| (C) entering into negotiations with one or more health care providers influence the department's choice among multiple potential networks by lowering the pricing terms offered by individual health care providers. These negotiations may result in identifying a single potential network that would differ in its health care provider composition from potential networks initially identified in Phase One. (g) Evaluation criteria for new facilities. (1) A new facility may petition the department for selective provider status in a specified market area or market areas. A new facility must complete the regular enrollment process with the department or its designee to participate in the Medical Assistance Program, including the execution of the standard provider agreement before the selective provider agreement can be implemented. In addition to the information required of health care providers under subsection (d) of this section, the new facility's petition shall describe the new facility and shall specify specialties, other services to be provided, and the size and location of the new facility. Upon receipt of an acceptable petition to evaluate, the department will negotiate selective provider reimbursement rate(s) with the new facility for covered inpatient services provided during the state fiscal year the petition is evaluated and, if the department desires, for one or two subsequent state fiscal years. The department shall grant the new facility selective provider status if the new facility agrees to meet the terms and conditions negotiated in this paragraph and the terms and conditions of the LoneSTAR Select Contracting Program(s) under this section. Under no circumstances shall the department negotiate a rate with the new facility that is higher than the lesser of either the reimbursement rate used to reimburse newly constructed hospitals described in §29.606 of this title (relating to Reimbursement Methodology for Inpatient Hospital Services) or the weighted arithmetic mean of the discounted rates for the existing state fiscal year in the market which the "new" hospital is located or for any subsequent fiscal year negotiated in this paragraph. Upon execution of a selective provider agreement between the department and the facility, the new facility shall cease to meet the definition of a new facility under this section and shall be subject to all regulations affecting contracted health care providers under this section. (2) No petition by a new facility for selective provider status and department consideration of or final action on such a petition shall require comprehensive reopening of selective provider contracting in the affected market area or of the specialities/services to be provided by the new facility. (3) The department shall grant or reject a petition from a new facility under subsection (g) of this section no later than 60 days after receipt by the department of a petition complying with paragraph (1) of this subsection. (4) New facilities granted selective provider status will be required at all times to be eligible to participate in the Medicare and Medicaid programs and to comply with all other applicable provisions under this section. (h) Execution of selective provider agreements. The department shall execute selective provider agreements at the conclusion of negotiations by: (1) requesting applicants to submit a binding revised application including the terms and conditions agreed to during negotiations with the department. The best and final offer of each health care provider shall be forwarded to the department for approval. The provider agreements shall be executed following the approval of the department; and (2) structuring the agreements as one year amendments to the provider agreement of each health care provider, with an option to the department of extending the amendments for up to two option years. The effective date of the reimbursement rates under the amendments may, by mutual agreement, be made retroactive to a date before the date of execution. At the conclusion of the first year, the department may adjust its exercise of options on a market-by-market basis so as to place the system on a three-year rolling system of renegotiations. If the performance of any health care provider under the contract is considered unsatisfactory, however, the department may elect not to exercise any subsequent options, even if it exercised options with all other selected health care providers in the market. (i) Reimbursement for acute care hospitals. Acute care hospitals in MSAs where the LoneSTAR Select Contracting Program I awards amended provided agreements will have their inpatient services reimbursed as follows. (1) Hospitals awarded selective provider agreements will be reimbursed for all inpatient services (emergency and non-emergency) according to the proposed rates they submitted with their proposals or according to the final negotiated rates that all parties agree will serve as the reimbursement mechanism for all inpatient services rendered by the hospital. (2) Hospitals not awarded selective provider agreements will be reimbursed for emergency inpatient services as currently stated in the State Plan until the patient is stabilized. After a patient is stabilized in a non-contracted hospital, inpatient services are no longer covered unless the non-contracted hospital receives an exception for the remaining number of days of stay required. A non-contracted hospital will not be reimbursed for non-emergency inpatient services to Medicaid recipients unless it receives a hardship exemption from the department. Further explanation of the payment methodology for emergency patients in non-contracted hospitals and the hardship exemption policy are as follows. (A) After a patient is stabilized in a non-contracted hospital, after being admitted with a diagnosis meeting the definition of a medical emergency, additional inpatient services are no longer covered, unless the non-contracted hospital receives an exception for the remaining number of days required. Any and all DRGs with an average length of stay less than three days (72 hours) will be eligible to be paid the full reimbursement amount without an exception being granted. Any and all DRGs with an average length of stay in excess of three days (72 hours) will be eligible to be paid the full reimbursement amount without an exception being granted if the patient is stabilized and discharged home within 72 hours from the initial admission. If an exception is not granted by the department, the hospital will no longer be eligible to receive reimbursement for services rendered to the patient. (i) A non-contracted hospital must contact the department prior to patient stabilization or as soon as is practicable after stabilization for determination of further reimbursable services provided by the non-contracted hospital. (ii) If a non-contracted hospital does not contact the department before the patient is discharged, the non-contracted hospital will be reimbursed on a per diem basis as though the patient were transferred upon stabilization. (I) The non-contracted hospital will not receive full reimbursement for the inpatient services rendered to the patient. (II) The initial claim will be denied; the non-contracted hospital will then be required to submit a complete copy of the patient's medical record to the department or its designee. (III) The department or its designee will determine when the patient was stabilized and establish a per diem reimbursement amount. (iii) As in current policy, each case will continue to be subject to all utilization review criteria. (B) Non-contracted hospitals will not be reimbursed for the non-emergency inpatient services provided to Medicaid recipients as stated in the current State Plan unless the hospital receives prior authorization from the department through a hardship exemption procedure. The hardship exemption procedure is developed for Medicaid recipients who might experience an unreasonable travel burden under the LoneSTAR Select Contracting Program. The exemption procedure requires the non-contracted hospital or the admitting physician to contact the department by telephone, facsimile or written communication and provide an explanation as to the particular circumstances that the department should be considering in determining the prior authorization of the non-emergency inpatient service(s) being requested. The Medicaid patient can not be admitted for reimbursable non-emergency inpatient services unless a hardship exemption is granted by the department. In all circumstances, the Medicaid patient must be subject to an unreasonable travel burden under the Medicaid program for the request to be considered. The department will provide a decision on all requests for the hardship exemption procedure as soon as is practicable after receiving the request (usually within 36 hours). The department will contact the requesting non-contracted hospital or attending physician by telephone with the decision; and subsequently provide a written communication. (i) The non-contracted hospital will be responsible for including the particular circumstances to be considered by the department in the patient's medical record; with this information being a permanent part of the medical record. Cont'd... |
