7 AAC 150.180 - Methodology and criteria for additional payments as a disproportionate share hospital
(a) A qualifying
hospital that provides services to a disproportionate share of low-income
patients with special needs is eligible for Medicaid payments as a
disproportionate share hospital (DSH). These payments are in addition to the
Medicaid payment rate established under
7
AAC 150.160 or
7
AAC 150.190. The department will not award payments
under this section to a qualifying hospital in a total amount that exceeds the
facility-specific limit calculated under (e)(3) of this section.
(b) To qualify for additional payments under
this section as a DSH, a hospital must meet the following criteria for each
qualifying year:
(1) the hospital must be a
general acute care hospital, a critical access hospital, a specialty hospital,
or an inpatient psychiatric hospital;
(2) unless it qualifies for the exception set
out in 42 U.S.C.
1396r-4(d)(2), the
hospital must meet the obstetrical staffing requirements of
42 U.S.C.
1396r-4(d), and must
provide the names and Medicaid provider numbers of at least two obstetricians
who meet the requirements of that section;
(3) the hospital must have a minimum Medicaid
utilization rate of not less than one percent for the qualifying year; for
purposes of this paragraph, the Medicaid utilization rate is calculated by
dividing the hospital's number of Medicaid-eligible inpatient days by the
hospital's total number of inpatient days provided to all patients;
(4) not later than October 1 of the calendar
year that precedes the payment period, the hospital must submit to the
department the following forms and documentation:
(A) the Medicare cost report filed for the
qualifying year;
(B) Medicaid
reporting forms for the qualifying year from the Medicaid Hospital and
Long-Term Care Facility Reporting Manual, adopted by reference in
7
AAC 160.900, including the audited financial
statements for the facility;
(C) an
uninsured care log for the qualifying year for each patient having uninsured
care; the log must be prepared and submitted in electronic spreadsheet format
using the Medicaid Log of Uninsured Care Reporting Form,
adopted by reference in
7
AAC 160.900; the hospital must certify the log as
accurate in an electronic attachment with the submission of the uninsured care
log; with respect to uninsured care, the log must specify, in sufficient detail
for the department to verify the information,
(i) total charges;
(ii) each admission date;
(iii) the number of patient days;
(iv) any payments made by the patient, or on
behalf of the patient by a third party, for services;
(v) each discharge date;
(vi) each service type;
(vii) each payment designation; and
(viii) each date service was provided for
outpatient hospital services.
(c) When making a DSH classification under
(d) of this section, the department will use the following data sources as
applicable:
(1) for determination of Medicaid
covered inpatient days, Medicaid charges, Medicaid payments, and Medicaid
non-covered inpatient days, the MR-0-14 report for the qualifying year that is
available at least six months after the end of the hospital's fiscal year at
the time the calculation is performed;
(2) for determination and calculation of
total hospital allowable costs, total inpatient hospital costs, Medicaid
allowable costs, and physician costs, the Medicare cost report filed for the
qualifying year and forms required by (b)(4)(A) of this section;
(3) for total hospital days, total hospital
revenues, cash subsidies, and patient revenues, the forms required by (b)(4)(B)
of this section;
(4) the log
required by (b)(4)(C) of this section;
(5) if the department determines that a piece
of data or a data source listed in (1) - (4) of this subsection is unavailable,
an alternate data source that the department determines to include the same
information as the sources in (1) - (4) of this subsection.
(d) A qualifying hospital may
receive disproportionate share payments allocated to one or more of the
following DSH classifications, if that hospital meets any additional criteria
applicable to that classification, and subject to the limitations set out in
(e) of this section:
(1) payments allocated to
each Medicaid inpatient utilization DSH (MIU DSH), if the qualifying hospital
has a state Medicaid inpatient utilization rate at least one standard deviation
above the mean of state Medicaid inpatient utilization rates for all hospitals
in this state; for purposes of this paragraph,
(A) the state Medicaid inpatient utilization
rate is a fraction, expressed as a percentage, of which the numerator is the
hospital's number of Medicaid-eligible inpatient days in this state for the
hospital's qualifying year and the denominator is the total number of the
hospital's inpatient days for its qualifying year; and
(B) the mean of Medicaid inpatient
utilization rates for all hospitals in the state is the fraction, expressed as
a percentage, of which the numerator is the total number of Medicaid-eligible
inpatient days for all hospitals in this state for their qualifying year and
the denominator is the total number of inpatient days for all hospitals in this
state for their qualifying year;
(2) payments allocated to each low-income DSH
(LI DSH), if the qualifying hospital has a low-income utilization rate
exceeding 25 percent; for purposes of this paragraph, the low-income
utilization rate is calculated as the sum of
(A) the fraction, expressed as a percentage,
of which the numerator is the sum of the total Medicaid hospital revenue paid
to the qualifying hospital for patient services provided to Medicaid-eligible
patients in this state in the hospital's qualifying year and the amount of cash
subsidies received directly from the state or from local governments for
patient services provided in this state in the hospital's qualifying year, and
the denominator is the total amount of hospital revenue for services, including
the amount of cash subsidies specified in this subparagraph for that hospital's
qualifying year; and
(B) the
fraction, expressed as a percentage, of which the numerator is the total amount
of the qualifying hospital's charges for inpatient hospital services
attributable to charity care for the hospital's qualifying year, less the
portion of any cash subsidies received directly from the state or from local
governments for inpatient hospital services, and the denominator is the total
amount of the hospital's charges for inpatient services for the hospital's
qualifying year; for a state-owned qualifying hospital that does not have a
charge structure, the hospital's charges for charity care are equal to the cash
subsidies received by the hospital from the state or from local
governments;
(3) payments
allocated to each designated evaluation and treatment DSH (DET DSH), if the
qualifying hospital
(A) is designated as an
evaluation and treatment facility as required by 7 AAC 72;
(B) enters into an agreement with the
department to provide designated evaluation and treatment services and complies
with the requirements of that agreement; and
(C) not later than 60 days after the end of
each payment period, provides documentation to the department of the qualifying
patients as defined in the agreement made under (B) of this paragraph; that
documentation must include the number of encounters, the crisis category, the
diagnosis at discharge, the provider and location of referral after discharge,
and payment source information;
(4) payments allocated to each designated
evaluation and stabilization DSH (DES DSH) if the qualifying hospital
(A) is designated as an evaluation and
stabilization facility as required by 7 AAC 72;
(B) enters into an agreement with the
department to provide designated evaluation and stabilization treatment
services and complies with the requirements of that agreement; and
(C) not later than 60 days after the end of
each payment period, provides documentation to the department of the qualifying
patients as defined in the agreement made under (B) of this paragraph; that
documentation must include the number of encounters, the crisis category, the
diagnosis at discharge, the provider and location of referral after discharge,
and payment source information;
(5) payments allocated to each
single-point-of-entry psychiatric DSH (SPEP DSH), if the qualifying hospital
(A) enters into an agreement with the
department to provide single-point-of-entry psychiatric services and complies
with the requirements of that agreement; and
(B) not later than 60 days after the end of
each payment period, provides documentation to the department of the qualifying
patients as defined in the agreement made under (A) of this paragraph; that
documentation must include the number of encounters, the crisis category, the
diagnosis at discharge, the provider and location of referral after discharge,
and payment source information;
(6) payments allocated to each institution
for mental disease DSH (IMD DSH), if the IMD has been designated under 7 AAC 72
to receive involuntary commitments under
AS
47.30.700 -
47.30.815;
(7) payments allocated to each children's
medical care DSH (CMC DSH), if the qualifying hospital
(A) enters into an agreement with the
department for medical and hospital care expenses for children in custody who
are not Medicaid-eligible, and complies with the requirements of that
agreement; and
(B) not later than
60 days after the end of each payment period, provides documentation to the
department of the qualifying patients as defined in the agreement made under
(A) of this paragraph; that documentation must include the number of
encounters;
(8) payments
allocated to each institutional community health care DSH (ICHC DSH), if the
qualifying hospital
(A) enters into an
agreement with the department for medical and hospital care expenses for
individuals in institutions who are not Medicaid-eligible, and complies with
the requirements of that agreement; and
(B) not later than 60 days after the end of
each payment period, provides documentation to the department of the qualifying
patients as defined in the agreement made under (A) of this paragraph; that
documentation must include the number of encounters;
(9) payments allocated to each rural hospital
clinic assistance DSH (RHCA DSH), if the qualifying hospital
(A) enters into an agreement with the
department to provide support services to a clinic; the support services that
the hospital provides must include
(i)
services by hospital professional employees at the clinic site; the hospital
may include, as services, the services of a primary care provider, nurse
midwife services, obstetrical services, and pediatrician's services;
and
(ii) assistance in arranging
safe transport for those who require emergency transport and
services;
(B) complies
with the requirements of the agreement made under (A) of this paragraph;
and
(C) not later than 60 days
after the end of each payment period, provides documentation to the department
of the qualifying patients as defined in the agreement made under (A) of this
paragraph; that documentation must include the number of encounters that the
hospital provided at the clinic, and the support services as described in
(A)(i) and (ii) of this paragraph;
(10) payments allocated to each mental health
clinic assistance DSH (MHCA DSH), if the qualifying hospital
(A) enters into an agreement with the
department to provide mental health services to a mental health
clinic;
(B) complies with the
requirements of the agreement made under (A) of this paragraph; and
(C) not later than 60 days after the end of
each payment period, provides documentation to the department of the qualifying
patients as defined in the agreement made under (A) of this paragraph; that
documentation must include the number of mental health encounters that the
hospital provided at the mental health clinic;
(11) payments allocated to each substance
abuse treatment provider DSH (SATP DSH), if the qualifying hospital
(A) enters into an agreement with the
department to provide substance abuse treatment services to a substance abuse
treatment provider;
(B) complies
with the requirements of the agreement made under (A) of this paragraph;
and
(C) not later than 60 days
after the end of each payment period, provides documentation to the department
of the qualifying patients as defined in the agreement made under (A) of this
paragraph; that documentation must include the number of substance abuse
treatment encounters that the hospital provided through the substance abuse
treatment provider.
(e) The department will determine, as of the
qualification date, a hospital's eligibility for additional Medicaid payments
under each classification in (d) of this section for the hospital's qualifying
year, in the following manner:
(1) for the
MIU or LI DSH classification, a disproportionate share payment to each
qualifying hospital will be made annually; for any other DSH classification, a
disproportionate share payment to each qualifying hospital will be made in
accordance with the agreement required for that classification;
(2) a disproportionate share payment is
subject to the availability of appropriations from the legislature;
(3) the total annual disproportionate share
payment for each qualifying hospital is subject to a facility-specific limit
calculated under this paragraph and the federal requirements in
42 U.S.C.
1396r-4(g); for the
hospital's qualifying year, the limit is the cost of services provided to
Medicaid patients, less the amount paid to the hospital under provisions of
this chapter other than this section, plus the cost of services provided to
patients without health insurance or another source of third-party payments
that applied to services rendered during the qualifying year, less any payments
made by those patients without insurance or another source of third-party
payment for those services; the hospital's cost of services for this
calculation is the total hospital allowable costs, as determined in
7
AAC 150.160 and
7
AAC 150.170, divided by the hospital's total adjusted
inpatient days; this result is multiplied by the total of the hospital's
adjusted inpatient days not covered by insurance or third-party payment and
Medicaid adjusted inpatient days; the cost of services includes the cost of
excluded services under an insurance policy; the cost of services does not
include amounts that were not paid to the hospital by the patient's health
insurance or other source of third-party payments because of per diem maximums,
coverage limitations, or unpaid patient co-payments or deductibles; for
purposes of this paragraph, third-party payments do not include state payments
to hospitals paid under 7 AAC 47 (general relief medical assistance) or
7
AAC 48.500 -
7
AAC 48.900 (chronic and acute medical
assistance);
(4) a disproportionate
share payment is not subject to the payment limitations in
7
AAC 150.160(b)(8), (c)(3), or
(m);
(5) the disproportionate share payment is not
used in calculating the hospital's future years' Medicaid payment rates or
future disproportionate share payments;
(6) in addition to the general
facility-specific limit set out in (3) of this subsection, the total
disproportionate share payment amount to institutions for mental disease (IMDs)
may not exceed the federal IMD disproportionate share cap in effect for the
applicable fiscal year; by the qualification date each year, the department
will prepare an estimate of the federal IMD disproportionate share allotment to
the state and compare that estimate with the department's estimated total
payment amounts to the qualifying hospitals under this section for the next
federal fiscal year; if the department's estimated total payment amounts exceed
the department's estimate of the federal IMD disproportionate share allotment,
the disproportionate share payment amounts to each qualifying hospital for the
next federal fiscal year will be adjusted downward on a prorated basis until
the total amount of the disproportionate share payments for all qualifying
hospitals combined is equal to the total federal IMD disproportionate share
allotment to the state for the next federal fiscal year; the federal IMD
disproportionate share allotment is subject to recalculation, reallocation, and
recoupment, as set out in (j) of this section for the disproportionate share
allotment;
(7) the department will
allocate the federal disproportionate share hospital allotment as follows:
(A) for the IMD DSH classification, the
department will distribute the maximum allowed under the federal IMD
disproportionate share cap and the federal IMD disproportionate share
allotment;
(B) the department will
allocate to the MIU DSH classification one percent of the remaining
disproportionate share allotment after the allocation to the IMD DSH
classification is determined;
(C)
the department will allocate to the LI DSH classification one percent of the
remaining disproportionate share allotment after the allocation to the IMD DSH
classification is determined;
(D)
the department will allocate to the DET DSH classification at least one percent
but not more than 30 percent of the remaining disproportionate share allotment
after deducting the allocation under (A) - (C) of this paragraph;
(E) the department will allocate to the DES
DSH classification at least one percent but not more than 30 percent of the
remaining disproportionate share allotment after deducting the allocation under
(A) - (C) of this paragraph;
(F)
the department will allocate to the SPEP DSH classification at least one
percent but not more than 20 percent of the remaining disproportionate share
allotment after deducting the allocations under (A) - (C) of this
paragraph;
(G) the department may
allocate to the CMC DSH classification from zero to 20 percent of the remaining
disproportionate share allotment after deducting the allocation under (A) - (F)
of this paragraph;
(H) the
department may allocate to the ICHC DSH classification from zero to 10 percent
of the remaining disproportionate share allotment after deducting the
allocation under (A) - (F) of this paragraph;
(I) the department may allocate to the RHCA
DSH classification from zero to 35 percent of the remaining disproportionate
share allotment after deducting the allocation under (A) - (F) of this
paragraph;
(J) each
disproportionate share payment for the MIU DSH classification will be
calculated based on the qualifying hospital's SDM, divided by the sum of the
SDMs of all qualifying MIU DSHs in the qualifying year; the resulting
percentage will be multiplied by the allocation amount calculated in (B) of
this paragraph;
(K) each
disproportionate share payment for the LI DSH classification will be calculated
based on the qualifying hospital's LUR, divided by the sum of the LURs of all
qualifying LI DSHs in the qualifying year; the resulting percentage will be
multiplied by the allocation amount calculated in (C) of this
paragraph;
(L) each
disproportionate share payment for the DET DSH, DES DSH, SPEP DSH, CMC DSH,
ICHC DSH, RHCA DSH, MHCA DSH, and SATP DSH classifications will be based on the
number of encounters to be performed by the qualifying hospital for that
classification, as calculated in (D) - (I) and (M) and (N) of this
paragraph;
(M) the department may
allocate to the MHCA DSH classification from zero to 35 percent of the
remaining disproportionate share allotment after deducting the allocation under
(A) - (F) of this paragraph;
(N)
the department may allocate to the SATP DSH classification from zero to 15
percent of the remaining disproportionate share allotment after deducting the
allocation under (A) - (F) of this paragraph;
(O) the department may allocate a percentage
greater than the maximum percentage in (D) - (I) and (M) and (N) of this
paragraph only if the combined allocation under (D) - (I) and (M) and (N) of
this paragraph does not exceed 100 percent of the remaining disproportionate
share allotment after deducting the allocation under (A) - (D) of this
paragraph and the department determines that the final allocation among all
classifications will promote the availability of efficient and economic access
to health care services; in making that determination, the department will
consider these factors:
(i) the distribution
of medical services and resources in the communities of the state;
(ii) the availability of health services to
the general population in the same geographic area.
(f) The department will
make to each qualifying hospital within the MIU DSH classification and to each
qualifying hospital within the LI DSH classification a minimum payment of
$10,000 per payment period and per classification, subject to the
facility-specific limit calculated under (e)(3) of this section, the federal
IMD disproportionate share cap in effect for the next federal fiscal year, and
the amount of appropriations from the legislature. During a payment period, the
department will not make total annual disproportionate share payments that
exceed the total amount allowed under the state's federal disproportionate
share allotment for the applicable federal fiscal years. An eligible hospital
choosing to participate must notify the department of the hospital's choice to
participate in writing before the qualification date of the hospital's choice
to participate and include one or more DSH classifications for which the
hospital chooses to participate. The department's determination regarding
participation by an eligible hospital is contingent upon the hospital's
submission of a certified log of uninsured care for the qualifying year and a
departmental determination that the hospital's facility-specific limit permits
the receipt of DSH payments. The department's determination under this
subsection is the department's final administrative action, unless a request
for reconsideration is filed
(1) under (g) of
this section, regarding whether a hospital is a qualifying hospital;
or
(2) under (h) of this section,
regarding the amount of a qualifying hospital's disproportionate share payment
under this section.
(g) A
hospital aggrieved by the department's decision under (f)(1) of this section
may request reconsideration of the decision by filing a request for
reconsideration with the department not later than 10 days after the date of
the department's notification under (f)(1) of this section. The request for
reconsideration must state the facts in the record that support a reversal of
the initial decision. The department's decision on reconsideration is the
department's final administrative action on a reconsideration request under
this subsection. If the department does not issue a decision on reconsideration
30 days or less after the deadline for filing a request for reconsideration,
and if the department does not waive the 30-day deadline, the request is
considered denied by the department. The denial is the department's final
administrative action on a reconsideration request under this
subsection.
(h) A qualifying
hospital aggrieved by the department's determination under (f)(2) of this
section may request reconsideration of the determination by filing a request
for reconsideration not later than 10 days after the date of the department's
list of amounts under (f) of this section. If the department has made the
disproportionate share payment under this section to the qualifying hospital,
the department will accept and consider a request for reconsideration under
this subsection. A request for reconsideration under this subsection must state
the facts in the record supporting a change in the payment amount. The
department's decision on reconsideration is the department's final
administrative action on a reconsideration request under this subsection. If
the department does not issue a decision on reconsideration 30 days or less
after the deadline for filing a request for reconsideration, and if the
department does not waive the 30-day deadline, the request is considered denied
by the department. The denial is the department's final administrative action
on a reconsideration request under this subsection.
(i) The administrative appeal process
provided under
7
AAC 150.220 and the exceptional relief process set out
in 7 AAC 150.240 are not available to
a hospital disputing an item on the department's list under (h) of this section
of qualifying hospitals and amounts.
(j) The department will recalculate and
reallocate the disproportionate share eligibility and payments for all
hospitals and will recoup payments from all hospitals on a prorated basis if
the
(1) disproportionate share eligibility and
payment for any hospital will be recalculated as a result of a decision under
(g) or (h) of this section or of a court decision; or
(2) outcome of a decision under (g) or (h) of
this section or of a court decision would cause the total disproportionate
share payments to exceed the federal allotment for the federal fiscal year in
which the payment rate was in effect.
(k) A hospital that receives a Medicaid
payment as a DSH
(1) is subject to an
independent certified audit under
42 U.S.C.
1396r-4(j)(2) and
42 C.F.R.
455.300 -
455.304 three years after the
payment year to determine if an overpayment occurred; and
(2) shall furnish, in addition to other
information and documents required under this chapter, any additional
information and documents necessary for completion of the
audit.
(l) If an
independent certified audit under
42 U.S.C.
1396r-4(j)(2) and
42 C.F.R.
455.300 -
455.304 identifies an overpayment
for the payment year under review, the department will immediately issue a
written determination based on the audit to recoup the amount of the
overpayment from the hospital. A hospital aggrieved by a recoupment under this
subsection may request reconsideration by filing a request for reconsideration
with the department. The department staff that oversees Medicaid payment rates
may reconsider recoupment of a DSH overpayment upon the department staffs own
motion or at the hospital's request. A hospital seeking reconsideration must
file a request for reconsideration not later than 30 days after the date of
mailing the written determination to the hospital or providing the hospital the
determination by electronic mail. The department staff shall deny a request for
reconsideration as untimely if the request is filed later than 30 days after
the date of mailing the written determination to the hospital or providing the
hospital the determination by electronic mail. A request for reconsideration
under this subsection must be filed at the Anchorage location of the department
office that oversees Medicaid payment rates. The department's decision on
reconsideration is the department's final administrative action on a
reconsideration request under this subsection. If the department does not issue
a decision on reconsideration 30 days after receiving the request, the request
is considered denied. The denial is the department's final administrative
action on a reconsideration request under this subsection. However, the
department may notify the hospital that the 30-day period for issuing a
decision on reconsideration is tolled if the department needs to request
additional information from the hospital or consult with other state or federal
agencies.
(m) In this section,
(1) "adjusted inpatient days" means patient
days calculated as the product of patient days multiplied by total hospital
inpatient and outpatient charges, divided by hospital inpatient
charges;
(2) "admission" means
admission to a hospital for inpatient care;
(3) "encounter" means a unit of service,
visit, or face-to-face contact that is a covered service under an agreement
with the department as required under (d)(3), (4), (5), (7), (8), (9), (10), or
(11) of this section;
(4)
"inpatient days" means patient days at licensed hospitals that are calculated
(A) to include patient days related to a
hospitalization for acute treatment of the following:
(i) injured, disabled, or sick
patients;
(ii) substance abuse
patients who are hospitalized for substance abuse detoxification;
(iii) swing-bed patients whose hospital level
of care is reduced to nursing facility level without a physical move of the
patient;
(iv) patients hospitalized
for rehabilitation services for the rehabilitation of injured, disabled, or
sick persons;
(v) patients in a
hospital receiving psychiatric services for the diagnosis and treatment of
mental illness;
(vi) newborn
infants in hospital nurseries; and
(B) not to include patient days related to
the treatment of patients
(i) at licensed
nursing facilities;
(ii) in a
residential treatment bed;
(iii) on
a leave of absence from a hospital beginning with the day the patient begins a
leave of absence;
(iv) who are in a
hospital for observation to determine the need for inpatient admission;
or
(v) who receive services at a
hospital during the day but are not housed there at midnight;
(5) "Medicaid-eligible
inpatient days" means patient days at licensed hospitals that are calculated
(A) to include Medicaid-covered and
Medicaid-noncovered days related to a hospitalization for acute treatment of
the following:
(i) injured, disabled, or sick
patients;
(ii) substance abuse
patients who are hospitalized for substance abuse detoxification;
(iii) swing-bed patients whose hospital level
of care is reduced to nursing facility level without a physical move of the
patient;
(iv) patients hospitalized
for rehabilitation services for the rehabilitation of injured, disabled, or
sick persons;
(v) patients in a
hospital receiving psychiatric services for the diagnosis and treatment of
mental illness;
(vi) newborn
infants in hospital nurseries; and
(B) not to include Medicaid covered and
Medicaid non-covered patient days related to the treatment of patients
(i) at licensed nursing facilities;
(ii) in a residential treatment
bed;
(iii) on a leave of absence
from a hospital beginning with the day the patient begins a leave of
absence;
(iv) who are in a hospital
for observation to determine the need for inpatient admission; or
(v) who receive services at a hospital during
the day but are not housed there at midnight;
(6) "payment designation" means a designation
related to the source of reported payments;
(7) "payment period" means the state fiscal
year plus 90 days;
(8)
"qualification date" means July 1 of each year;
(9) "qualifying hospital" means a hospital
that qualifies as a DSH under this section;
(10) "qualifying year" means the hospital's
fiscal year ending
(A) at least 11 but not
later than 23 months before the beginning of the state fiscal year in which the
disproportionate share payment is made; and
(B) during the most recent 12-month reporting
cycle in which all facilities have filed a complete year-end report with the
department;
(11) "service
type" means a descriptor for the type of service provided during an inpatient
stay or an outpatient visit;
(12)
"uninsured care" means an inpatient or outpatient hospital service furnished by
a hospital to an individual who has no health insurance or other source of
third-party coverage in effect at the time the service was
rendered.
Notes
The mailing address for sending documentation required under 7 AAC 150.180, and for filing requests for reconsideration under 7 AAC 150.180, is the Department of Health and Social Services, Office of Rate Review, 3601 C Street Suite 978, Anchorage, AK 99503-5924.
Authority: AS 47.05.010
AS 47.07.070
AS 47.07.073
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