Current through Register Vol. 50, No. 9, March 1, 2024
RELATES TO:
KRS
45.229,
142.303,
205.565,
205.637,
205.638,
205.639,
205.640,
205.6405,
205.6406,
205.6407,
205.6408,
216.380,
42 C.F.R.
413.17,
433.51,
438.340,
440.140,
447.271,
447.272,
42 U.S.C.
1396a,
1395ww
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 to qualify for federal funds.
KRS
205.6406(13) requires the
department to promulgate an administrative regulation to implement the Hospital
Rate Improvement Program,
KRS
205.6405 to
205.6408.
This administrative regulation establishes the requirements for implementing
the Hospital Rate Improvement Program for qualifying hospitals.
Section 1. Definitions.
(1) "Assessment" is defined by
KRS
205.6405(1).
(2) "Department" means the Department for
Medicaid Services or its designee.
(3) "Federal financial participation" is
defined by
42 C.F.R.
400.203.
(4) "Program year" is defined by
KRS
205.6405(14).
(5) "Qualifying hospital" is defined by
KRS
205.6405(16).
(6) "Received date" means the date a claim is
accepted and approved into the Medicaid Management Information System and does
not mean the date a claim is actually paid.
(7) "Upper payment limit" or "UPL" is defined
by
KRS
205.6405(19).
Section 2. Hospital Rate
Improvement Program.
(1) Prior to the start
of each program year and in accordance with the payment methodology required by
KRS
205.6406(2), the department
shall calculate for each qualifying hospital:
(a) A per-discharge uniform add-on amount
that the qualifying hospital is eligible to receive as a supplemental payment
for the program year for Medicaid fee-for-service discharges; and
(b) A per discharge uniform add-on amount
that the qualifying hospital is eligible to receive as a supplemental payment
for the program year for Medicaid managed care discharges.
(2) With the exception of the initial
implementation year, no less than thirty (30) days prior to the beginning of
each program year, the department shall provide each qualifying hospital
written notice of the total per-discharge uniform add-on amounts for both
Medicaid fee-for-service and Medicaid managed care discharges. The notice shall
include the data sources and methodologies used to arrive at the value for each
variable upon which the qualifying hospital's per-discharge uniform add-on
amounts shall be calculated for the program year.
(3) For each quarter in a program year, the
department shall:
(a) Calculate each
qualifying hospital's supplemental payments for Medicaid fee-for-service and
Medicaid managed care in accordance with
KRS
205.6406(3) through (11) by:
1. Excluding all inpatient claims with
discharge dates preceding October 1, 2018 from enhanced payment
calculations;
2. Reducing the
number of inpatient claims eligible for enhanced reimbursement by the number of
previously enhanced claims that have been voided in the Medicaid Management
Information System; and
3.
Excluding from enhanced payment calculations partial or adjusted inpatient
claims that have previously received an enhanced payment;
(b) Make a quarterly Medicaid fee-for-service
supplemental payment to each qualifying hospital, or its designee acting as a
fiscal intermediary, in accordance with the methodology in
KRS
205.6406(3)(a) and (c);
and
(c) Make a quarterly Medicaid
managed care supplemental payment to each qualifying hospital, or its designee
acting as a fiscal intermediary, in accordance with the methodology in
KRS
205.6406(3)(b), (d), and
(e).
(4) Payment of the quarterly Medicaid managed
care supplemental payment shall be made by distribution to each Medicaid
managed care organization through a quarterly supplemental capitation
payment.
(5) The department shall
submit with, or prior to, the quarterly supplemental capitation payment
directions to the Medicaid managed care organization for the payment of the
quarterly Medicaid managed care supplemental payments to qualifying
hospitals.
(6) In accordance with
KRS
205.6406(6), each Medicaid
managed care organization shall remit to each qualifying hospital, or its
designee, as directed by the department the quarterly Medicaid managed care
supplemental payment within five (5) business days of receipt of the quarterly
supplemental capitation payment. The department shall establish contractual
penalty provisions to require that each Medicaid managed care organization
remit the required amounts within five (5) business days.
(7) In accordance with
KRS
205.6406(9), a qualifying
hospital may seek review by the department of any quarterly supplemental
payment that the qualifying hospital suspects is in error.
(a) The qualifying hospital shall submit a
detailed listing of any disputed claim or claims for department consideration
and potential updates to the Medicaid Management Information System.
(b) Once each claim is received and validated
in the Medicaid Management Information System, the department shall adjust the
qualifying hospital's future quarterly supplemental payment to account for any
warranted correction.
(c) If the
department determines that a correction is not warranted, the hospital may
request an administrative appeal pursuant to
907
KAR 1:671.
(8) In order to receive a supplemental
payment and to pay the assessment for that quarter, an entity shall be a
qualifying hospital each day of a quarter for the program year.
(9) Medicaid Management Information System
(MMIS) fee-for-service and managed care encounter data, queried by the claim
received date, shall be utilized to calculate the quarterly payments.
(10) For each quarter in a program year, the
department shall:
(a) Calculate each
qualifying hospital's per-discharge hospital assessment in accordance with the
methodology in
KRS
205.6406(3)(g) and (h);
and
(b) Provide notice to each
qualifying hospital in accordance with
KRS
205.6406(3)(i).
(11) A qualifying hospital's
per-discharge hospital assessment shall be calculated using the Medicare cost
report period ending in the calendar year that is two (2) calendar years prior
to the first day of a program year. For example, for the program year beginning
July 1, 2019, cost report periods ending in calendar year 2017 shall be
utilized.
(a) If a qualifying hospital's cost
report period referenced in this subsection is greater than or less than a
normal calendar year of 365 days, the total discharges used in accordance with
KRS
205.6406(3)(g) shall be
annualized to a 365-day period.
(b)
If a qualifying hospital is newly enrolled in the Medicaid program and does not
have cost report information available for the period established in this
subsection, the department may utilize the cost report information of a
comparable hospital to approximate the newly enrolled hospital's
utilization.
(12) A
qualifying hospital shall pay its calculated per-discharge hospital assessment
in accordance with
KRS
205.6406(7).
(13) If a hospital assessment is not received
in a timely manner, the department may deny or withhold future quarterly
supplemental payments until the assessment is submitted.
(14) A qualifying hospital may authorize a
third-party entity to serve as a fiscal intermediary to facilitate the
implementation of this administrative regulation by providing letter notice to
the department.
Section
3. Reporting Requirements.
(1)
Throughout a program year, a qualifying hospital shall submit any documentation
or information to the department that the department requests in a timely
manner as designated by the department. This request may include any
documentation pertaining to:
(a) Resolution
of a quarterly supplemental payment that the qualifying hospital suspects is in
error; or
(b) Quality metrics set
forth in the department's Quality Strategy filed with the Centers for Medicare
and Medicaid Services pursuant to
42 C.F.R.
438.340.
(2) If a qualifying hospital fails to provide
the department with any requested documentation in a timely manner, the
department may deny or withhold future quarterly supplemental payments, until
the documentation is submitted.
Section 4. Upper Payment Limit. A
supplemental payment referenced in this administrative regulation is not
intended to cause aggregate Medicaid hospital reimbursement to exceed the
aggregate statewide upper payment limit for privately-owned and non-state
government-owned hospitals established in:
(1)
42 C.F.R.
447.271;
(2)
42 C.F.R.
447.272; or
(3) Any other applicable statute or
administrative regulation.
Section
5. Federal Approval and Federal Financial Participation. The
department's coverage of services pursuant to this administrative regulation
shall be contingent upon:
(1) Receipt of
federal financial participation for the coverage; and
(2) Centers for Medicare and Medicaid
Services' approval for the coverage.
STATUTORY AUTHORITY:
KRS
194A.030(2),
194A.050(1),
205.520(3),
205.560,
205.6406(13),
42 C.F.R.
447.252,
447.253,
42 U.S.C.
1396a