Haw. Code R. § 17-1739-55 - Payment for acute care services -general provisions

(a) The Hawaii medicaid program shall reimburse qualified providers for inpatient institutional services based solely on the prospective payment rates developed for each facility as determined in accordance with this subchapter. The estimated average proposed payment rate under this subchapter is reasonably expected to pay no more in the aggregate for inpatient hospital services than the amount that the department reasonably estimates would be paid for those services under Medicare principles of reimbursement.

(b) A hospital-specific retrospective settlement adjustment shall be made for those providers whose medicaid charges are less than medicaid payments on the cost report and do not qualify as nominal charge providers under Medicare principles of reimbursement.

(c) Prospective rates shall be derived from historical facility costs, and facilities shall be classified based on discharge volume and participation in an approved intern and resident teaching program.

(d) Providers which average fewer than 250 medicaid discharges per year shall be classified as classification I facilities and shall receive payment based on either an all-inclusive psychiatric services per diem rate or an all-inclusive nonpsychiatric services per diem rate, which includes an adjustment for capital, disproportionate share, and medical education and, for proprietary facilities, return on equity and gross excise tax.

(e) Providers which average two hundred fifty medicaid discharges or more per year shall be separated into two facility classifications (classifications II and III) and shall receive payment based upon the type of services required by the patient. Psychiatric services will be paid on the basis of an all-inclusive per diem rate. Nonpsychiatric claims will be designated as requiring either surgical, medical, or maternity care and will be paid on the basis of a routine per diem rate for the service type plus an ancillary per discharge rate for the service type. The per diem and per discharge rates shall include adjustments for capital, medical education, disproportionate share, and for proprietary facilities, return on equity and gross excise tax.

(f) The freestanding rehabilitation hospital shall be excluded from classifications I, II, and III and shall receive payment based on either an all-inclusive psychiatric services per diem rate or an all-inclusive nonpsychiatric services per diem rate, with the same adjustments noted above.

(g) Claims for payment shall be submitted following discharge of a patient, except as follows:

(1) Claims for nonpsychiatric inpatient stays which exceed $35,000 shall be submitted in accordance with section 17-1739-72;

(2) If a patient is hospitalized in the freestanding rehabilitation hospital for more than thirty days, the facility may submit an interim claim for payment every thirty days until discharge. The final claim for payment shall cover services rendered on all those days not previously included in an interim claim.

(h) The prospective payment rates shall be paid in full for each medicaid discharge. Hospitals may not separately bill the patient or the medicaid program for medical services rendered during an inpatient stay, except for outlier payments and as provided in section 17-1739-56 below.

(i) At the point that a patient reaches outlier status, the facility is eligible for interim payments computed pursuant to section 17-1739-72.

Notes

Haw. Code R. § 17-1739-55

[Eff 11/13/95] (Auth: HRS § 346-59) (Imp: 42 C.F.R. §447.252)