| the following amounts.
(i) For the physician group practice pool in demonstration
years nine and ten, or the non-state-owned physician group practice
pool beginning in demonstration year eleven, the governmental ambulance
provider pool, and the publicly owned dental provider pool:
(I) for demonstration year nine, an amount to equal
the percentage of the applicable total uncompensated-care pool amount
paid to each group in demonstration year six; and
(II) for demonstration years ten and after, an amount
to equal a percentage determined by HHSC annually based on factors
including the amount of reported charity-care costs and the ratio
of reported charity-care costs to hospitals' charity-care costs. For
physicians, current year charity-care costs will be used, while for
dental and ambulance providers, prior year charity-care costs will
be used.
(ii) For the non-state-owned hospital pool, all of
the remaining funds after the allocations described in clause (i)
of this subparagraph. HHSC will further allocate the funds in the
non-state-owned hospital pool among all hospitals in the pool and
create non-state-owned hospital sub-pools as follows:
(I) calculate a revised maximum payment amount for
each non-state-owned hospital as described in subsection (g)(6) of
this section and allocate that amount to the hospital; and
(II) group all non-state-owned hospitals and non-state-owned
physician groups into sub-pools based on its geographic location within
one of the state's Medicaid service delivery areas (SDAs), as described
in subsection (g)(7) of this section.
(3) Availability of funds. Payments made under this
section are limited by the availability of funds identified in subsection
(d) of this section and timely received by HHSC. If sufficient funds
are not available for all payments for which the providers in each
pool or sub-pool are eligible, HHSC will reduce payments as described
in subsection (h)(2) of this section.
(4) Redistribution. If for any reason funds allocated
to a provider pool or to individual providers within a sub-pool are
not paid to providers in that pool or sub-pool for the demonstration
year, the funds will be redistributed to other provider pools based
on each pool's pro-rata share of remaining uncompensated costs for
the same demonstration year. The redistribution will occur when the
reconciliation for that demonstration year is performed.
(g) Uncompensated-care payment amount.
(1) Application.
(A) Cost and payment data reported by a hospital in
the uncompensated-care application is used to calculate the annual
maximum uncompensated-care payment amount for the applicable demonstration
year, as described in paragraph (2) of this subsection.
(B) Unless otherwise instructed in the application,
a hospital must base the cost and payment data reported in the application
on its applicable as-filed CMS 2552 Cost Report(s) For Electronic
Filing Of Hospitals corresponding to the data year and must comply
with the application instructions or other guidance issued by HHSC.
(i) When the application requests data or information
outside of the as-filed cost report(s), a hospital must provide all
requested documentation to support the reported data or information.
(ii) For a new hospital, the cost and payment data
period may differ from the data year, resulting in the eligible uncompensated
costs based only on services provided after the hospital's Medicaid
enrollment date. HHSC will determine the data period in such situations.
(2) Calculation.
(A) A hospital's annual maximum uncompensated-care
payment amount is the sum of the components described in clauses (i)
- (iv) of this subparagraph.
(i) The hospital's inpatient and outpatient charity-care
costs pre-populated in or reported on the uncompensated-care application,
as described in paragraph (3) of this subsection, reduced by interim
DSH payments for the same program period, if any, that reimburse the
hospital for the same costs. To identify DSH payments that reimburse
the hospital for the same costs, HHSC will:
(I) use self-reported information on the application
to identify charges that can be claimed by the hospital in both DSH
and Uncompensated Care (UC), convert the charges to cost, and reduce
the cost by any applicable payments described in paragraph (3) of
this subsection;
(II) calculate a DSH-only uninsured shortfall by reducing
the hospital's total uninsured costs, calculated as described in §355.8066
of this subchapter, by the result from subclause (I) of this clause;
and
(III) reduce the interim DSH payment amount by the
sum of:
(-a-) the DSH-only uninsured shortfall calculated as
described in subclause (II) of this clause; and
(-b-) the hospital's Medicaid shortfall, calculated
as described in §355.8066 of this subchapter.
(ii) Other eligible costs for the data year, as described
in paragraph (4) of this subsection.
(iii) Cost and payment adjustments, if any, as described
in paragraph (5) of this subsection.
(iv) For each transferring public hospital, the amount
transferred to HHSC to that hospital and private hospitals to support
DSH payments for the same demonstration year.
(B) A hospital also participating in the DSH program
cannot receive total uncompensated-care payments under this section
(relating to inpatient and outpatient hospital services provided to
uninsured charity-care individuals) and DSH payments that exceed the
hospital's total eligible uncompensated costs. For purposes of this
requirement, "total eligible uncompensated costs" means the hospital's
state payment cap for interim payments or DSH hospital-specific limit
(HSL) in the UC reconciliation plus the unreimbursed costs of inpatient
and outpatient services provided to uninsured charity-care patients
not included in the state payment cap or HSL for the corresponding
program year.
(3) Hospital charity-care costs.
(A) For each hospital required by Medicare to submit
schedule S-10 of the Medicaid cost report, HHSC will pre-populate
the uncompensated-care application described in paragraph (1) of this
subsection with the uninsured charity-care charges and payments reported
by the hospital on schedule S-10 for the hospital's cost reporting
period ending in the calendar year two years before the demonstration
year. For example, for demonstration year 9, which coincides with
the federal fiscal year 2020, HHSC will use data from the hospital's
cost reporting period ending in the calendar year 2018. Hospitals
should also report any additional payments associated with uninsured
charity charges that were not captured in worksheet S-10 in the application
described in paragraph (1) of this subsection.
(B) For each hospital not required by Medicare to submit
schedule S-10 of the Medicaid cost report, the hospital must report
its hospital charity-care charges and payments in compliance with
the instructions on the uncompensated-care application described in
paragraph (1) of this subsection.
(i) The instructions for reporting eligible charity-care
costs in the application will be consistent with instructions contained
in schedule S-10.
(ii) An IMD may not report charity-care charges for
services provided during the data year to patients aged 21 through
64.
(4) Other eligible costs.
(A) In addition to inpatient and outpatient charity-care
costs, a hospital may also claim reimbursement under this section
for uncompensated charity care, as specified in the uncompensated-care
application, that is related to the following services provided to
uninsured patients who meet the hospital's charity-care policy:
(i) direct patient-care services of physicians and
mid-level professionals; and
(ii) certain pharmacy services.
(B) A payment under this section for the costs described
in subparagraph (A) of this paragraph are not considered inpatient
or outpatient Medicaid payments for the purpose of the DSH audit described
in §355.8065 of this subchapter.
(5) Adjustments. When submitting the uncompensated-care
application, a hospital may request that cost and payment data from
the data year be adjusted to reflect increases or decreases in costs
resulting from changes in operations or circumstances.
(A) A hospital:
(i) may request that costs not reflected on the as-filed
cost report, but which would be incurred for the demonstration year,
be included when calculating payment amounts; and
Cont'd... |
