| (A) owned and operated by a governmental entity; or
(B) operated under a lease from a governmental entity
in which the hospital and governmental entity are both located in
the same county, and the hospital and governmental entity have both
signed an attestation that they wish the hospital to be treated as
a public hospital for all purposes under both this section and §355.8212
of this subchapter (relating to Waiver Payments to Hospitals for Uncompensated
Charity Care).
(35) Obstetrical services--The medical care of a woman
during pregnancy, delivery, and the post-partum period provided at
the hospital listed on the DSH application.
(36) PMSA--Primary Metropolitan Statistical Area as
defined by the United States Office of Management and Budget.
(37) Public funds--Funds derived from taxes, assessments,
levies, investments, and other public revenues within the sole and
unrestricted control of a governmental entity. Public funds do not
include gifts, grants, trusts, or donations, the use of which is conditioned
on supplying a benefit solely to the donor or grantor of the funds.
(38) Public Health Hospital (PHH)--The Texas Center
for Infectious Disease or any successor facility operated by the Department
of State Health Services.
(39) Ratio of cost-to-charges--A ratio that covers
all applicable hospital costs and charges relating to inpatient care
and outpatient care. This ratio will be calculated for inpatient and
outpatient services and, does not distinguish between payer types
such as Medicare, Medicaid, or private pay.
(40) Rural public hospital--A hospital that is a rural
hospital as defined in §355.8052 of this chapter and is either:
(A) owned and operated by a governmental entity; or
(B) is under a lease from a governmental entity in
which the hospital and governmental entity are both located in the
same county and the hospital and governmental entity have both signed
an attestation that they wish to be treated as a public hospital for
all purposes under this section.
(41) State institution for mental diseases (State IMD)--A
hospital that is primarily engaged in providing psychiatric diagnosis,
treatment, or care of individuals with mental illness defined in §1905(i)
of the Social Security Act and that is owned and operated by a state
university or other state agency. State IMD hospitals are reimbursed
as freestanding psychiatric facilities under §355.761 of this
chapter.
(42) State-owned hospital--A hospital that is defined
as a state IMD, state-owned teaching hospital, or a Public Health
Hospital (PHH) in this section.
(43) State-owned teaching hospital--A hospital that
is a state-owned teaching hospital as defined in §355.8052 of
this chapter.
(44) State payment cap--The maximum payment amount,
as applied to payments that will be made for the DSH program year,
that a hospital may receive in reimbursement for the cost of providing
Medicaid-allowable services to individuals who are Medicaid-eligible
or uninsured. The state payment cap is calculated using the methodology
described in §355.8066 of this title (relating to Hospital-Specific
Limit Methodology) using interim cost and payment data from the DSH
data year.
(45) Tax Revenue--Funds derived from local taxes that
are assessed and payable to a hospital or a hospital district. For
purposes of this section, Tax Revenue does not include mandatory payments
received by a local governmental entity that is authorized by a relevant
chapter of Subtitle D, Title 4, Texas Health and Safety Code, to operate
a Local Provider Participation Fund (LPPF).
(46) Third-party coverage--Creditable insurance coverage
consistent with the definitions in 45 Code of Federal Regulations
(CFR) Parts 144 and 146, or coverage based on a legally liable third-party
payer.
(47) Total Medicaid inpatient days--Total number of
inpatient days based on adjudicated claims data for covered services
for the relevant DSH data year.
(A) The term includes:
(i) Medicaid-eligible days of care adjudicated by managed
care organizations or HHSC;
(ii) days that were denied payment for spell-of-illness
limitations;
(iii) days attributable to individuals eligible for
Medicaid in other states, including dually eligible patients;
(iv) days with adjudicated dates during the period;
and
(v) days for dually eligible patients for purposes
of the MIUR calculation described in subsection (d)(1) of this section.
(B) The term excludes:
(i) days attributable to Medicaid-eligible patients
ages 21 through 64 in an IMD;
(ii) days denied for late filing and other reasons;
and
(iii) days for dually eligible patients for purposes
of the following calculations:
(I) Total Medicaid inpatient days, as described in
subsection (d)(3) of this section; and
(II) Pass one distribution, as described in subsection
(h)(4) of this section.
(48) Total Medicaid inpatient hospital payments--Total
amount of Medicaid funds that a hospital received for adjudicated
claims for covered inpatient services during the DSH data year. The
term includes payments that the hospital received:
(A) for covered inpatient services from managed care
organizations and HHSC; and
(B) for patients eligible for Medicaid in other states.
(49) Total state and local subsidies--Total amount
of state and local payments that a hospital received for inpatient
and outpatient care during the DSH data year. The term includes payments
under state and local programs that are funded entirely with state
general revenue funds and state or local tax funds, such as County
Indigent Health Care, Children with Special Health Care Needs, and
Kidney Health Care. The term excludes payment sources that contain
federal dollars such as Medicaid payments, Children's Health Insurance
Program (CHIP) payments funded under Title XXI of the Social Security
Act, Substance Abuse and Mental Health Services Administration, Ryan
White Title I, Ryan White Title II, Ryan White Title III, and contractual
discounts and allowances related to TRICARE, Medicare, and Medicaid.
The term also includes tax revenue.
(50) Transferring public hospital--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.
(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) Merged Hospitals.
(i) HHSC will consider a merger of two or more hospitals
for purposes of determining eligibility and calculating a hospital's
DSH program year payments under this section if:
(I) a hospital that was a party to the merger submits
to HHSC documents verifying the merger status with Medicare prior
to the deadline for submission of the DSH application; and
(II) the hospital submitting the information under
subclause (I) assumed all Medicaid-related liabilities of each hospital
that is a party to the merger, as determined by HHSC after review
of the applicable agreements.
Cont'd... |
