| (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.
(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 aggregate
limit 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
aggregate limit for the pool, each provider in the pool is eligible
to receive their maximum uncompensated-care payment for the payment
period from subparagraph (B)(ii) of this paragraph without any reduction
to remain within the pool aggregate limit.
(D) If the cumulative maximum payment amount for the
pool from subparagraph (B)(iii) of this paragraph is more than the
aggregate limit 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) HHSC will calculate a capped payment amount equal
to the product of the 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) If the payment period is not the final payment
period for the demonstration year, the revised maximum uncompensated-care
payment for the payment period equals the lesser of:
(I) the maximum uncompensated-care payment for the
payment period from subparagraph (B)(ii) of this paragraph; or
(II) the difference between the capped payment amount
from clause (i) of this subparagraph and the prior period payments
from subparagraph (B)(i) of this paragraph.
(iii) If the payment period is the final payment period
for the demonstration year:
(I) HHSC will calculate an IGT-supported maximum uncompensated-care
payment for the payment period equal to the amount of the maximum
uncompensated-care payment for the payment period from subparagraph
(B)(ii) of this paragraph that is supported by an IGT commitment.
(-a-) For hospitals and physician group practices,
HHSC will obtain from each RHP anchor a current breakdown of IGT commitments
from all governmental entities, including governmental entities outside
of the RHP, that will be providing IGTs for uncompensated-care payments
for each hospital and physician group practice within the RHP that
is eligible for such payments for the payment period.
(-b-) Ambulance and dental providers will be assumed
to have commitments for 100 percent of the non-federal share of their
payments. The non-federal share for ambulance providers is provided
through certified public expenditures (CPEs); for ambulance providers,
references to IGTs in this subsection should be read as references
to CPEs.
(II) HHSC will calculate an IGT-supported maximum uncompensated-care
payment for the demonstration year to equal the IGT-supported maximum
uncompensated-care payment for the payment period from subclause (I)
of this clause plus the provider's prior period payments from subparagraph
(B)(i) of this paragraph.
(III) For providers with an IGT-supported maximum uncompensated-care
payment amount for the demonstration year from subclause (II) of this
clause that is less than or equal to their capped payment amount from
clause (i) of this subparagraph, the provider's revised maximum uncompensated-care
payment for the payment period equals the IGT-supported maximum uncompensated-care
payment amount for the payment period from subclause (I) of this clause.
For these providers, the difference between their capped payment amount
from clause (i) of this subparagraph and their IGT-supported maximum
uncompensated-care payment amount for the demonstration year from
subclause (II) of this clause is their unfunded cap room.
(IV) HHSC will sum all unfunded cap room from subclause
(III) of this clause to determine the total unfunded cap room for
the pool.
(V) For providers with an IGT-supported maximum uncompensated-care
payment amount for the demonstration year from subclause (II) of this
clause that is greater than their capped payment amount from clause
(i) of this subparagraph, the provider's revised maximum uncompensated-care
payment amount for the payment period is calculated as follows:
Cont'd... |
