Ohio Admin. Code 4123-6-37.1 - Payment of hospital inpatient services
(A) HPP .
Except as provided in paragraphs (A)(7) and (A)(8) of this
rule, reimbursement for 2024
2025 or after will be calculated as follows:
(1)
(a)
Reimbursement for hospital inpatient services, other than outliers as defined
in paragraph (A)(3) of this rule, services provided by hospitals subject to
reimbursement under paragraph (A)(4) of this rule, or acute or subacute
inpatient detoxification services subject to reimbursement on a per diem basis
under paragraph (A)(7) of this rule, will be calculated using the applicable
medicare severity diagnosis related group (MS-DRG) reimbursement rate for the
hospital inpatient service under the medicare inpatient prospective payment
system multiplied by a payment adjustment factor of 1.181
1.210 plus a new
technology add-on payment (if applicable), according to the following formula:
MS-DRG reimbursement rate x 1.181
1.210 + new
technology add-on payment (if applicable) = bureau reimbursement for
(b) In
the event the centers for medicare and medicaid services makes subsequent
adjustments to the medicare reimbursement rates under the medicare inpatient
prospective payment system as implemented by the materials specified in
paragraph (A)(10) of this rule other than technical corrections, including but
not limited to adjustments related to federal budget sequestration pursuant to
the Budget Control Act of 2011, 125 Stat. 239,
2 U.S.C.
900 to
907d as amended as of the effective
date of this rule, the "applicable medicare severity diagnosis related group
(MS-DRG) reimbursement rate for the hospital inpatient service under the
medicare inpatient prospective payment system" as specified in this paragraph
will be determined by the bureau without regard to such subsequent
adjustments.
(2) In
addition to the payment specified by paragraph (A)(1) of this rule, hospitals
operating approved graduate medical education programs and receiving additional
reimbursement from medicare for costs associated with these programs will
receive an additional per diem amount for direct graduate medical education
costs associated with hospital inpatient services reimbursed by the bureau.
Hospital specific per diem rates for direct graduate medical education will be
calculated annually by the bureau effective February first of each year, using
the most current cost report data available from the centers for medicare and
medicaid services, according to the following formula:
1.181
1.210 x [(total approved amount for resident cost
+ total approved amount for allied health cost)/ total
Direct graduate medical education per diems will not be applied
to outliers as defined in paragraph (A)(3) of this rule, services provided by
hospitals subject to reimbursement under paragraph (A)(4) of this rule, or
acute or subacute
(3)
(a)
Reimbursement for outliers as determined by medicare's inpatient prospective
payment system outlier methodology will be calculated using the applicable
medicare severity diagnosis related group (MS-DRG) reimbursement rate for the
hospital inpatient service under the medicare inpatient prospective payment
system multiplied by a payment adjustment factor of 1.181
1.210 plus the
applicable medicare operating outlier amount and medicare capital outlier
amount plus a new technology add-on payment (if applicable), according to the
following formula:
(MS-DRG reimbursement rate x 1.181
1.210) +
medicare operating outlier amount + medicare capital outlier amount + new
technology add-on payment (if applicable) = bureau reimbursement for
(b) In the event the centers for medicare and
medicaid services makes subsequent adjustments to the medicare reimbursement
rates under the medicare inpatient prospective payment system as implemented by
the materials specified in paragraph (A)(10) of this rule other than technical
corrections, including but not limited to adjustments related to federal budget
sequestration pursuant to the Budget Control Act of 2011, 125 Stat. 239,
2 U.S.C.
900 to
907d as amended as of the effective
date of this rule, the "applicable medicare severity diagnosis related group
(MS-DRG) reimbursement rate for the hospital inpatient service under the
medicare inpatient prospective payment system" as specified in this paragraph
will be determined by the bureau without regard to such subsequent
adjustments.
(4)
Reimbursement for inpatient services provided by hospitals and distinct-part
units of hospitals designated by the medicare program as exempt from the
medicare inpatient prospective payment system will be determined as follows:
(a) For hospitals the department of health
and human services, centers for medicare and medicaid services maintains
hospital -specific cost-to-charge ratio information on, reimbursement will be
equal to the hospital 's allowable billed charges multiplied by the hospital 's
reported operating cost-to-charge ratio information referenced in paragraph
(A)(10)(c) of this rule multiplied by a payment adjustment factor of
1.14, not to exceed seventy per
cent of the hospital 's allowed billed charges.
(b) For hospitals the department of health
and human services, centers for medicare and medicaid services does not
maintain hospital -specific cost-to-charge ratio information on, reimbursement
will be equal to the hospital 's allowable billed charges multiplied by the
applicable fiscal year 2024
2025 urban or
rural statewide average operating cost-to-charge ratio set forth in table 8A of
the federal rule referenced in paragraph (A)(10)(b) of this rule (the Ohio
average operating cost-to-charge ratio will be used for hospitals outside the
United States) multiplied by a payment adjustment factor of
1.14, not to exceed seventy per
cent of the hospital 's allowed billed charges.
(5) Reimbursement for inpatient services
provided by hospitals and distinct-part units of hospitals that do not
participate in the medicare program will be calculated in accordance with the
applicable provisions of paragraphs (A)(1) and (A)(3) of this rule using the
national standardized amount for fiscal year 2024
2025, full
update, as found at 88
89 Fed. Reg. 59356
69990 (2023
2024).
(6) Reimbursement for inpatient services
provided by "new hospitals" as defined in
42 C.F.R.
412.300(b) as published in
the October 1, 2023
2024 Code of Federal Regulations will be calculated in
the same manner as provided under paragraph (A)(4)(b) of this rule.
(7) Reimbursement for acute or subacute
inpatient detoxification services will be calculated in accordance with the
applicable provisions of paragraph (A) of this rule, unless the hospital elects
to be reimbursed for these services on a per diem basis, in which case the
hospital will be reimbursed the lesser of the charges billed by the hospital
for the allowed services rendered, the all-inclusive per diem rates set forth
in Table 1 of the appendix to this rule, or the rate the MCO contracted or
negotiated with the hospital .
(8)
Except for services subject to reimbursement on a per diem basis under
paragraph (A)(7) of this rule, if the MCO has contracted or negotiated a
different payment rate with a hospital pursuant to rule
4123-6-10 of the Administrative
Code, reimbursement will be at the contracted or negotiated rate.
(9) For purposes of this rule, hospitals must
report the applicable inpatient revenue codes for accommodation and ancillary
services set forth in Table 2 of the appendix to this rule.
(10) For purposes of this rule, the "medicare
severity diagnosis related group (MS-DRG) reimbursement rate," "medicare
operating outlier amount," "medicare capital outlier amount," and "new
technology add-on payment" will be determined in accordance with the medicare
program established under Title XVIII of the Social Security Act, 79 Stat. 286
(1965), 4 2 U.S.C. 1395 to 1395lll as amended as of the effective date of this
rule, excluding 4 2 U.S.C. 1395ww(m), as implemented by the following
materials, which are incorporated by reference:
(a) 42 C.F.R. Part 412 as published in the
October 1, 2023
2024 Code of Federal Regulations, excluding
42 C.F.R.
412.113(f),
42 C.F.R.
412.113(g), and 42 C.F.R.
Part 412 Subpart O;
(b)
Department of health and human services, centers for medicare and medicaid
services' "42 CFR Parts 411,
405, 412, 419, 488,
489 and
413, 431, 482, 485, 495, and 512 medicare and
medicaid programs and the children's health insurance 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 2024
2025 rates; quality programs
and medicare promoting interoperability
program requirements for eligible hospitals
and critical access hospitals; rural emergency hospital and physician -owned
hospital requirements; and provider and supplier disclosure of
ownership; and medicare disproportionate
share hospital (DSH) payments: counting certain days associated with section
1115 demonstrations in the medicaid fraction
other policy changes final rule,"
88
89 Fed.
Reg. 58640 - 59438
68986 - 70046 (2023
2024).
(c) The department of health and human
services, centers for medicare and medicaid services' hospital -specific
cost-to-charge ratio information as of the July 2023
2024 update to
the department of health and human services, centers for medicare and medicaid
services' inpatient provider specific file (IPSF).
(B) QHP or self insuring employer
(non-QHP ):
A
(1) The
applicable rate under the methodology set forth in paragraph (A) of this rule;
or
(2)
(a) For hospitals the department of health
and human services, centers for medicare and medicaid services maintains
hospital -specific cost-to-charge ratio information on, the hospital 's allowable
billed charges multiplied by the hospital 's reported operating cost-to-charge
ratio information referenced in paragraph (A)(10)(c) of this rule multiplied by
a payment adjustment factor of
1.14, not to exceed seventy per
cent of the hospital 's allowed billed charges;
(b) For hospitals the department of health
and human services, centers for medicare and medicaid services does not
maintain hospital -specific cost-to-charge ratio information on, the hospital 's
allowable billed charges multiplied by the applicable fiscal year
2024
2025
urban or rural statewide average operating cost-to-charge ratio set forth in
table 8A of the federal rule referenced in paragraph (A)(10)(b) of this rule
(the Ohio average operating cost-to-charge ratio will be used for hospitals
outside the United States) multiplied by a payment adjustment factor of
1.14, not to exceed seventy per
cent of the hospital 's allowed billed charges; or
(3) The rate negotiated between the hospital
and the QHP or self-insuring employer in accordance with rule
4123-6-46 of the Administrative
Code.
Notes
Promulgated Under: 119.03
Statutory Authority: 4121.12, 4121.121, 4121.30, 4121.31, 4123.05
Rule Amplifies: 4121.12, 4121.121, 4121.44, 4121.441, 4123.66
Prior Effective Dates: 01/01/2007, 04/01/2007, 01/01/2008, 02/01/2009, 02/01/2010, 02/01/2011, 02/01/2012, 02/03/2013, 02/01/2014, 02/01/2015, 02/01/2016, 02/01/2017, 02/01/2018, 02/01/2019, 02/01/2020, 02/01/2021, 02/01/2022, 02/01/2023, 02/01/2024, 05/01/2024
State regulations are updated quarterly; we currently have two versions available. Below is a comparison between our most recent version and the prior quarterly release. More comparison features will be added as we have more versions to compare.
(A) HPP .
Except as provided in paragraphs (A)(7) and (A)(8) of this rule, reimbursement for
(1)
(a) Reimbursement for hospital inpatient services, other than outliers as defined in paragraph (A)(3) of this rule, services provided by hospitals subject to reimbursement under paragraph (A)(4) of this rule, or acute or subacute inpatient detoxification services subject to reimbursement on a per diem basis under paragraph (A)(7) of this rule, will be calculated using the applicable medicare severity diagnosis related group (MS- DRG) reimbursement rate for the hospital inpatient service under the medicare inpatient prospective payment system multiplied by a payment adjustment factor of 1.181 plus a new technology add-on payment (if applicable), according to the following formula:
MS-DRG reimbursement rate x 1.181 + new technology add-on payment (if applicable) = bureau reimbursement for
(b) In the event the centers for medicare and medicaid services makes subsequent adjustments to the medicare reimbursement rates under the medicare inpatient prospective payment system as implemented by the materials specified in paragraph (A)(10) of this rule other than technical corrections, including but not limited to adjustments related to federal budget sequestration pursuant to the Budget Control Act of 2011, 125 Stat. 239, 2 U.S.C. 900 to 907d as amended as of the effective date of this rule, the "applicable medicare severity diagnosis related group (MS-DRG) reimbursement rate for the hospital inpatient service under the medicare inpatient prospective payment system" as specified in this paragraph will be determined by the bureau without regard to such subsequent adjustments.
(2) In addition to the payment specified by paragraph (A)(1) of this rule, hospitals operating approved graduate medical education programs and receiving additional reimbursement from medicare for costs associated with these programs will receive an additional per diem amount for direct graduate medical education costs associated with hospital inpatient services reimbursed by the bureau. Hospital specific per diem rates for direct graduate medical education will be calculated annually by the bureau effective February first of each year, using the most current cost report data available from the centers for medicare and medicaid services, according to the following formula:
1.181 x [(total approved amount for resident cost + total approved amount for allied health cost)/ total
Direct graduate medical education per diems will not be applied to outliers as defined in paragraph (A)(3) of this rule, services provided by hospitals subject to reimbursement under paragraph (A)(4) of this rule, or acute or subacute
(3)
(a) Reimbursement for outliers as determined by medicare's inpatient prospective payment system outlier methodology will be calculated using the applicable medicare severity diagnosis related group (MS- DRG) reimbursement rate for the hospital inpatient service under the medicare inpatient prospective payment system multiplied by a payment adjustment factor of 1.130 1.181 plus the applicable medicare operating outlier amount and medicare capital outlier amount plus a new technology add-on payment (if applicable), according to the following formula:
(MS-DRG reimbursement rate x 1.181) + medicare operating outlier amount + medicare capital outlier amount + new technology add-on payment (if applicable) = bureau reimbursement for
(b) In the event the centers for medicare and medicaid services makes subsequent adjustments to the medicare reimbursement rates under the medicare inpatient prospective payment system as implemented by the materials specified in paragraph (A)(10) of this rule other than technical corrections, including but not limited to adjustments related to federal budget sequestration pursuant to the Budget Control Act of 2011, 125 Stat. 239, 2 U.S.C. 900 to 907d as amended as of the effective date of this rule, the "applicable medicare severity diagnosis related group (MS-DRG) reimbursement rate for the hospital inpatient service under the medicare inpatient prospective payment system" as specified in this paragraph will be determined by the bureau without regard to such subsequent adjustments.
(4) Reimbursement for inpatient services provided by hospitals and distinct-part units of hospitals designated by the medicare program as exempt from the medicare inpatient prospective payment system will be determined as follows:
(a) For hospitals the department of health and human services, centers for medicare and medicaid services maintains hospital -specific cost-to- charge ratio information on, reimbursement will be equal to the hospital 's allowable billed charges multiplied by the hospital 's reported operating cost-to-charge ratio information referenced in paragraph (A)(10)(c) of this rule multiplied by a payment adjustment factor of 1.14, not to exceed seventy per cent of the hospital 's allowed billed charges.
(b) For hospitals the department of health and human services, centers for medicare and medicaid services does not maintain hospital -specific cost- to-charge ratio information on, reimbursement will be equal to the hospital 's allowable billed charges multiplied by the applicable fiscal year 2024 urban or rural statewide average operating cost-to-charge ratio set forth in table 8A of the federal rule referenced in paragraph (A)(10)(b) of this rule (the Ohio average operating cost-to-charge ratio will be used for hospitals outside the United States) multiplied by a payment adjustment factor of 1.14, not to exceed seventy per cent of the hospital 's allowed billed charges.
(5) Reimbursement for inpatient services provided by hospitals and distinct-part units of hospitals that do not participate in the medicare program will be calculated in accordance with the applicable provisions of paragraphs (A)(1) and (A)(3) of this rule using the national standardized amount for fiscal year 2024, full update, as found at 88 Fed. Reg. 59356 (2023).
(6) Reimbursement for inpatient services provided by "new hospitals" as defined in 42 C.F.R. 412.300(b) as published in the October 1, 2023 Code of Federal Regulations will be calculated in the same manner as provided under paragraph (A)(4)(b) of this rule.
(7) Reimbursement for acute or subacute inpatient detoxification services will be calculated in accordance with the applicable provisions of paragraph (A) of this rule, unless the hospital elects to be reimbursed for these services on a per diem basis, in which case the hospital will be reimbursed the lesser of the charges billed by the hospital for the allowed services rendered, the all-inclusive per diem rates set forth in Table 1 of the appendix to this rule, or the rate the MCO contracted or negotiated with the hospital .
(8) Except for services subject to reimbursement on a per diem basis under paragraph (A)(7) of this rule, if the MCO has contracted or negotiated a different payment rate with a hospital pursuant to rule 4123-6-10 of the Administrative Code, reimbursement will be at the contracted or negotiated rate.
(9) For purposes of this rule, hospitals must report the applicable inpatient revenue codes for accommodation and ancillary services set forth in Table 2 of the appendix to this rule.
(10) For purposes of this rule, the "medicare severity diagnosis related group (MS- DRG) reimbursement rate," "medicare operating outlier amount," "medicare capital outlier amount," and "new technology add-on payment" will be determined in accordance with the medicare program established under Title XVIII of the Social Security Act, 79 Stat. 286 (1965), 42 U.S.C. 1395 to 1395lll as amended as of the effective date of this rule, excluding 4 2 U.S.C. 1395ww(m), as implemented by the following materials, which are incorporated by reference:
(a) 42 C.F.R. Part 412 as published in the October 1, 2023 Code of Federal Regulations;
(b) Department of health and human services, centers for medicare and medicaid services' "42 CFR Parts 411, 412, 419, 488, 489 and 495 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 2024 rates; quality programs and medicare promoting interoperability program requirements for eligible hospitals and critical access hospitals; rural emergency hospital and physician -owned hospital requirements; and provider and supplier disclosure of ownership; and medicare disproportionate share hospital (DSH) payments: counting certain days associated with section 1115 demonstrations in the medicaid fraction final rule," 88 Fed. Reg. 58640 - 59438 (2023).
(c) The department of health and human services, centers for medicare and medicaid services' hospital -specific cost-to-charge ratio information as of the July 2023 update to the department of health and human services, centers for medicare and medicaid services' inpatient provider specific file (IPSF).
(B) QHP or self insuring employer (non-QHP ):
A
(1) The applicable rate under the methodology set forth in paragraph (A) of this rule; or
(2)
(a) For hospitals the department of health and human services, centers for medicare and medicaid services maintains hospital -specific cost- to-charge ratio information on, the hospital 's allowable billed charges multiplied by the hospital 's reported operating cost-to-charge ratio information referenced in paragraph (A)(10)(c) of this rule multiplied by a payment adjustment factor of 1.14, not to exceed seventy per cent of the hospital 's allowed billed charges;
(b) For hospitals the department of health and human services, centers for medicare and medicaid services does not maintain hospital -specific cost- to-charge ratio information on, the hospital 's allowable billed charges multiplied by the applicable fiscal year 2024 urban or rural statewide average operating cost-to-charge ratio set forth in table 8A of the federal rule referenced in paragraph (A)(10)(b) of this rule (the Ohio average operating cost-to-charge ratio will be used for hospitals outside the United States) multiplied by a payment adjustment factor of 1.14, not to exceed seventy per cent of the hospital 's allowed billed charges; or
(3) The rate negotiated between the hospital and the QHP or self-insuring employer in accordance with rule 4123-6-46 of the Administrative Code.
Notes
Promulgated Under: 119.03
Statutory Authority: 4121.12, 4121.121, 4121.30, 4121.31, 4123.05
Rule Amplifies: 4121.12, 4121.121, 4121.44, 4121.441, 4123.66
Prior Effective Dates: 01/01/2007, 04/01/2007, 01/01/2008, 02/01/2009, 02/01/2010, 02/01/2011, 02/01/2012, 02/03/2013,02/01/2014, 02/01/2015, 02/01/2016, 02/01/2017,02/01/2018, 02/01/2019, 02/01/2020, 02/01/2021,02/01/2022, 02/01/2023, 02/01/2024