| (D) A hospital that believes that it qualifies for
an exception authorized by Section 1923(g) of the Social Security
Act to the calculation described in this paragraph may request that
HHSC calculate the recoupment prevention payment ceiling in accordance
with the exception authorized by federal law. HHSC will adhere to
CMS' determination on eligibility for exception authorized by Section
1923(g) of the Social Security Act whenever available. The hospital
must submit the request in accordance with subsection (f) of this
section.
(4) State Payment Cap.
(A) For program periods beginning October 1, 2022,
HHSC will determine the lesser of between the two payment ceilings
described in paragraphs (2) and (3) of this subsection. The lesser
of the two payment ceilings will constitute the State Payment Cap
for the DSH program described in §355.8065 of this division and
in the UC program described in §355.8212 of this subchapter.
(B) For program periods beginning on or after October
1, 2019 and ending on or before September 30, 2022, the state payment
cap is described in paragraph (2) of this subsection.
(C) For program periods beginning on or after October
1, 2017 and ending on or before September 30, 2019, the state payment
cap uses the costs in paragraph (2)(A) of this subsection and the
payments for inpatient and outpatient claims under Title XIX of the
Social Security Act, including graduate medical services and out-of-state
payments, and payments on behalf of the uninsured.
(D) For program periods beginning on or after October
1, 2013 and ending on or before September 30, 2017, the state payment
cap uses the costs in paragraph (2)(A) of this subsection and the
payments from all payor sources, including graduate medical services
and out-of-state payments, excluding third-party commercial insurance
payors for inpatient and outpatient claims.
(d) Hospital-Specific Limit.
(1) HHSC will calculate the individual components of
a hospital's hospital-specific limit using the calculation set out
in subsection (c)(3) of this section, except that HHSC will:
(A) use information from the hospital's Medicaid cost
report(s) that cover the program year and from cost settlement payment
or recoupment amounts attributable to the program year for the calculations
described in subsection (c)(1) of this section. If a hospital has
two or more Medicaid cost reports that cover the program year, the
data from each cost report will be pro-rated based on the number of
months from each cost report period that fall within the program year;
(B) include supplemental payments (including upper
payment limit payments) and uncompensated-care waiver payments (excluding
payments associated with pharmacies, clinics, and physicians) attributable
to the hospital for the program year when calculating the total payments
to be subtracted from total costs as described in subsection (c)(3)(A)
of this section;
(C) use the hospital's actual charges and payments
for services described in subsection (c)(1)(A) and (c)(1)(B) of this
section provided to Medicaid-eligible and uninsured patients during
the program year; and
(D) include charges and payments for claims submitted
after the 95-day filing deadline for Medicaid-allowable services provided
during the program year unless such claims were submitted after the
Medicare filing deadline.
(2) For payments to a hospital under the DSH program,
the hospital-specific limit will be calculated at the time of the
independent audit conducted under §355.8065(o) of this division.
(3) Federally authorized exceptions to the Hospital-specific
limit (HSL) calculation. A hospital that believes that it qualifies
for an exception authorized by Section 1923(g) of the Social Security
Act to the calculation described in paragraph (f)(3) of this section
may request that HHSC or its contractors calculate the HSL in accordance
with the exception authorized by federal law. HHSC will adhere to
CMS' determination on eligibility for exception authorized by Section
1923(g) of the Social Security Act whenever available. The following
conditions and procedures will apply to all such requests received
by HHSC or its contractors.
(A) The hospital must submit its request in writing
to HHSC within 90 days of the end of the federal fiscal year, and
the request must include any and all necessary data and justification
necessary for the determination of the eligibility of the hospital
to receive the exception.
(B) If HHSC approves the request, HHSC or its contractors
will calculate the HSL using the methodology authorized under federal
law.
(C) HHSC will notify the hospital of the results of
the HSL calculation in writing.
(e) Due date for DSH and UC Application.
(1) HHSC Provider Finance Department must receive a
hospital's completed application no later than 30 calendar days from
the date of HHSC's written request to the hospital for the completion
of the application, unless an extension is granted as described in
paragraph (2) of this subsection.
(2) HHSC Provider Finance Department will extend this
deadline provided that HHSC receives a written request for the extension
by email no later than 30 calendar days from the date of the request
for the completion of the application.
(3) The extension gives the requester a total of 45
calendar days from the date of the written request for completion
of the application.
(4) If a deadline described in paragraph (1) or (3)
of this subsection is a weekend day, national holiday, or state holiday,
then the deadline for submission of the completed application is the
next business day.
(5) HHSC will not accept an application or request
for an extension that is not received by the stated deadline. A hospital
whose application or request for extension is not received by the
stated deadline will be ineligible for DSH or uncompensated-care waiver
payments for that program year.
(f) Verification and right to request a review of data.
This subsection applies to calculations under this section beginning
with calculations for program year 2014.
(1) Claim adjudication. Medicaid participating hospitals
are responsible for resolving disputes regarding adjudication of Medicaid
claims directly with the appropriate Medicaid contractors as claims
are adjudicated. The review of data described under paragraph (2)
of this subsection is not the appropriate venue for resolving disputes
regarding adjudication of claims.
(2) Request for review of data.
(A) HHSC will pre-populate certain fields in the DSH
and UC Application, including data from its Medicaid contractors.
(i) A hospital may request that HHSC review any data
in the hospital's DSH and UC Application that is pre-populated by
HHSC.
(ii) A hospital may not request that HHSC review self-reported
data included in the DSH and UC Application by the hospital.
(B) A hospital must submit via email a written request
for review and all supporting documentation to HHSC Hospital Rate
Analysis within 30 days following the distribution of the pre-populated
DSH and UC Application to the hospital by HHSC. The request must allege
the specific data omissions or errors that, if corrected, would result
in a more accurate HSL.
(3) HHSC's review.
(A) HHSC will review the data that is the subject of
a hospital's request. The review is:
(i) limited to the hospital's allegations that data
is incomplete or incorrect;
(ii) supported by documentation submitted by the hospital
or by the Medicaid contractor;
(iii) solely a data review; and
(iv) not an adversarial hearing.
(B) HHSC will notify the hospital of the results of
the review.
(i) If changes to the Medicaid data are made as a result
of the review process, HHSC will use the corrected data for the HSL
calculations described in this section and for other purposes described
in §355.8065 and §355.8212 of this subchapter.
(ii) If no changes are made, HHSC will use the Medicaid
data from the Medicaid contractors.
(C) HHSC will not consider requests for review submitted
after the deadline specified in paragraph (2)(B) of this subsection.
(D) HHSC will not consider requests for review of the
following calculations that rely on the Medicaid data and other information
described in this subsection:
(i) the state payment cap or hospital-specific limit
calculated as described in this section, unless it is related to exceptions
permitted by Section 1923(g) of the Social Security Act;
(ii) DSH program qualification or payment amounts calculated
as described in §355.8065 of this title; or
(iii) uncompensated-care payment amounts calculated
as described in §355.8201 or §355.8212 of this subchapter.
|
| Source Note: The provisions of this §355.8066 adopted to be effective July 1, 2012, 37 TexReg 4577; amended to be effective October 6, 2013, 38 TexReg 6581; amended to be effective April 23, 2014, 39 TexReg 3221; amended to be effective June 25, 2019, 44 TexReg 3091; amended to be effective February 1, 2020, 45 TexReg 525; amended to be effective June 20, 2023, 48 TexReg 3187 |
