Current through February, 2024
(a) Acute care
providers shall have the right to request a rate reconsideration if one of the
following conditions has occurred since the base year:
(1) Extraordinary circumstances including but
not limited to acts of God, changes in life and safety code requirements,
changes in licensure law, rules or regulations, significant changes in case mix
or the nature of service, or addition of new services occurring subsequent to
the base year. Mere inflation of costs, absent extraordinary circumstances,
shall not be a ground for rate reconsideration;
(2) Reduction in medicaid average length of
stay within a facility which produced a decrease in the average cost per
discharge but an increase in the average cost per day. This paragraph shall not
include reductions in average length of stay resulting from a change in case
mix. The rate reconsideration relief provided under this section shall be the
lesser of actual growth in the cost per day since the base year or seventy-five
per cent of the reduction in the average cost per discharge (inflated) since
the base year divided by the current average length of stay. In no case shall
the add-on exceed the actual ancillary and room and board costs of the
facility; and
(3) The addition of
an approved intern and resident teaching program. This is the only circumstance
that is eligible for a rate reconsideration request by a new
provider.
(b) A provider
may also obtain a rate reconsideration if it provides an atypically high
percentage of special care, determined as follows. In order to obtain the
relief, the provider must meet each of the tests and follow each of the
procedures defined below:
(1) One or more of
the facility's per diem rates is affected by the ceiling in its classification
for that type of service;
(2) The
percentage of the facility's base year medicaid special care days over total
base year medicaid days (excluding days that are reported in the nursery cost
center on the cost report) is greater than one hundred fifty per cent of the
same average for all other facilities in its classification. The data to
perform the comparison shall be obtained from the base year medicaid cost
reports;
(3) The facility's average
per diem costs for both general inpatient routine service and special care,
excluding capital related costs and medical education costs, are no greater
than one hundred twenty per cent of the weighted average for all other
facilities in the same classification. The data to perform the comparison shall
be obtained from the base year medicaid cost reports;
(4) The provider must analyze its base year
costs and vary its special care percentage to determine its break-even point.
This analysis shall be performed for each PPS rate that was affected by a
component ceiling;
(5) The provider
must compute its special care percentage based upon the most recent information
available;
(6) The provider must
certify to the department in conjunction with its rate reconsideration request
that, based upon its most recently filed cost report, the percentage defined in
section 17-1739-78(b)(2) continues to exceed one hundred fifty per cent of the
average for all other facilities in its classification during the base year.
The certification shall be based upon a cost report classification method that
is consistent with the method that the facility used in the base year medicaid
cost report; and
(7) The provider
must submit the results of all of the foregoing analyses and calculations,
along with its certification, to the department as part of its rate
reconsideration request. For each rate category in which the most recent
special care percentage exceeds the break-even point, the provider shall have
the applicable PPS rate increased by the amount that it was reduced due to the
application of the component ceilings. For each rate category in which the most
recent special care percentage is equal to or less than the break-even point,
the provider shall receive no increase in its PPS rates.
(c) Requests for reconsideration shall be
submitted in writing to the department and shall set forth the reasons for the
requests. Each request shall be accompanied by sufficient documentation to
enable the department to act upon the requests. Documentation shall include the
data necessary to demonstrate that the circumstances for which reconsideration
is requested meet the requirements noted above. Documentation shall include:
(1) A presentation of data to demonstrate
reasons for the hospital's request for rate reconsideration; and
(2) If the reconsideration request is based
on changes in patient mix, then the facility must document the change using
diagnosis related group case-mix index or other well-established case-mix
measures, accompanied by a showing of cost implications.
(d) A request for reconsideration shall be
submitted within sixty days after the prospective rate is provided to the
facility by the department or at other times throughout the year if the
department determines that extraordinary circumstances occurred. The addition
of an approved intern and resident teaching program shall be one example of
that type of extraordinary circumstance that justifies a mid-year rate
reconsideration request.
(e) The
provider shall be notified of the department's discretionary decision in
writing within a reasonable time after receipt of the written
request.
(f) Pending the
department's discretionary decision on a request for rate reconsideration, the
facility shall be paid the prospective payment rate initially determined by the
department. If the reconsideration request is granted, the resultant new
prospective payment rate shall be effective no earlier than the first date of
the prospective rate year.
(g) A
provider may appeal the department's decision on the rate reconsideration. The
appeal shall be filed in accordance with the requirements of chapter
17-1736.
(h) Rate reconsiderations
granted under this section shall be effective for the remainder of the
prospective rate year. If the facility believes its experience justifies
continuation of the rate in subsequent rate years, it shall submit information
to update the documentation specified in subsection (c) within sixty days of
notice of the facility's rate for each subsequent rate year. The department
shall review the documentation and notify the facility of its determination as
described in subsection (e). The department may, at its discretion, grant a
rate adjustment which is automatically renewable until the base year is
recalculated.
