Arkansas Administrative Code
Agency 016 - DEPARTMENT OF HUMAN SERVICES
Division 06 - Medical Services
Rule 016.06.07-005 - Hospital Update Number 96 and Arkansas State Plan Amendment #2006-003
Universal Citation: AR Admin Rules 016.06.07-005
Current through Register Vol. 49, No. 9, September, 2024
Section II Hospital/Critical Access Hospital (CAH)/End Stage Renal Disease (ESRD)
250.203
Cost Settlement
A. The Division of Medical Services or its
designee audits each hospital's cost report.
1. Allowable costs are determined and
validated in accordance with CMS Publication 15-1 (costs and allowable costs)
and CMS Publication 15-2 (cost reports).
2. Accounting exceptions specific to Title
XIX or to the Arkansas Medicaid Program are noted in this section
(Reimbursement, section 250.000) of this provider manual.
B. With the exception of special payments and
adjustments listed below in part C, Arkansas Medicaid limits total inpatient
reimbursement to the lowest of three amounts. The amounts compared are:
1. Allowable costs after application of the
TEFRA rate of increase limit (the TEFRA rate of increase limit does not apply
to Arkansas State Operated Teaching Hospitals for cost reporting periods ending
on and after June 30, 2000),
2. The
hospital's customary charges to the general public for the services
and
3. An upper limit per Medicaid
day.
C. Special
adjustments or payments apply to some hospitals.
1. In-state hospitals and certain qualifying
out-of-state hospitals receive "disproportionate share hospital" payments. See
Sections 250.300 through 250.500 for details.
2. Arkansas State Operated Teaching Hospitals
receive direct graduate medical education (GME) payments. See Section 250.621
for details.
3. Arkansas State
Operated Teaching Hospitals receive an adjustment based on the Medicare daily
upper limit. See Section 250.622 for details.
4. Arkansas private, acute care, critical
access, psychiatric and rehabilitative hospitals receive an adjustment based on
the Medicaid upper payment limit. See section 250.623 for details.
5. Arkansas non-state government-owned or
operated acute care and critical access hospitals receive an adjustment based
on the Medicare upper payment limit. See section 250.624 for details.
250.220
Customary Charges
A. The lesser of
allowable costs and charges is the amount to be compared to the upper limit
amount.
1. The amount carried forward from the
TEFRA rate-of-increase limitation calculations is compared to the hospital's
charges for services furnished during the cost reporting period to
Medicaid-eligible inpatients aged one year and older.
2. The lesser amount is carried forward for
comparison to the upper limit amount.
B. Charges are obtained from the hospital's
inpatient Medicaid claims for dates of service within the cost reporting
period.
250.230
Daily Upper Limit
A daily upper limit to inpatient hospital reimbursement is established in the Title XIX State Plan.
A. A daily upper limit amount of $675.00 is
effective for dates of service April 1, 1996 through June 30, 2006. The $675.00
daily upper limit for this period represents the 90th percentile of the
cost-based perdiems (per the cost settlements of their fiscal year-end 1994
cost reports) of all hospitals subject to the Arkansas Medicaid daily upper
limit at the time of the computation.
B. For dates of service July 1, 2006 and
after, DMS will review the hospital cost report data at least biennially and
adjust the daily upper limit reimbursement amount if necessary
C. The daily upper limit does not apply to
the following.
1. Pediatric
hospitals
2. Arkansas State
Operated Teaching Hospitals, effective for cost reporting periods ending on or
after June 30, 2000)
3. Inpatient
services for children under the age of 1
4. Inpatient services from the first birthday
to discharge for children over the age of one who were admitted on or before
their first birthday and remained as inpatients past their first
birthday
D. The daily
upper limit is determined as follows.
1. The
aggregate daily upper limit amount is calculated by multiplying the
cost-reporting period's Medicaid-covered days (in all affected hospitals) by
the daily upper limit amount in force at the time.
2. The aggregate daily upper limit amount is
compared to the amount carried forward from the comparison of TEFRA-limited
costs or charges.
3. The lesser of
those two amounts becomes the new aggregate daily upper limit amount, subject
to any additional payments or adjustments that may apply, such as direct
graduate medical education (GME) costs or disproportionate share hospital (DSH)
payments.
4. Effective for dates of
service on or after July 1, 2006, Medicaid will review at least biennially,
hospital cost report data as described in part C above and will adjust the
daily upper limit amount if necessary.
250.240
Limited Acute Care Hospital
Inpatient Quality Incentive Payment
A.
Effective for claims with dates of service on or after July 1, 2006, all acute
care hospitals with the exception of pediatric hospitals, Arkansas State
operated teaching hospitals, rehabilitative hospitals, inpatient psychiatric
hospitals, critical access hospitals, and out-of-state hospitals (in both
bordering and non-bordering states) may qualify for an Inpatient Quality
Incentive Payment (IQIP).
1. An IQIP is a per
diem-based payment in addition to the hospital's cost-based interim per
diem.
2. A qualifying hospital's
IQIP is the lesser of $50 (per Medicaid-covered day during the subject
cost-reporting period) or 5.8% (also per Medicaid-covered day) of the
hospital's interim per diem.
B. Annually, Arkansas Medicaid will designate
the quality measures to be reported and will establish a required compliance
rate for each measure.
1. To the extent
practicable, Medicaid will attempt to choose the quality measures that
hospitals report to the Title XVIII (Medicare) Program.
2. To qualify for an IQIP, a hospital must
meet or exceed Medicaid's required compliance rate on two-thirds (66.7%) of
Arkansas Medicaid's designated quality measures for the most recently completed
reporting period.
3. A hospital
that meets or exceeds the compliance rate on 66.7% of a reporting period's
specified quality measures will receive an IQIP for that year.
250.600
In-State
Hospital Class Groups
250.610
Pediatric Hospitals
A pediatric hospital is an acute care hospital that has in effect an agreement with the Division of Medical Services (DMS) to participate in Medicaid as a hospital and the majority of its patients are under 21. See section 201.110 for participation requirements for pediatric hospitals.
A. Medicaid reimburses pediatric hospitals
for inpatient services by means of an interim per diem with year-end cost
settlement.
1. Unless supplemented by state
law or rule, reasonable costs are determined in accordance with
42
U.S.C. §
1395x(v)(1)(A)
and the implementing federal regulations.
2. Medicaid adjusts interim per diem rates
annually upon receipt and review of initial cost reports.
B. Medicaid reimburses pediatric hospitals
for outpatient services by a fee-for-service methodology, at the lesser of the
billed charge or the Medicaid fee schedule maximum, with year-end cost
settlement.
C. A new pediatric
hospital is a pediatric hospital enrolling with Medicaid for the first time.
1. The TEFRA rate-of-increase limit base year
for new pediatric hospitals is the first full 12-month cost reporting period
beginning after the State grants approval for the hospital to operate under
Medicaid as a pediatric hospital.
2. A new pediatric hospital may request an
exemption from the TEFRA rate-of-increase limit.
a. The hospital must submit a written request
at least 180 days before the end of the first full 12-month cost reporting
period that began on or after the hospital's approved date of enrollment with
Medicaid.
b. If a new pediatric
hospital requests and receives an exemption to the TEFRA rate-of-increase
limit, the hospital's base year will be the first full cost reporting period
beginning at least two years after the effective date of the state's approval
for the hospital to operate as a pediatric hospital.
D. Pediatric hospitals are exempt
from limitation by the Arkansas Medicaid daily upper limit.
E. Pediatric hospitals are not eligible for
Inpatient Quality Incentive Payments (IQIP). See section
250.240 for information regarding
IQIP.
Disclaimer: These regulations may not be the most recent version. Arkansas may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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