| (iii) is located in an MSA.
(33) Safety-Net add-on--An adjustment to the base SDA
for a safety-net hospital to reflect the higher costs of providing
Medicaid inpatient services in a hospital that provides a significant
percentage of its services to Medicaid and/or uninsured patients.
(34) Safety-Net hospital--An urban or children's hospital
that meets the eligibility and qualification requirements described
in §355.8065 of this division (relating to Disproportionate Share
Hospital Reimbursement Methodology) for the most recent federal fiscal
year for which such eligibility and qualification determinations have
been made.
(35) Standard Dollar Amount (SDA)--A standardized payment
amount calculated by HHSC for the costs incurred by prospectively-paid
hospitals in Texas for furnishing covered inpatient hospital services.
(36) State-owned teaching hospital--Acute care hospitals
owned and operated by the state of Texas.
(37) Teaching hospital--A hospital for which CMS has
calculated and assigned a percentage Medicare education adjustment
factor under 42 CFR §412.105.
(38) Teaching medical education add-on--An adjustment
to the base SDA for a children's teaching hospital with a program
approved by the Accreditation Council for Graduate Medical Education
(ACGME) to reflect higher patient care costs relative to non-teaching
children's hospitals.
(39) TEFRA target cap--A limit set under the Social
Security Act §1886(b) (42 U.S.C. §1395ww(b)) and applied
to a hospital's cost settlement under methods and procedures in the
Tax Equity and Fiscal Responsibility Act of 1982 (TEFRA). TEFRA target
cap is not applied to services provided to patients under age 21,
and incentive and penalty payments associated with this limit are
not applicable to those services.
(40) Tentative settlement--Reconciliation of cost in
the Medicare/Medicaid hospital fiscal year-end cost report performed
by HHSC within six months after HHSC receives an acceptable cost report
filed by a hospital.
(41) Texas provider identifier (TPI)--A unique number
assigned to a provider of Medicaid services in Texas.
(42) Trauma add-on--An adjustment to the base SDA for
a trauma hospital to reflect the higher costs of obtaining and maintaining
a trauma facility designation, as well as the direct costs of providing
trauma services, relative to non-trauma hospitals or to hospitals
with lower trauma facility designations. To be eligible for the trauma
add-on, a hospital must be eligible to receive an allocation from
the trauma facilities and emergency medical services account under
Texas Health and Safety Code Chapter 780.
(43) Trauma hospital--An inpatient hospital that meets
the Texas Department of State Health Services criteria for a Level
I, II, III, or IV trauma facility designation under 25 Texas Administrative
Code §157.125 (relating to Requirements for Trauma Facility Designation).
(44) Universal mean--Average base year cost per claim
for all urban hospitals.
(45) Urban hospital--Hospital located in a metropolitan
statistical area and not fitting the definition of rural hospitals,
children's hospitals, state-owned teaching hospitals, or freestanding
psychiatric hospitals.
(c) Base children's hospitals SDA calculations. HHSC
will use the methodologies described in this subsection to determine
average statewide base SDA and a final SDA for each children's hospital.
(1) HHSC calculates the average base year cost per
claim as follows.
(A) To calculate the total inpatient base year cost
per children's hospital:
(i) sum the allowable inpatient charges by hospital
for the base year claims; and
(ii) multiply clause (i) of this subparagraph by the
hospital's inpatient RCC and the inflation update factors to inflate
the base year cost to the current year.
(B) Sum the amount of all hospitals' base year costs
from subparagraph (A) of this paragraph.
(C) Subtract an amount equal to the estimated outlier
payment amount for the base year claims for all children's hospitals
from subparagraph (B) of this paragraph.
(D) To derive the average base year cost per claim,
divide the result from subparagraph (C) of this paragraph by the total
number of base year claims.
(2) HHSC calculates the base children's SDA as follows.
(A) From the amount determined in paragraph (1)(C)
of this subsection, HHSC sets aside an amount for add-ons as described
in paragraph (3) of this subsection. In determining the amount to
set aside, HHSC considers factors including other funding available
to reimburse high-cost hospital functions and services, available
data sources, historical costs, Medicare practices, and feedback from
hospital industry experts.
(B) The amount remaining from paragraph (1)(C) of this
subsection after HHSC sets aside the amount for add-ons in subparagraph
(A) of this paragraph is then divided by the sum of the relative weights
for all children's base year claims to derive the base SDA.
(3) A children's hospital may receive increases to
the base SDA for any of the following.
(A) Add-on amounts, which will be determined or adjusted
based on the following.
(i) Impact files.
(I) HHSC will use the most recent finalized impact
file available at the time of realignment to calculate add-ons; and
(II) HHSC will use the impact file in effect at the
last realignment to calculate add-ons for new hospitals, except as
otherwise specified in this section.
(ii) Geographic wage reclassification. If a hospital
becomes eligible for the geographic wage reclassification under Medicare,
the hospital will become eligible for the adjustment upon the next
realignment.
(iii) Teaching medical education add-on during the
fiscal year. If a hospital becomes eligible for the teaching medical
education add-on, the hospital will receive an increased final SDA
to include these newly eligible add-ons, effective for claims that
have a date of discharge occurring on or after the first day of the
next state fiscal year.
(iv) Safety-net add-on during the fiscal year. The
hospital will receive an increased final SDA to include these newly
eligible add-ons, effective for claims that have a date of discharge
occurring on or after the first day of the next state fiscal year.
(v) New children's hospital teaching medical education
add-on. If an eligible children's hospital is new to the Medicaid
program and a cost report is not available, the teaching medical education
add-on will be calculated at the beginning of the state fiscal year
after a cost report is received.
(B) Geographic wage add-on.
(i) CBSA assignment. For claims with dates of admission
beginning September 1, 2013, and continuing until the next realignment,
the geographic wage add-on for children's hospitals will be calculated
based on the corresponding CBSA in the impact file in effect on September
1, 2011.
(ii) Designated impact file. Subsequent add-ons will
be based on the impact file available at the time of realignment.
(iii) Wage index. To determine a children's hospital
geographic wage add-on, HHSC first calculates a wage index for Texas
as follows.
(I) HHSC identifies the Medicare wage index factor
for each CBSA in Texas.
(II) HHSC identifies the lowest Medicare wage index
factor in Texas.
(III) HHSC divides the Medicare wage index factor in
subclause (I) of this clause for each CBSA by the lowest Medicare
wage index factor identified in subclause (II) of this clause and
subtracts one from each resulting quotient.
(iv) County assignment. HHSC will initially assign
a hospital to a CBSA based on the county in which the hospital is
located. A hospital that has been approved for geographic reclassification
under Medicare may request that HHSC recognize its Medicare CBSA reclassification
under the process described in subparagraph (E) of this paragraph.
(v) Medicare labor-related percentage. HHSC uses the
Medicare labor-related percentage available at the time of realignment.
(vi) Geographic wage add-on calculation. The final
geographic wage add-on is equal to the product of the base SDA calculated
in subsection (c)(2)(B) of this section, the wage index calculated
in clause (iii)(III) of this subparagraph, and the Medicare labor-related
percentage in clause (v) of this subparagraph.
(C) Teaching medical education add-on.
(i) Eligibility. A teaching hospital that is a children's
hospital is eligible for the teaching medical education add-on. Each
children's hospital is required to confirm, under the process described
in subparagraph (E) of this paragraph, that HHSC's determination of
the hospital's eligibility for the add-on is correct.
(ii) Teaching medical education add-on calculation.
Cont'd... |
