| (-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.
(E) If a partial year uncompensated-care application
was used to determine the preceding demonstration year's payments,
data from that application may be annualized for use in computation
of an advance payment amount.
(8) Payments of unspent funds.
(A) HHSC will use the methodology described in this
paragraph to calculate payment amounts to hospitals for uncompensated-care
payments that are made after July 31, 2020, using any remaining funding
for uncompensated-care program years beginning before October 1, 2017.
(B) The basis for each hospital's payment allocation
will be the total amount of payments received by the hospital in the
data year that are from a third-party payor for a Medicaid-enrolled
patient and associated with third-party coverage as defined in §355.8066
of this subchapter (relating to Hospital-Specific Limit Methodology).
(C) All hospitals' payment allocations will be based
on 100 percent of the amount described in subparagraph (B) of this
paragraph, except:
(i) Children's hospitals as defined in §355.8065
of this subchapter (related to Disproportionate Share Hospital Reimbursement
Methodology) will receive a payment allocation based on 150 percent
of the amount described in subparagraph (B) of this paragraph.
(ii) State-owned teaching hospitals, state-owned IMDs,
state chest hospitals, physician group practices, ambulance providers,
and dental providers will not receive a payment allocation under the
methodology described in this paragraph.
(D) Each hospital's payment amount will be allocated
by:
(i) applying the appropriate percentage described in
subparagraph (C) of this paragraph to the amount described in subparagraph
(B) of this paragraph;
(ii) dividing the amount calculated in clause (i) of
this subparagraph by the total amount of payments described in subparagraph
(B) of this paragraph for all participating hospitals; and
(iii) multiplying the amount in clause (ii) of this
subparagraph by the remaining uncompensated-care funding for the program
year.
(E) Each payment amount will be compared to actual
costs incurred by the hospital as determined by the reconciliation
calculated for the demonstration year, as described in subsection
(i) of this section.
(i) A hospital will receive the lesser of its actual
costs, as determined by the reconciliation calculated for the demonstration
year under subsection (i) of this section, or the hospital's allocation
described in subparagraph (D) of this paragraph.
(ii) If, following the determination described in clause
(i) of this subparagraph, there is funding remaining in the UC program
year, the remaining funding amounts will be placed into a second pool.
(iii) The second pool will be allocated to hospitals
that have not received UC payments that exceed their actual costs,
as determined by the reconciliation calculated for the demonstration
year under subsection (i) of this section after accounting for any
additional payment the hospital is receiving under the methodology
described in this paragraph. Any distribution under this subparagraph
will be allocated by:
(I) Dividing the hospital's total uncompensated-care
costs, as determined by the reconciliation calculated for the demonstration
year under subsection (i) of this section, by the total uncompensated-care
costs for all participating hospitals, as determined by the reconciliation
calculated for the demonstration year under subsection (i) of this
section; and
(II) Multiplying the amount described in subclause
(I) of this clause by the funding remaining in the uncompensated-care
program year after the distribution described in subparagraph (D)
of this paragraph.
(h) Payment methodology.
(1) Notice. Prior to making any payment described in
subsection (g) of this section, HHSC will give notice of the following
information:
(A) the payment amount for the payment period (based
on whether the payment is made quarterly, semi-annually, or annually);
(B) the maximum IGT amount necessary for a hospital
to receive the amount described in subparagraph (A) of this paragraph;
and
(C) the deadline for completing the IGT.
(2) Payment amount. The amount of the payment to a
hospital will be determined based on the amount of funds transferred
by the affiliated governmental entity or entities as follows:
(A) If the governmental entity transfers the maximum
amount referenced in paragraph (1) of this subsection, the hospital
will receive the full payment amount calculated for that payment period.
Cont'd... |
