048-24 Wyo. Code R. §§ 24-4 - Definitions

(a) "Admission". The act by which an individual is admitted to a hospital as an inpatient or an outpatient. "Admission" does not include a new born child or an individual that is transferred from one unit of a hospital to another unit in the hospital or to a distinct part hospital unit.

(b) "Allowable costs". Medicare allowable costs, except as otherwise specified by this Chapter.

(c) "Base year". A hospital's first 12 month cost reporting period ending on or after September 30, 1982 and before September 30, 1983.

(d) "Chapter I". Chapter I, Rules for Medicaid Administrative Hearings, of the Wyoming Medic-aid rules.

(e) "Claim". A request by a provider for Medicaid payment for services provided to a recipient.

(f) "Cost report". An itemized statement of a hospital's costs for its most recently completed fiscal year, including an audited or unaudited financial statement, prepared in accordance with GAAP and the instructions of the Department. A cost report must include the information and be prepared in the form specified by the Department and the intermediary, and must be submitted in hardcopy and on computer disc using software designated by the Department. "Cost report" includes any supplemental request by the Department for additional information relating to the hospitals costs and the hospitals efforts to achieve efficiencies or other cost savings.

(g) "Covered service". A health service or supply eligible for Medicaid reimbursement pursuant to the rules and policies of the Department. "Covered service" does not include nursing facility services.

(h) "Credit balance". Medicaid funds received by a hospital that are owed to the Department for any reason.

(i) "Department". The Wyoming Department of Health, its designee, agent or successor.

(j) "Desk review". A review by the Department of a hospitals cost report to determine:

(i) if the cost report has been prepared and submitted in compliance with this rule;

(ii) that costs have been properly allocated; and

(iii) that costs are allowable.

(k) "Director". The Director of the Department or the Director's designee.

(l) "Disproportionate share hospital". A disproportionate share hospital as defined by Pub. L. No. 100-203, Section 4112, 101 Stat. 1330-149- 50, which is incorporated by reference.

(m) "Distinct part hospital unit". A distinct part hospital unit excluded from the Medicare prospective payment system pursuant to 42 C.F.R. 412.20(b)(1), which is incorporated by this reference.

(n) "Division". The Division of Health Care Financing of the Department, its agent, designee or successor.

(o) "Excess payments". Medicaid funds received by a provider which exceed the Medicaid allowable payment established by the Department.

(p) "Extraordinary circumstances". A catastrophic occurrence, beyond the control of a provider, which results in substantially higher costs and which meets the criteria set forth in (i) through (v), "Extraordinary circumstances" include, but are not limited to, labor strikes, fire, earthquakes, floods or similar circumstances which result in substantial cost increases, and which:

(i) Is a one-time occurrence;

(ii) Could not have reasonably been predicted;

(iii) Is not insurable;

(iv) Is not covered by federal or state disaster relief; and

(v) Is not the result of intentional, reckless or negligent actions or inactions by any director, officer, employee or agent of the provider.

(q) "Field audit". An examination, verification and review of a hospital's financial records and any supporting or related documentation conducted by employees, agents or representatives of the Department or HHS.

(r) "Financial records". All records, in whatever form, used or maintained by a hospital in the conduct of its business affairs and which are necessary to substantiate or understand the information contained in the hospital's cost reports.

(s) "Generally accepted accounting principles (GAAP)." Accounting concepts, standards and procedures established by the American Institute of Certified Public Accountants.

(t) "Generally accepted auditing standards (GAAS)." Auditing standards, practices, and procedures established by the American Institute of Certified Public Accountants.

(u) "HCFA". The Health Care Financing Administration of HHS, its agent, designee or successor.

(v) "HHS". The United States Department of Health and Human Services, its agent, designee or successor.

(w) "Hospital". An institution that:

(i) is approved to participate as a hospital under Medicare;

(ii) is maintained primarily for the treatment and care of patients with disorders other than mental diseases or tuberculosis;

(iii) has a provider agreement;

(iv) is enrolled in the Medicaid program; and

(v) is licensed to operate as a hospital by the State of Wyoming or, if the institution is out-of-state, licensed by the state in which the institution is located.

(x) "Inpatient". An inpatient as defined by 42 C.F.R. 440.2(a), which is incorporated by this reference.

(y) "Inpatient hospital service". "Inpatient hospital services" as defined in 42 C.F.R. 440.10, which is incorporated by this reference.

(z) "Interim rate". The interim reimbursement rate established pursuant to Sections 5 and 6.

(aa) "Low income utilization rate". The "low income utilization rate" as defined by Pub. L. No. 100-203, 4 11 2(b)(3), 101 Stat. 1330-149, which is incorporated by reference.

(bb) "Medicaid". Medical assistance and services provided pursuant to Title XIX of the Social Security Act and the Wyoming Medical Assistance and Services Act.

(cc) "Medicaid utilization rate". The "Medicaid utilization rate" as defined by Pub. L. No. 100-203 4112(b)(2), 101 Stat. 1330-149, which is incorporated by reference.

(dd) "Medical record". All documents, in whatever form, in the possession of or subject to the control of the hospital which describe the recipients diagnosis, condition or treatment, including, but not limited to, the plan of care for the recipient.

(ee) "Medicare". The health insurance program for the aged and disabled established pursuant to Title XVIII of the Social Security Act.

(ff) "Medicare allowable costs." Costs incurred by a hospital which are allowable under Medicare principles of cost reimbursement.

(gg) "Medicare intermediary". The intermediary for Medicare Part A appointed pursuant to 42 U.S.C. 1395 u.

(hh) "Medicare principles of cost reimbursement." The inpatient hospital reimbursement principles established by Medicare as set forth in the Provider Reimbursement Manual and HCFAs instructions for administering the Manual, which are incorporated by reference. The Provider Reimbursement Manual and the HCFA instructions are published by HCFA and are available from that agency. The Provider Reimbursement Manual is also published in the CCH Medicare and Medicaid Guide, beginning at 7227, and is available from Commerce Clearing House, 4025 West Peterson Avenue, Chicago, Illinois 60646.

(ii) "Most recently settled Medicare cost report. " A facility's most recent cost report which has been (i) submitted to Medicare, in accordance with Medicare standards and procedures; (ii) cost settled by the Medicare intermediary using Medicare principles of cost reimbursement; and (iii) for which a notice of program reimbursement has been issued. A cost report is considered settled notwithstanding a request to reopen.

(jj) "New hospital." A hospital which has not filed an audited Medicare cost report with the Department.

(kk) "Nonallowable costs. " Costs which are not related to covered services. Nonallowable costs include, but are not limited to:

(i) Costs related to other services as described in Section 11; and

(ii) As otherwise specified in this Chapter and the other rules of the Department.

(ll) "Notice of disproportionate share payments. " Written notice from the Department to a hospital, sent by certified mail, of the amount of disproportionate share payments, if any, to which the hospital is entitled pursuant to this rule.

(mm) "Notice of Medicaid Program Reimbursement." Written notice from the Department to a hospital, sent by certified mail, which includes, if available, the hospitals Medicaid allowable costs, cost to charge ratio and interim reimbursement rate.

(nn) "Notice of Program Reimbursement." Written notice from the Medicare intermediary to the Department of a hospital's Medicaid allowable costs, cost to charge ratio and interim reimbursement rate.

(oo) "Nursing facility services." Intermediate care facility services as defined by 42 U.S.C.S 1396d(d), Skilled nursing facility services as defined by 42 U.S.C. 1396 d(f) or nursing facility services as defined by Pub. L. No. 100-203, section 4211 (a).

(pp) "Outpatient." An outpatient as defined by 42 C.F.R. 440.2(a), which is incorporated by this reference.

(qq) "Outpatient hospital service." "Outpatient hospital services" as defined in 42 C.F.R. 440.20(a), which is incorporated by this reference.

(rr) "Overpayments." The amount by which the interim rate a hospital received exceeds the final cost-settled amount determined pursuant to Section 8.

(ss) "Provider." A hospital which has a current provider agreement, is licensed to provide services and is enrolled with the Department as a provider.

(tt) "Provider agreement." A written contract between a provider and the Department in which the provider agrees to comply with the provisions of the contract and applicable federal and State statutes and regulations as a prerequisite to receiving Medicaid funds for services provided to recipients.

(uu) "Recipient." A person who has been determined eligible for Medicaid.

(vv) "Reopen." A request by a hospital, the intermediary or the department, pursuant to the procedures and standards established by Medicare, to re-examine or review the correctness established of a cost settlement determination or decision made by or on behalf of Medicare.

(ww) "Request for consideration of disproportionate payment." A request by a hospital located outside the State of Wyoming that the Department determine whether the hospital is entitled to disproportionate share payment. Such a request must be in writing, sent by certified mail, include the information necessary for the Department to compute the hospital's Medicaid utilization rate or the hospitals low income utilization rate, depending on whether the hospital is requesting payments pursuant to paragraphs 9(b)(i) or 9(b)(ii), and be prepared in the form specified by the Department. "Request for consideration of disproportionate payments" includes any supplemental request by the Department for additional information.

(xx) "Request for consideration of disproportionate share payments based on low income utilization rate." A request by a hospital located in the State of Wyoming that the Department determine whether the hospital is entitled to disproportionate share payments based on the hospital's low income utilization rate. Such a request must be in writing, sent by certified mail, include the information necessary for the Department to compute the hospitals low income utilization rate, and be prepared in the form specified by the Department. "Request for consideration of disproportionate payments based on low income utilization rate" includes any supplemental request by the Department for additional information.

(yy) "Request for TEFRA target rate adjustment." A request, pursuant to Section 16, for a rate adjustment. "Request for TEFRA target rate adjustment" does not include any request to reopen a provider's cost report or any request for a change in a providers Medicaid rate based on Medicare principles of cost reimbursement; any such requested change must be handled pursuant to the procedures and standards established by Medicare.

(zz) "Swing-bed." A bed in a hospital which is certified for either inpatient services or nursing facility services.

(aaa) "Swing-bed services." Nursing facility services provided to a recipient in a swing-bed.

(bbb) "Target amount." "Target amount "as defined by 42 U.S.C. 1395 ww(b)(3), which is incorporated by this reference.

(ccc) "TEFRA." The Tax Equity and Fiscal Responsibility Act, Pub. L. No. 97-248, 96 Stat. 370 (1982).

(ddd) "TEFRA limits." The limits established pursuant to 42 C.F.R. 413.40, which is incorporated by this reference, and inflated by the TEFRA update factor as published from time to time in the Federal Register.

(eee) "TEFRA target rate adjustment. " A change in a hospitals Medicaid rate based on extraordinary circumstances or the criteria specified in subsection 16(c), other than a change based on Medicare principles of cost reimbursement.

(fff) "TEFRA update factor." The increase in the ceiling on hospital increases determined by HCFA pursuant to 42 C.F.R. 413.40 and published from time to time in the Federal Register.

Notes

048-24 Wyo. Code R. §§ 24-4