Current through Register Vol. 50, No. 9, March 1, 2024
RELATES TO:
KRS
205.639,
205.640,
42
C.F.R. 440.10,
440.140,
447.250-447.280,
42 U.S.C.
1395ww(d)(4)(C)(i),
1395x(mm),
1396a,
1396b,
1396d
NECESSITY, FUNCTION, AND CONFORMITY: The Cabinet for Health and
Family Services, Department for Medicaid Services has responsibility to
administer the Medicaid Program.
KRS
205.520(3) authorizes the
cabinet, by administrative regulation, to comply with a requirement that may be
imposed, or opportunity presented by federal law for the provision of medical
assistance to Kentucky's indigent citizenry. This administrative regulation
establishes provisions regarding supplemental payments totaling $195 million in
aggregate to hospitals reimbursed via the diagnosis-related group (DRG)
reimbursement methodology which agreed, in April 2009, to accept the
supplemental payments.
Section 1.
Definitions.
(1) "Aggregate cost gap" means
the difference between a hospital's cost and Medicaid payments received by the
hospital for DRG services for the period beginning July 1, 2004 through June
30, 2007 trended to the midpoint of the January 2009 through December 2010
payment period.
(2) "Department"
means the Department for Medicaid Services or its designee.
(3) "DRG" means diagnosis-related
group.
(4) "Federal financial
participation" is defined by
42 C.F.R.
400.203.
(5) "Pediatric teaching hospital" is defined
by
KRS
205.565(1).
(6) "Related to the provider" is defined by
42 C.F.R.
413.17.
(7) "University hospital" is defined by
KRS
205.639(4).
Section 2. Supplemental Payments
to DRG Hospitals Which Have Agreed To Accept the Payments.
(1) The department shall issue eight (8)
payments:
(a) To a hospital:
1. Reimbursed via the DRG reimbursement
methodology which agreed, in April 2009, to accept the supplemental payments;
and
2. As a supplement to its
reimbursement for inpatient hospital services paid via the DRG reimbursement
methodology;
(b)
Beginning with two (2) payments issued during the calendar quarter ending June
30, 2009, followed by one (1) payment for each subsequent calendar quarter
until the quarter ending December 31, 2010; and
(c) Representing calendar quarters beginning
with the calendar quarter ending March 31, 2009 and ending with the calendar
quarter ending on December 31, 2010.
(2) A supplemental payment referenced in
subsection (1) of this section shall be paid from an aggregate supplemental
payment pool:
(a) That shall not exceed $195
million; and
(b) That shall be
reduced by the amount of the share of a hospital, if any, that foregoes its
share of the aggregate supplemental payment pool in accordance with Section 3
of this administrative regulation.
(3) A hospital's share of the aggregate
supplemental payment pool referenced in subsection (2) of this section shall:
(a) Equal its proportionate share of its
aggregate cost gap compared to the aggregate cost gap of all hospitals
reimbursed via the DRG reimbursement methodology:
1. Which agreed to accept the supplemental
payments referenced in subsection (1) of this section; and
2. Except for the excluded hospitals
referenced in Section 4(2), (3), or (4) of this administrative
regulation;
(b) Be
divided into thirty-six (36) equal units; and
(c) Be paid on a descending balance basis
with the:
1. First quarterly payment
representing eight (8) equal units;
2. Second quarterly payment representing
seven (7) equal units;
3. Third
quarterly payment representing six (6) equal units;
4. Fourth quarterly payment representing five
(5) equal units;
5. Fifth quarterly
payment representing four (4) equal units;
6. Sixth quarterly payment representing three
(3) equal units;
7. Seventh
quarterly payment representing two (2) equal units; and
8. Eighth quarterly payment representing one
(1) unit.
Section 3. Foregoing Supplemental Payments.
(1) A hospital shall forego its share of the
aggregate supplemental payment pool referenced in Section 2(2) of this
administrative regulation if it at any time does not agree to accept the
supplemental payments referenced in Section 2(1) of this administrative
regulation.
(2) If a hospital
foregoes its share of the aggregate supplemental payment pool referenced in
Section 2(2) in this administrative regulation, its share of the aggregate
supplemental payment pool shall:
(a) Not be
paid to the hospital; and
(b) Be
subtracted from the $195 million aggregate supplemental payment pool.
Section 4. Excluded
Hospitals. The department shall not make a supplemental payment referenced in
Section 2(1) of this administrative regulation to the following hospitals
reimbursed via the DRG reimbursement methodology;
(1) A hospital which foregoes its share of
the aggregate supplemental payment pool in accordance with Section 3 of this
administrative regulation;
(2) A
university hospital;
(3) A
pediatric teaching hospital; or
(4)
A hospital which owns, operates, is any way affiliated with, has any common
ownership with, or has any common operation with a pediatric teaching
hospital.
Section 5.
Federal Financial Participation. A supplemental payment referenced in Section
2(1) of this administrative regulation shall be contingent upon the
department's receipt of federal financial participation for the
payment.
Section 6. Upper Payment
Limit.
(1) A supplemental payment referenced
in Section 2(1) of this administrative regulation shall not exceed the limit
established in:
(a)
42 C.F.R.
447.271;
(b)
42 C.F.R.
447.272; or
(c) Any other applicable statute or
regulation.
(2) This
administrative regulation shall not be interpreted to require the department to
make a payment which:
(a) Would exceed the
limit established in:
1.
42 C.F.R.
447.271;
2.
42 C.F.R.
447.272; or
3. Any other applicable statute or
regulation; or
(b) Is
not subject to federal financial participation.
STATUTORY AUTHORITY:
KRS
194A.030(2),
194A.050(1),
205.520(3),
205.560(2)
and (5),
42 C.F.R.
447.252,
447.253,
42 U.S.C.
1396a