(47) Urban public hospital - Class one--A hospital
that is owned and operated by one of the following entities: the Dallas
County Hospital District, the El Paso County Hospital District, the
Harris County Hospital District, the Tarrant County Hospital District,
or the University Health System of Bexar County.
(48) Urban public hospital - Class two--A hospital
operated by or under a lease contract with one of the following entities:
the Ector County Hospital District, the Lubbock County Hospital District,
or the Nueces County Hospital District.
(c) Eligibility. To be eligible to participate in the
DSH program, a hospital must:
(1) be enrolled as a Medicaid hospital in the State
of Texas;
(2) have received a Medicaid payment for an inpatient
claim, other than a claim for a dually eligible patient, that was
adjudicated during the relevant DSH data year; and
(3) apply annually by completing the application packet
received from HHSC by the deadline specified in the packet.
(A) Only a hospital that meets the condition specified
in paragraph (2) of this subsection will receive an application packet
from HHSC.
(B) The application may request self-reported data
that HHSC deems necessary to determine each hospital's eligibility.
HHSC may audit self-reported data.
(C) A hospital that fails to submit a completed application
by the deadline specified by HHSC will not be eligible to participate
in the DSH program in the year being applied for or to appeal HHSC's
decision.
(D) For purposes of DSH eligibility, a multi-site hospital
is considered one provider unless it submits separate Medicaid cost
reports for each site. If a multi-site hospital submits separate Medicaid
cost reports for each site, for purposes of DSH eligibility, it must
submit a separate DSH application for each site.
(E) HHSC will consider a merger of two or more hospitals
for purposes of the DSH program for any hospital that submits documents
verifying the merger status with Medicare prior to the deadline for
submission of the DSH application. Otherwise, HHSC will determine
the merged entity's eligibility for the subsequent DSH program year.
Until the time that the merged hospitals are determined eligible for
payments as a merged hospital, each of the merging hospitals will
continue to receive any DSH payments to which it was entitled prior
to the merger.
(d) Qualification. For each DSH program year, in addition
to meeting the eligibility requirements, applicants must meet at least
one of the following qualification criteria, which are determined
using information from a hospital's application, from HHSC, or from
HHSC's Medicaid contractors, as specified by HHSC:
(1) Medicaid inpatient utilization rate. A hospital's
Medicaid inpatient utilization rate is calculated by dividing the
hospital's total Medicaid inpatient days by its total inpatient census
days for the DSH data year.
(A) A hospital located outside an MSA or PMSA must
have a Medicaid inpatient utilization rate greater than the mean Medicaid
inpatient utilization rate for all Medicaid hospitals.
(B) A hospital located inside an MSA or PMSA must have
a Medicaid inpatient utilization rate that is at least one standard
deviation above the mean Medicaid inpatient utilization rate for all
Medicaid hospitals.
(2) Low-income utilization rate. A hospital must have
a low-income utilization rate greater than 25 percent.
(A) The low-income utilization rate is the sum (expressed
as a percentage) of the fractions calculated in clauses (i) and (ii)
of this subparagraph:
(i) The sum of the total Medicaid inpatient hospital
payments and the total state and local payments paid to the hospital
for inpatient care in the DSH data year, divided by a hospital's gross
inpatient revenue multiplied by the hospital's ratio of cost-to-charges
(inpatient only) for the same period: (Total Medicaid Inpatient Hospital
Payments + Total State and Local Payments)/(Gross Inpatient Revenue
x Ratio of Costs to Charges (inpatient only)).
(ii) Inpatient charity charges in the DSH data year
minus the amount of payments for inpatient hospital services received
directly from state and local governments, excluding all Medicaid
payments, in the DSH data year, divided by the gross inpatient revenue
in the same period: (Total Inpatient Charity Charges - Total State
and Local Payments)/Gross Inpatient Revenue).
(B) HHSC will determine the ratio of cost-to-charges
(inpatient only) by using information from the appropriate worksheets
of each hospital's Medicaid cost report or reports that correspond
to the DSH data year. In the absence of a Medicaid cost report for
that period, HHSC will use the latest available submitted Medicaid
cost report or reports.
(3) Total Medicaid inpatient days.
(A) A hospital must have total Medicaid inpatient days
at least one standard deviation above the mean total Medicaid inpatient
days for all hospitals participating in the Medicaid program, except;
(B) A hospital in a county with a population of 290,000
persons or fewer, according to the most recent decennial census, must
have total Medicaid inpatient days at least 70 percent of the sum
of the mean total Medicaid inpatient days for all hospitals in this
subset plus one standard deviation above that mean.
(C) Days for dually eligible patients are not included
in the calculation of total Medicaid inpatient days under this paragraph.
(4) Children's hospitals, state-owned hospitals, and
state chest hospitals. Children's hospitals, state-owned hospitals,
state chest hospitals, and State IMDs that do not otherwise qualify
as disproportionate share hospitals under this subsection will be
deemed to qualify. A hospital deemed to qualify must still meet the
eligibility requirements under subsection (c) of this section and
the conditions of participation under subsection (e) of this section.
(5) Merged hospitals. Merged hospitals are subject
to the application requirement in subsection (c)(3)(E) of this section.
HHSC will aggregate the data used to determine qualification under
this subsection from the merged hospitals to determine whether the
single Medicaid provider that results from the merger qualifies as
a Medicaid disproportionate share hospital.
(6) Hospitals that held a single Medicaid provider
number during the DSH data year, but later added one or more Medicaid
provider numbers. Upon request, HHSC will apportion the Medicaid DSH
funding determination attributable to a hospital that held a single
Medicaid provider number during the DSH data year (data year hospital),
but subsequently added one or more Medicaid provider numbers (new
program year hospital(s)) between the data year hospital and its associated
new program year hospital(s). In these instances, HHSC will apportion
the Medicaid DSH funding determination for the data year hospital
between the data year hospital and the new program year hospital(s)
based on estimates of the division of Medicaid inpatient and low income
utilization between the data year hospital and the new program year
hospital(s) for the program year, so long as all affected providers
satisfy the Medicaid DSH conditions of participation under subsection
(e) of this section and qualify as separate hospitals under subsection
(d) of this section based on HHSC's Medicaid DSH qualification criteria
in the applicable Medicaid DSH program year. In determining whether
the new program year hospital(s) meet the Medicaid DSH conditions
of participation and qualification, proxy program year data may be
used.
(e) Conditions of participation. HHSC will require
each hospital to meet and continue to meet for each DSH program year
the following conditions of participation:
(1) Two-physician requirement.
(A) In accordance with Social Security Act §1923(e)(2),
a hospital must have at least two licensed physicians (doctor of medicine
or osteopathy) who have hospital staff privileges and who have agreed
to provide nonemergency obstetrical services to individuals who are
entitled to medical assistance for such services.
(B) Subparagraph (A) of this paragraph does not apply
if the hospital:
(i) serves inpatients who are predominantly under 18
years of age; or
(ii) was operating but did not offer nonemergency obstetrical
services as of December 22, 1987.
(C) A hospital must certify on the DSH application
that it meets the conditions of either subparagraph (A) or (B) of
this paragraph, as applicable, at the time the DSH application is
submitted.
(2) Medicaid inpatient utilization rate. At the time
of qualification and during the DSH program year, a hospital must
have a Medicaid inpatient utilization rate, as calculated in subsection
(d)(1) of this section, of at least one percent.
(3) Trauma system.
Cont'd... |