| (a) Introduction. Hospitals participating in the Texas
Medicaid program that meet the conditions of participation and that
serve a disproportionate share of low-income patients are eligible
for reimbursement from the disproportionate share hospital (DSH) fund.
The Texas Health and Human Services Commission (HHSC) will establish
each hospital's eligibility for and amount of reimbursement using
the methodology described in this section.
(b) Definitions.
(1) Adjudicated claim--A hospital claim for payment
for a covered Medicaid service that is paid or adjusted by HHSC or
another payer.
(2) Available DSH funds--The total amount of funds
that may be distributed to eligible qualifying DSH hospitals for the
DSH program year, based on the federal DSH allotment for Texas (as
determined by the Centers for Medicare & Medicaid Services) and
available non-federal funds. HHSC may divide available DSH funds for
a program year into one or more portions of funds to allow for partial
payment(s) of total available DSH funds at any one time with remaining
funds to be distributed at a later date(s). If HHSC chooses to make
a partial payment, the available DSH funds for that partial payment
are limited to the portion of funds identified by HHSC for that partial
payment.
(3) Available general revenue funds--The total amount
of state general revenue funds appropriated to provide a portion of
the non-federal share of DSH payments for the DSH program year for
non-state-owned hospitals. If HHSC divides available DSH funds for
a program year into one or more portions of funds to allow for partial
payment(s) of total available DSH funds as described in paragraph
(2) of this subsection, the available general revenue funds for that
partial payment are limited to the portion of general revenue funds
identified by HHSC for that partial payment.
(4) Bad debt--A debt arising when there is nonpayment
on behalf of an individual who has third-party coverage.
(5) Centers for Medicare & Medicaid Services (CMS)--The
federal agency within the United States Department of Health and Human
Services responsible for overseeing and directing Medicare and Medicaid,
or its successor.
(6) Charity care--The unreimbursed cost to a hospital
of providing, funding, or otherwise financially supporting health
care services on an inpatient or outpatient basis to indigent individuals,
either directly or through other nonprofit or public outpatient clinics,
hospitals, or health care organizations. A hospital must set the income
level for eligibility for charity care consistent with the criteria
established in §311.031, Texas Health and Safety Code.
(7) Charity charges--Total amount of hospital charges
for inpatient and outpatient services attributed to charity care in
a DSH data year. These charges do not include bad debt charges, contractual
allowances, or discounts given to other legally liable third-party
payers.
(8) Children's hospital--A hospital within Texas that
is recognized by Medicare as a children's hospital and is exempted
by Medicare from the Medicare prospective payment system.
(9) Disproportionate share hospital (DSH)--A hospital
identified by HHSC that meets the DSH program conditions of participation
and that serves a disproportionate share of Medicaid or indigent patients.
(10) DSH data year--A twelve-month period, two years
before the DSH program year, from which HHSC will compile data to
determine DSH program qualification and payment.
(11) DSH program year--The twelve-month period beginning
October 1 and ending September 30.
(12) Dually eligible patient--A patient who is simultaneously
eligible for Medicare and Medicaid.
(13) Governmental entity--A state agency or a political
subdivision of the state. A governmental entity includes a hospital
authority, hospital district, city, county, or state entity.
(14) HHSC--The Texas Health and Human Services Commission
or its designee.
(15) Hospital-specific limit (HSL) --The maximum payment
amount, as applied to payments made during a prior DSH program year,
that a hospital may receive in reimbursement for the cost of providing
Medicaid-allowable services to individuals who are Medicaid-eligible
or uninsured. The hospital-specific limit is calculated using the
methodology described in §355.8066 of this title (relating to
Hospital-Specific Limit Methodology) using actual cost and payment
data from the DSH program year.
(16) Independent certified audit--An audit that is
conducted by an auditor that operates independently from the Medicaid
agency and the audited hospitals and that is eligible to perform the
DSH audit required by CMS.
(17) Indigent individual--An individual classified
by a hospital as eligible for charity care.
(18) Inpatient day--Each day that an individual is
an inpatient in the hospital, whether or not the individual is in
a specialized ward and whether or not the individual remains in the
hospital for lack of suitable placement elsewhere. The term includes
observation days, rehabilitation days, psychiatric days, and newborn
days. The term does not include swing bed days or skilled nursing
facility days.
(19) Inpatient revenue--Amount of gross inpatient revenue
derived from the most recent completed Medicaid cost report or reports
related to the applicable DSH data year. Gross inpatient revenue excludes
revenue related to the professional services of hospital-based physicians,
swing bed facilities, skilled nursing facilities, intermediate care
facilities, other nonhospital revenue, and revenue not identified
by the hospital.
(20) Institution for mental diseases (IMD)--A hospital
that is primarily engaged in providing psychiatric diagnosis, treatment,
or care of individuals with mental illness.
(21) Intergovernmental transfer (IGT)--A transfer of
public funds from a governmental entity to HHSC.
(22) Low-income days--Number of inpatient days attributed
to indigent patients, calculated as described in subsection (h)(4)(A)(ii)
of this section.
(23) Low-income utilization rate--A ratio, calculated
as described in subsection (d)(2) of this section, that represents
the hospital's volume of inpatient charity care relative to total
inpatient services.
(24) Mean Medicaid inpatient utilization rate--The
average of Medicaid inpatient utilization rates for all hospitals
that have received a Medicaid payment for an inpatient claim, other
than a claim for a dually eligible patient, that was adjudicated during
the relevant DSH data year.
(25) Medicaid contractor--Fiscal agents and managed
care organizations with which HHSC contracts to process data related
to the Medicaid program.
(26) Medicaid cost report--Hospital and Hospital Health
Care Complex Cost Report (Form CMS 2552), also known as the Medicare
cost report.
(27) Medicaid hospital--A hospital meeting the qualifications
set forth in §354.1077 of this title (relating to Provider Participation
Requirements) to participate in the Texas Medicaid program.
(28) Medicaid inpatient utilization rate (MIUR)--A
ratio, calculated as described in subsection (d)(1) of this section,
that represents a hospital's volume of Medicaid inpatient services
relative to total inpatient services.
(29) MSA--Metropolitan Statistical Area as defined
by the United States Office of Management and Budget. MSAs with populations
greater than or equal to 137,000, according to the most recent decennial
census, are considered "the largest MSAs."
(30) Non-federal percentage--The non-federal percentage
equals one minus the federal medical assistance percentage (FMAP)
for the program year.
(31) Non-urban public hospital--A rural public-financed
hospital, as defined in paragraph (37) of this subsection, or a hospital
owned and operated by a governmental entity other than hospitals in
Urban public hospital - Class one or Urban public hospital - Class
two.
(32) Obstetrical services--The medical care of a woman
during pregnancy, delivery, and the post-partum period provided at
the hospital listed on the DSH application.
(33) PMSA--Primary Metropolitan Statistical Area as
defined by the United States Office of Management and Budget.
(34) Public funds--Funds derived from taxes, assessments,
levies, investments, and other public revenues within the sole and
unrestricted control of a governmental entity. Public funds do not
include gifts, grants, trusts, or donations, the use of which is conditioned
on supplying a benefit solely to the donor or grantor of the funds.
(35) Ratio of cost-to-charges (inpatient only)--A ratio
that covers all applicable hospital costs and charges relating to
inpatient care. This ratio does not distinguish between payer types
such as Medicare, Medicaid, or private pay.
(36) Rural public hospital--A hospital owned and operated
by a governmental entity that is located in a county with 500,000
or fewer persons, based on the most recent decennial census.
(37) Rural public-financed hospital--A hospital operating
under a lease from a governmental entity in which the hospital and
governmental entity are both located in the same county with 500,000
or fewer persons, based on the most recent decennial census, where
the hospital and governmental entity have both signed an attestation
that they wish the hospital to be treated as a public hospital for
all purposes under both this section and §355.8201 of this title
(relating to Waiver Payments to Hospitals for Uncompensated Care).
(38) State chest hospital--A public health facility
operated by the Department of State Health Services designated for
the care and treatment of patients with tuberculosis.
(39) State institution for mental diseases (State IMD)--A
hospital that is primarily engaged in providing psychiatric diagnosis,
treatment, or care of individuals with mental illness and that is
owned and operated by a state university or other state agency.
(40) State-owned hospital--A hospital owned and operated
by a state university or other state agency.
(41) State payment cap--The maximum payment amount,
as applied to payments that will be made for the DSH program year,
that a hospital may receive in reimbursement for the cost of providing
Medicaid-allowable services to individuals who are Medicaid-eligible
or uninsured. The state payment cap is calculated using the methodology
described in §355.8066 of this title (relating to Hospital-Specific
Limit Methodology) using interim cost and payment data from the DSH
data year.
(42) Third-party coverage--Creditable insurance coverage
consistent with the definitions in 45 Code of Federal Regulations
(CFR) Parts 144 and 146, or coverage based on a legally liable third-party
payer.
(43) Total Medicaid inpatient days--Total number of
inpatient days based on adjudicated claims data for covered services
for the relevant DSH data year.
(A) The term includes:
(i) Medicaid-eligible days of care adjudicated by managed
care organizations or HHSC;
(ii) days that were denied payment for spell-of-illness
limitations;
(iii) days attributable to individuals eligible for
Medicaid in other states, including dually eligible patients;
(iv) days with adjudicated dates during the period;
and
(v) days for dually eligible patients for purposes
of the MIUR calculation described in subsection (d)(1) of this section.
(B) The term excludes:
(i) days attributable to Medicaid-eligible patients
ages 21 through 64 in an IMD;
(ii) days denied for late filing and other reasons;
and
(iii) days for dually eligible patients for purposes
of the following calculations:
(I) Total Medicaid inpatient days, as described in
subsection (d)(3) of this section; and
(II) Pass one distribution, as described in subsection
(h)(4) of this section.
(44) Total Medicaid inpatient hospital payments--Total
amount of Medicaid funds that a hospital received for adjudicated
claims for covered inpatient services during the DSH data year. The
term includes payments that the hospital received:
(A) for covered inpatient services from managed care
organizations and HHSC; and
(B) for patients eligible for Medicaid in other states.
(45) Total state and local payments--Total amount of
state and local payments that a hospital received for inpatient care
during the DSH data year. The term includes payments under state and
local programs that are funded entirely with state general revenue
funds and state or local tax funds, such as County Indigent Health
Care, Children with Special Health Care Needs, and Kidney Health Care.
The term excludes payment sources that contain federal dollars such
as Medicaid payments, Children's Health Insurance Program (CHIP) payments
funded under Title XXI of the Social Security Act, Substance Abuse
and Mental Health Services Administration, Ryan White Title I, Ryan
White Title II, Ryan White Title III, and contractual discounts and
allowances related to TRICARE, Medicare, and Medicaid.
(46) Urban public hospital--Any of the urban hospitals
listed in paragraph (47) or (48) of this subsection.
Cont'd... |
