| (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.
(B) If a governmental entity does not transfer the
maximum amount referenced in paragraph (1) of this subsection, HHSC
will determine the payment amount to each hospital owned by or affiliated
with that governmental entity as follows:
(i) At the time the transfer is made, the governmental
entity notifies HHSC, on a form prescribed by HHSC, of the share of
the IGT to be allocated to each hospital owned by or affiliated with
that entity and provides the non-federal share of uncompensated-care
payments for each entity with which it affiliates in a separate IGT
transaction; or
(ii) In the absence of the notification described in
clause (i) of this subparagraph, each hospital owned by or affiliated
with the governmental entity will receive a portion of its payment
amount for that period, based on the hospital's percentage of the
total payment amounts for all hospitals owned by or affiliated with
that governmental entity.
(C) For a hospital that is affiliated with multiple
governmental entities, in the event those governmental entities transfer
more than the maximum IGT amount that can be provided for that hospital,
HHSC will calculate the amount of IGT funds necessary to fund the
hospital to its payment limit and refund the remaining amount to the
governmental entities identified by HHSC.
(3) Final payment opportunity. Within payments described
in this section, a governmental entity that does not transfer the
maximum IGT amount described in paragraph (1) of this subsection during
a demonstration year will be allowed to fund the remaining payments
at the time of the final payment for that demonstration year. The
IGT will be applied in the following order:
(A) To the final payment up to the maximum amount;
(B) To remaining balances for prior payment periods
in the demonstration year.
(i) Reconciliation. HHSC will reconcile actual costs
incurred by the hospital for the demonstration year with uncompensated-care
payments, if any, made to the hospital for the same period:
(1) If a hospital received payments in excess of its
actual costs, the overpaid amount will be recouped from the hospital,
as described in subsection (j) of this section.
(2) If a hospital received payments less than its actual
costs, and if HHSC has available waiver funding for the demonstration
year in which the costs were accrued, the hospital may receive reimbursement
for some or all of those actual documented unreimbursed costs.
(3) If a hospital submitted a request as described
in subsection (g)(4)(A)(i) of this section that impacted its interim
hospital-specific limit, HHSC will conduct an additional reconciliation
for certain demonstration years as follows:
(A) For demonstration years 3-5 (October 1, 2013 -
September 30, 2016), HHSC will compare the hospital's adjusted interim
hospital-specific limit from subsection (g)(4)(A)(i) of this section
for the demonstration year to its final hospital-specific limit as
described in §355.8066(c)(2) of this title for the demonstration
year.
(B) For demonstration years 6-8 (October 1, 2016 -
September 30, 2019), HHSC will compare the hospital's adjusted interim
hospital-specific limit from subsection (g)(4)(A)(i) of this section
for the demonstration year to a proxy-final hospital-specific limit
that is described in §355.8066(c)(2) of this title for the demonstration
year, except this proxy-final hospital-specific limit will not offset
third-party and Medicare payments for claims and encounters where
Medicaid was a secondary payer.
(C) If the final hospital-specific limit for demonstration
years 3-5 or proxy-final hospital-specific limit for demonstration
years 6-8 limit is less than the adjusted interim hospital-specific
limit, HHSC will recalculate the hospital's uncompensated-care payment
for the demonstration year substituting the final hospital-specific
limit for demonstration years 3-5 or proxy-final hospital-specific
limit for demonstration years 6-8 for the adjusted interim hospital-specific
limit with no other changes to the data used in the original calculation
of the hospital's uncompensated-care payment other than any necessary
reductions to the original IGT amount and will recoup any payment
received by the hospital that is greater than the recalculated uncompensated-care
payment. Recouped funds may be redistributed to other hospitals that
received payments less than their actual costs using the methodology
described in subsection (k) of this section.
Cont'd... |
