| (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:
(-a-) For each provider, HHSC will calculate an overage
amount to equal the difference between the IGT-supported maximum uncompensated-care
payment amount for the demonstration year from subclause (II) of this
clause and their capped payment amount for the demonstration year
from clause (i) of this subparagraph. Unfunded cap room from subclause
(IV) of this clause will be distributed to these providers based on
each provider's overage as a percentage of the pool-wide overage.
(-b-) For each provider, the provider's revised maximum
uncompensated-care payment amount for the payment period is equal
to the sum of its capped payment amount from clause (i) of this subparagraph
and its portion of its pool's unfunded cap room from item (-a-) of
this subclause less its prior period payments from subparagraph (B)(i)
of this paragraph.
(E) Once reductions to ensure that uncompensated-care
expenditures do not exceed the aggregate limit for the demonstration
year for the pool are calculated, HHSC will not re-calculate the resulting
payments for any provider for the demonstration year, including if
the IGT commitments upon which the reduction calculations were based
are different than actual IGT amounts.
(F) Notwithstanding the calculations described in subparagraphs
(A) - (E) of this paragraph, if the payment period is the final payment
period for the demonstration year, to the extent the payment is supported
by IGT, each rural hospital is guaranteed a payment at least equal
to its interim hospital specific limit from paragraph (2)(A) of this
subsection multiplied by the value from subsection (f)(2)(B)(i)(I)
of this section for the demonstration year less any prior period payments.
If this guarantee will cause payments for a pool to exceed the aggregate
pool limit, the reduction required to stay within the pool limit will
be distributed proportionally across all non-rural and non-urban RRC
providers in the pool based on each provider's resulting payment from
subparagraphs (A) - (E) of this paragraph as compared to the payments
to all non-rural and non-urban RRC hospitals in the pool resulting
from subparagraphs (A) - (E) of this paragraph.
(G) Notwithstanding the calculations described in subparagraphs
(A) - (E) of this paragraph, if the payment period is the final payment
period for the demonstration year, to the extent the payment is supported
by IGT, each urban RRC is guaranteed a payment at least equal to its
interim hospital specific limit from paragraph (2)(A) of this subsection
multiplied by 54% for the demonstration year less any prior period
payments. If this guarantee will cause payments for a pool to exceed
the aggregate pool limit, the reduction required to stay within the
pool limit will be distributed proportionally across all non-rural
and non-urban RRC providers in the pool based on each provider's resulting
payment from subparagraphs (A) - (E) of this paragraph as compared
to the payments to all non-rural and non-urban RRC hospitals in the
pool resulting from subparagraphs (A) - (E) of this paragraph.
(6) 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.
(7) 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 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 (5)(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.
Cont'd... |
