42 CFR 412.538 - Limitation on long-term care hospital admissions from referring hospitals.

§ 412.538 Limitation on long-term care hospital admissions from referring hospitals.

(a)Scope.

(1) The provisions of this section apply to all long-term care hospitals excluded from the hospital inpatient prospective payment system under § 412.23(e), except as specified in paragraph (a)(2) of this section, effective for discharges occurring on or after October 1, 2018.

(2) Notwithstanding the preceding paragraphs of this section, the provisions of this section do not apply to -

(i) A long-term care hospital described in § 412.23(e)(2)(ii); or

(ii) A long-term care hospital described in § 412.23(e)(2)(i) that meets the criteria in § 412.22(f).

(3) For purposes of this section, all long-term care hospitals described in paragraph (a)(1) of this section and all referring hospitals are as identified by CCN.

(b)Discharges at or below the applicable percent threshold. For any long-term care hospital that is not exempted by paragraph (a)(2) of this section with discharges occurring as described in paragraph (a)(1) of this section, of which no more than the applicable percent threshold (as defined in paragraph (e) of this section) was admitted to the long-term care hospital from a single referring hospital, payments are the amount otherwise payable under this subpart without adjustment under this section.

(c)Discharges in excess of the applicable percent threshold. For any long-term care hospital that is not exempted by paragraph (a)(2) of this section with discharges occurring as described in paragraph (a)(1) of this section, of whom more than the applicable percentage threshold (as defined in paragraph (e) of this section) was admitted to the long-term care hospital from a single referring hospital, payments for the Medicare discharges that caused the long-term care hospital to exceed or remain in excess of such threshold are paid at the lesser of the amount otherwise payable under this subpart without adjustment under this section or the amount equivalent to the hospital inpatient prospective payment system amount as defined in paragraph (f) of this section. Payments for discharges not in excess of the applicable percentage threshold (as defined in paragraph (e) of this section) are the amount otherwise payable under this subpart without adjustment under this section.

(d)Determination of exceeding the applicable percentage threshold.

(1)General. The determination of whether a long-term care hospital (as described in paragraph (a)(1)) of this section has exceeded its applicable percentage threshold (as defined in paragraph (e) of this section) in regard to discharges described in paragraph (a)(1) of this section that were admitted from a single referring hospital is made by comparing the long-term care hospital's percentage of Medicare discharges occurring as described in paragraph (a)(1) of this section (as calculated under paragraph (d)(2) of this section) to the long-term care hospital's applicable percentage threshold in paragraph (e) of this section.

(2)Percentage of Medicare discharges. For each referring hospital, the percentage of Medicare discharges admitted to the long-term care hospital is calculated by dividing the amount in paragraph (d)(2)(i) of this section by the amount in paragraph (d)(2)(ii) of this paragraph.

(i) The number of the long-term care hospital's Medicare discharges in the cost reporting period that were admitted from a single referring hospital on whose behalf an outlier payment was not made to that referring hospital, and for whom payment was not made by a Medicare Advantage plan.

(ii) The long-term care hospital's total number of Medicare discharges in its cost reporting period for whom payment was not made by a Medicare Advantage plan.

(e)Applicable percentage threshold.

(1)General. For the purposes of this section, except as provided for in paragraphs (e)(2) and (3) of this section, “applicable percentage threshold” means 25 percent.

(2)Special treatment of exclusively rural long-term care hospitals. In the case of a long-term care hospital that is located in a rural area as defined in § 412.503, the applicable percentage threshold means 50 percent. If a long-term care hospital has multiple locations, all locations of the long-term care hospital must be in a rural area (as defined in § 412.503) in order to be treated as rural under this section.

(3)Special treatment for long-term care hospitals located in an MSA with an MSA-dominant hospital. In the case of a long-term care hospital that admits Medicare patients from a referring MSA-dominant hospital (as defined in § 412.503), the applicable percentage threshold means the MSA-dominant hospital's percentage of total subsection (d) hospital Medicare discharges in the MSA in which the long-term care hospital is located during the cost reporting period for which the adjustment under this section is made, but in no case is less than 25 percent or more than 50 percent. The determination of the applicable percentage threshold in this paragraph does not include discharges paid by a Medicare Advantage plan. If a long-term care hospital has multiple locations payable under this subpart, all locations of the long-term care hospital must be in an MSA with an MSA-dominant hospital in order to be treated as such under this section.

(f)Determining the amount equivalent to the hospital inpatient prospective payment system amount. - (1) As specified in paragraphs (b) and (c) of this section, CMS calculates an amount payable under subpart O that is equivalent to an amount that would be paid for the services provided if such services had been provided in an inpatient prospective payment system hospital (that is, the amount that would be determined under the rules at § 412.1(a)). This amount is based on the sum of the applicable hospital inpatient prospective payment system operating standardized amount and capital Federal rate in effect (as set forth in section § 412.529(d)(4)) at the time of the long-term care hospital discharge.

(2) In addition to the payment amount under paragraph (f)(1) of this section, an additional payment for high-cost outlier cases is based on the applicable fixed-loss amount established for the hospital inpatient prospective payment system in effect at the time of the long-term care hospital discharge.

[ 81 FR 57269, Aug. 22, 2016, as amended at 82 FR 38513, Aug. 14, 2017]

This is a list of United States Code sections, Statutes at Large, Public Laws, and Presidential Documents, which provide rulemaking authority for this CFR Part.

This list is taken from the Parallel Table of Authorities and Rules provided by GPO [Government Printing Office].

It is not guaranteed to be accurate or up-to-date, though we do refresh the database weekly. More limitations on accuracy are described at the GPO site.


United States Code

Title 42 published on 20-Oct-2017 03:48

The following are ALL rules, proposed rules, and notices (chronologically) published in the Federal Register relating to 42 CFR Part 412 after this date.

  • 2017-10-04; vol. 82 # 191 - Wednesday, October 4, 2017
    1. 82 FR 46138 - Medicare Program; Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the Long-Term Care Hospital Prospective Payment System and Policy Changes and Fiscal Year 2018 Rates; Quality Reporting Requirements for Specific Providers; Medicare and Medicaid Electronic Health Record (EHR) Incentive Program Requirements for Eligible Hospitals, Critical Access Hospitals, and Eligible Professionals; Provider-Based Status of Indian Health Service and Tribal Facilities and Organizations; Costs Reporting and Provider Requirements; Agreement Termination Notices; Correction
      GPO FDSys XML | Text
      DEPARTMENT OF HEALTH AND HUMAN SERVICES, Centers for Medicare & Medicaid Services
      Final rule; correction.
      This correction is effective October 1, 2017.
      42 CFR Parts 405, 412, 413, 414, 416, 486, 488, 489, and 495

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