paragraph (2)(A) of this subsection will be subject
to the reconciliation described in subsection (i)(2) of this section.
(D) Notwithstanding the availability of adjustments
impacting the interim hospital-specific limit described in this paragraph,
no adjustments to the interim hospital-specific limit will be considered
for purposes of Medicaid DSH payment calculations described in §355.8065
of this title.
(5) Reduction to stay within uncompensated-care pool
aggregate limits. 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 aggregate
limit 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 aggregate limit.
(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)(C) 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.
Cont'd... |
