| (ii) If the requirements of clause (i) are not met,
HHSC will not consider the merger for purposes of determining eligibility
or calculating a hospital's DSH program year payments under this section.
Until HHSC determines that the hospitals are 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. For purposes
of paragraph (2) of this section, the term "low-income utilization
rate" is calculated using the calculation described in 42 U.S.C. §1396r-4
(b)(3).
(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
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.
(B) Days for dually eligible patients are not included
in the calculation of total Medicaid inpatient days under this paragraph.
(4) State-owned hospitals. State-owned hospitals 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.
In accordance with requirements 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 with multiple Medicaid provider numbers.
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.
(A) The hospital must be in active pursuit of designation
or have obtained a trauma facility designation as defined in §780.004
and §§773.111 - 773.120, Texas Health and Safety Code, respectively,
and consistent with 25 TAC §157.125 (relating to Requirements
for Trauma Facility Designation) and §157.131 (relating to the
Designated Trauma Facility and Emergency Medical Services Account).
A hospital that has obtained its trauma facility designation must
maintain that designation for the entire DSH program year.
(B) HHSC will receive an annual report from the Office
of EMS/Trauma Systems Coordination regarding hospital participation
in regional trauma system development, application for trauma facility
designation, and trauma facility designation or active pursuit of
designation status before final qualification determination for interim
DSH payments. HHSC will use this report to confirm compliance with
this condition of participation by a hospital applying for DSH funds.
(C) The following hospital types are exempted from
the condition of participation described in this paragraph: Children's
Hospitals, IMDs, Public Health Hospitals, and State IMDs.
(4) Maintenance of local funding effort. A hospital
district in one of the state's largest MSAs or in a PMSA must not
reduce local tax revenues to its associated hospitals as a result
of disproportionate share funds received by the hospital. For this
provision to apply, the hospital must have more than 250 licensed
beds.
(5) Retention of and access to records. A hospital
must retain and make available to HHSC records and accounting systems
related to DSH data for at least five years from the end of each DSH
program year in which the hospital qualifies, or until an open audit
is completed, whichever is later.
(6) Compliance with audit requirements. A hospital
must agree to comply with the audit requirements described in subsection
(o) of this section.
(7) Merged hospitals. Merged hospitals are subject
to the application requirement in subsection (c)(3)(E) of this section.
If HHSC receives documents verifying the merger status with Medicare
prior to the deadline for submission of the DSH application, the merged
entity must meet all conditions of participation. If HHSC does not
receive the documents verifying the merger status with Medicare prior
to the deadline for submission of the DSH application, any proposed
merging hospitals that are receiving DSH payments must continue to
meet all conditions of participation as individual hospitals to continue
receiving DSH payments for the remainder of the DSH program year.
(8) Changes that may affect DSH participation. A hospital
receiving payments under this section must notify HHSC's Provider
Finance Department within 30 days of changes in ownership, operation,
provider identifier, designation as a trauma facility or as a children's
hospital, or any other change that may affect the hospital's continued
eligibility, qualification, or compliance with DSH conditions of participation.
At the request of HHSC, the hospital must submit any documentation
supporting the change.
Cont'd... |
