| (a) Introduction. The Texas Health and Human Services
Commission (HHSC) uses the methodology described in this section to
calculate a hospital-specific limit for each Medicaid hospital participating
in either the Disproportionate Share Hospital (DSH) program, described
in §355.8065 of this division (relating to Disproportionate Share
Hospital Reimbursement Methodology), or in the Texas Healthcare Transformation
and Quality Improvement Program (the waiver), described in §355.8201
of this subchapter (relating to Waiver Payments to Hospitals for Uncompensated
Care) and §355.8212 of this subchapter (relating to Waiver Payments
to Hospitals for Uncompensated Charity Care).
(b) Definitions.
(1) Adjudicated claim--A hospital claim for payment
for a covered Medicaid service that is paid or adjusted by HHSC or
another payor.
(2) Centers for Medicare and 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.
(3) Data year--A 12-month period that is two years
before the program year from which HHSC will compile data to determine
DSH or uncompensated-care waiver program qualification and payment.
(4) Demonstration Year--The time period described in
the definition for "Demonstration year" in §355.8212 of this
subchapter.
(5) 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.
(6) DSH and Uncompensated Care (UC) Application--The
HHSC data collection tool completed by each hospital applying for
participation in DSH or UC and used by HHSC to calculate the state
payment cap and hospital-specific limit, as described in this section,
and to estimate the hospital's DSH and UC payments for the program
year, as described in §355.8065 of this division (relating to
Disproportionate Share Hospital Reimbursement Methodology) and §355.8212
of this subchapter. A hospital may be required to complete multiple
applications due to different data requirements between the state
payment cap and hospital-specific limit calculations.
(7) DSH and UC Application Request Form--An online
survey sent to hospitals or its representatives to request a DSH and
UC application and to collect information necessary to prepopulate
the DSH and UC application.
(8) Dually eligible patient--A patient who is simultaneously
enrolled in Medicare and Medicaid.
(9) Federal Fiscal Year (FFY)--The 12-month period
beginning October 1 and ending September 30. The period also corresponds
to the waiver demonstration year.
(10) Full-Offset Payment Ceiling--The maximum payment
cap derived using the full-offset methodology as described in subsection
(c)(1) of this section.
(11) HHSC--The Texas Health and Human Services Commission
or its designee.
(12) Hospital-specific limit--The maximum payment amount
authorized by Section 1923(g) of the Social Security Act that a hospital
may receive in reimbursement for the cost of providing Medicaid-allowable
services to individuals who are Medicaid-eligible or uninsured for
payments made during a prior program year. The amount is calculated
as described in subsection (d) of this section using actual cost and
payment data from that period. The term does not apply to payment
for costs of providing services to non-Medicaid-eligible individuals
who have third-party coverage; and costs associated with pharmacies,
clinics, and physicians. The calculation of the hospital-specific
limit must be consistent with federal law.
(13) Inflation update factor--Cost of living index
based on the annual CMS Prospective Payment System Hospital Market
Basket Index.
(14) Institution for mental diseases (IMD)--A hospital
that is primarily engaged in providing psychiatric diagnosis, treatment,
or care of individuals with mental illness, defined in §1905(i)
of the Social Security Act. IMD hospitals are reimbursed as freestanding
psychiatric facilities under §355.8060 of this division (relating
to Reimbursement Methodology for Freestanding Psychiatric Facilities)
and §355.761 of this chapter (relating to Reimbursement Methodology
for Institutions for Mental Diseases (IMD)).
(15) Medicaid contractor--Fiscal agents and managed
care organizations with which HHSC contracts to process data related
to the Medicaid program.
(16) Medicaid cost-to-charge ratio (inpatient and outpatient)--A
Medicaid cost report-derived cost center ratio calculated for each
ancillary cost center that covers all applicable hospital costs and
charges relating to inpatient and outpatient care for that cost center.
This ratio is used in calculating the hospital-specific limit and
does not distinguish between payor types such as Medicare, Medicaid,
or private pay.
(17) Medicaid cost report--Hospital and Hospital Health
Care Complex Cost Report (Form CMS 2552), also known as the Medicare
cost report.
(18) 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.
(19) Medicaid payor type--The categories of payors
on Medicaid claims. These are categorized in the DSH and UC application
as Medicaid, where Medicaid is the sole payor, Medicare, for claims
associated with the care of dually eligible patients, and other insurance,
for claims for which the hospital received payment from a third-party
payor for a Medicaid-enrolled patient.
(20) Outpatient charges--Amount of gross outpatient
charges related to the applicable data year and used in the calculation
of a payment limit or cap.
(21) Program year--The 12-month period beginning October
1 and ending September 30. The period corresponds to the waiver demonstration
year.
(22) Recoupment Prevention Payment Ceiling--The maximum
payment cap derived using the methodology described in subsection
(c)(2) of this section that considers Medicaid only costs and payments
in the methodology.
(23) State payment cap--The maximum payment amount,
as applied to interim payments that will be made for the 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 amount is calculated as described in subsection
(c) of this section using interim cost and payment data from the data
year. The term does not apply to payment for costs of providing services
to non-Medicaid-eligible individuals who have third-party coverage
or costs associated with pharmacies, clinics, and physicians.
(24) The waiver--The Texas Healthcare Transformation
and Quality Improvement Program, a Medicaid demonstration waiver under §1115
of the Social Security Act that was approved by CMS. Pertinent to
this section, the waiver establishes a funding pool to assist hospitals
with uncompensated-care costs.
(25) 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
payor.
(26) Total state and local subsidies--Total state and
local subsidies is defined in §355.8065 of this division.
(27) Uncompensated Care Hospital--A hospital identified
by HHSC that meets the UC program eligibility criteria to receive
a payment as defined in §355.8212 of this subchapter.
(28) Uncompensated-care waiver payments--Payments to
hospitals participating in the waiver that are intended to defray
the uncompensated costs of eligible services provided to eligible
individuals.
(29) Uninsured cost--The cost to a hospital of providing
inpatient and outpatient hospital services to uninsured patients as
defined by CMS.
(c) Calculating a state payment cap. Using information
from each hospital's DSH and UC Application, Medicaid cost reports
and from HHSC's Medicaid contractors, HHSC will determine the hospital's
state payment cap in compliance with paragraphs (1), (2), (3), and
(4) of this subsection. The state payment cap will be used for both
DSH and uncompensated care waiver interim payment determinations.
(1) Calculation of uninsured and Medicaid costs and
payments.
(A) Uninsured charges and payments.
(i) Each hospital will report in its application its
inpatient and outpatient charges for services that would be covered
by Medicaid that were provided to uninsured patients discharged during
the data year. In addition to the charges in the previous sentence,
for DSH calculation purposes only, an IMD may report charges for Medicaid-allowable
services that were provided during the data year to Medicaid-eligible
and uninsured patients ages 21 through 64.
Cont'd... |
