| (ii) Each hospital will report in its application all
payments received during the data year, regardless of when the service
was provided, for services that would be covered by Medicaid and were
provided to uninsured patients.
(I) For purposes of this paragraph, a payment received
is any payment from an uninsured patient or from a third party (other
than an insurer) on the patient's behalf, including payments received
for emergency health services furnished to undocumented aliens under §1011
of the Medicare Prescription Drug, Improvement, and Modernization
Act of 2003, Pub. L. No. 108-173, except as described in subclause
(II) of this clause.
(II) State and local subsidies to hospitals for indigent
care are not included as payments made by or on behalf of uninsured
patients.
(B) Medicaid charges and payments.
(i) HHSC will request from its Medicaid contractors
the inpatient and outpatient charge and payment data for claims for
services provided to Medicaid-enrolled individuals that are adjudicated
during the data year.
(I) The requested data will include, but is not limited
to, charges and payments for:
(-a-) claims associated with the care of dually eligible
patients, including Medicare charges and payments;
(-b-) claims or portions of claims that were not paid
because they exceeded the spell-of-illness limitation;
(-c-) outpatient claims associated with the Women's
Health Program; and
(-d-) claims for which the hospital received payment
from a third-party payor for a Medicaid-enrolled patient.
(II) HHSC will exclude charges and payments for:
(-a-) claims for services that do not meet the definition
of "medical assistance" contained in §1905(a) of the Social Security
Act. Examples include:
(-1-) claims for the Children's Health Insurance Program;
and
(-2-) inpatient claims associated with the Women's
Health Program or any successor program; and
(-b-) claims submitted after the 95-day filing deadline.
(ii) HHSC will request from its Medicaid contractors
the inpatient and outpatient Medicaid cost settlement payment or recoupment
amounts attributable to the cost report period determined in subparagraph
(C)(i) of this paragraph.
(iii) HHSC will notify hospitals following HHSC's receipt
of the requested data from the Medicaid contractors. A hospital's
right to request a review of data it believes is incorrect or incomplete
is addressed in subsection (e) of this section.
(iv) Each hospital will report on the application the
inpatient and outpatient Medicaid days, charges and payment data for
out-of-state claims adjudicated during the data year.
(v) HHSC may apply an adjustment factor to Medicaid
payment data to more accurately approximate Medicaid payments, including
for directed payments, following a rebasing or other change in reimbursement
rates under other sections of this division.
(C) Calculation of in-state and out-of-state Medicaid
and uninsured total costs for the data year.
(i) Cost report period for data used to calculate cost-per-day
amounts and cost-to-charge ratios. HHSC will use information from
the Medicaid cost report for the hospital's fiscal year that ends
during the calendar year that falls two years before the end of the
program year for the calculations described in clauses (ii)(I) and
(iii)(I) of this subparagraph. For example, for program year 2013,
the cost report year is the provider's fiscal year that ends between
January 1, 2011, and December 31, 2011.
(I) For hospitals that do not have a full year cost
report that meets this criteria, a partial year cost report for the
hospital's fiscal year that ends during the calendar year that falls
two years before the end of the program year will be used if the cost
report covers a period greater than or equal to six months in length.
(II) The partial year cost report will not be prorated.
If the provider's cost report that ends during this time period is
less than six months in length, the most recent full year cost report
will be used.
(ii) Determining inpatient routine costs.
(I) Medicaid inpatient cost per day for routine cost
centers. Using data from the Medicaid cost report, HHSC will divide
the allowable inpatient costs by the inpatient days for each routine
cost center to determine a Medicaid inpatient cost per day for each
routine cost center.
(II) Inpatient routine cost center cost. For each Medicaid
payor type and the uninsured, HHSC will multiply the Medicaid inpatient
cost per day for each routine cost center from subclause (I) of this
clause times the number of inpatient days for each routine cost center
from the data year to determine the inpatient routine cost for each
cost center.
(III) Total inpatient routine cost. For each Medicaid
payor type and the uninsured, HHSC will sum the inpatient routine
costs for the various routine cost centers from subclause (II) of
this clause to determine the total inpatient routine cost.
(iii) Determining inpatient and outpatient ancillary
costs.
(I) Inpatient and outpatient Medicaid cost-to-charge
ratio for ancillary cost centers. Using data from the Medicaid cost
report, HHSC will divide the allowable ancillary cost by the sum of
the inpatient and outpatient charges for each ancillary cost center
to determine a Medicaid cost-to-charge ratio for each ancillary cost
center.
(II) Inpatient and outpatient ancillary cost center
cost. For each Medicaid payor type and the uninsured, HHSC will multiply
the cost-to-charge ratio for each ancillary cost center from subclause
(I) of this clause by the ancillary charges for inpatient claims and
the ancillary charges for outpatient claims from the data year to
determine the inpatient and outpatient ancillary cost for each cost
center.
(III) Total inpatient and outpatient ancillary cost.
For each Medicaid payor type and the uninsured, HHSC will sum the
ancillary inpatient and outpatient costs for the various ancillary
cost centers from subclause (II) of this clause to determine the total
ancillary cost.
(iv) Determining total Medicaid and uninsured cost.
For each Medicaid payor type and the uninsured, HHSC will sum the
result of clause (ii)(III) of this subparagraph and the result of
clause (iii)(III) of this subparagraph plus organ acquisition costs
to determine the total cost.
(2) Calculation of the full-offset payment ceiling.
(A) Total hospital cost. HHSC will sum the total cost
for all Medicaid payor types and the uninsured from paragraph (1)(C)(iv)
of this section to determine the total hospital cost for Medicaid
and the uninsured.
(B) Total hospital payments. HHSC will reduce the total
hospital cost under subparagraph (A) of this paragraph by total payments
from all payor sources, including graduate medical services and out-of-state
payments. HHSC shall reduce the total hospital cost by supplemental
payments or uncompensated-care waiver payments (excluding payments
associated with pharmacies, clinics, and physicians) attributed to
the hospital for the program year to prevent total interim payments
to a hospital for the program year from exceeding the state payment
cap for that program year.
(C) Inflation adjustment. HHSC will trend each hospital's
full-offset payment ceiling using the inflation update factor. HHSC
will trend each hospital's state payment cap from the midpoint of
the data year to the midpoint of the program year.
(3) Calculation of the Recoupment Prevention Payment
Ceiling.
(A) Total hospital cost. HHSC will calculate total
cost in accordance with Section 1923(g) of the Social Security Act.
For example, starting with the program period beginning October 1,
2022, HHSC will sum the total cost from paragraph (1)(C)(iv) for the
Medicaid primary payor type and the uninsured only.
(B) Total hospital payments. HHSC will reduce the total
hospital cost under subparagraph (A) of this paragraph by total payments
in accordance with Section 1923(g) of the Social Security Act. For
example, starting with the program period beginning October 1, 2022,
HHSC will reduce the total hospital cost under subparagraph (A) of
this paragraph by the total payments from Medicaid and the uninsured,
including graduate medical services and out-of-state payments. HHSC
shall reduce the total hospital cost by supplemental payments or uncompensated-care
waiver payments (excluding payments associated with pharmacies, clinics,
and physicians) attributed to the hospital for the program year to
prevent total interim payments to a hospital for the program year
from exceeding the state payment cap for that program year.
(C) Inflation adjustment. HHSC will trend each hospital's
recoupment prevention payment ceiling using the inflation update factor.
HHSC will trend each hospital's state payment cap from the midpoint
of the data year to the midpoint of the program year.
Cont'd... |
