Current through Register 1518, March 29, 2024
(1)
General Provisions.
(a) The Health Safety Net pays Acute
Hospitals based on claims in accordance with the requirements of
101 CMR
613.00: Health Safety Net Eligible
Services. The Health Safety Net Office monitors the volume of claims
submitted and may adjust or withhold payments if it appears that there has been
a substantial change in the Provider's service delivery patterns and/or billing
activity including, but not limited to, unbundling of services, upcoding, or
other billing maximization activities.
(b)
Payment Types.
1. The Health Safety Net Office calculates
Health Safety Net payments for each Acute Hospital for the following categories
of claims for which the Health Safety Net is the primary payer:
a. Inpatient - Medical (under
101
CMR 614.06(2)(a) and (b))
;
b. Inpatient - Psychiatric (under
101
CMR 614.06(2)(c))
;
c. Inpatient - Rehabilitation
(under
101
CMR 614.06(2)(d))
;
d. Outpatient Services (under
101
CMR 614.06(3)) ;
e. Physician Services (under
101
CMR 614.06(4)) ;
f. Dental Services (under
101
CMR 614.06(5)) ;
g. Acute Hospital Outpatient Pharmacies
(under
101
CMR 614.06(6)) ;
h. Vaccine Administration (under
101
CMR 614.06(7)) ;
i. Emergency Bad Debt - Inpatient Medical
(under
101
CMR 614.06(9)) ;
j. Emergency Bad Debt - Inpatient Psychiatric
(under
101
CMR 614.06(9)) ;
k. Emergency Bad Debt - Outpatient (under
101
CMR 614.06(9)) ;
and
l. Medical Hardship (under
101
CMR 614.06(10)).
2. Under
101
CMR 614.06(8), the Health
Safety Net Office establishes payments for claims which the Health Safety Net
is the secondary payer.
3. The
Health Safety Net Office reduces payments by the amount of Emergency Bad Debt
recoveries and investment income on free care endowment funds. The Health
Safety Net Office determines the offset of free care endowment funds by
allocating free care endowment income between Massachusetts residents and
nonresidents using the best data available and offsetting the Massachusetts
portion against Health Safety Net claims.
(c)
Method of
Payment. The Health Safety Net may make payments to Acute
Hospitals for Eligible Services through a safety net care payment under the
Massachusetts Section 1115 Demonstration Waiver, a MassHealth supplemental
Acute Hospital rate payment, or a combination thereof. The Health Safety Net
Office may limit an Acute Hospital's payment for Eligible Services to comply
with requirements under the Massachusetts Section 1115 Demonstration Waiver
governing safety net care, including cost limits or any other federally
required limit on payments under
42 U.S.C. §
1396a(a)(13) or
42 CFR
447.
(d)
Provider Preventable
Conditions. The Health Safety Net does not pay for services
related to Provider Preventable Conditions defined in
42 CFR
447.26. The Health Safety Net Office may
issue administrative bulletins clarifying billing requirements and payment
specifications for Provider Preventable Conditions.
(2)
Pricing for Inpatient
Services. The Health Safety Net Office prices Acute Hospital
claims in accordance with the Medicare Inpatient Prospective Payment System
(IPPS) for non-psychiatric claims and the Inpatient Psychiatric Facility
Prospective Payment System (IPF-PPS) for psychiatric claims for the current
Fiscal Year. Medicare pricing data is published in the Federal
Register and pricing methodologies are described in
42 CFR
412. Claims from Acute Hospitals classified
by Medicare as Critical Access Hospitals (CAHs), PPS-exempt Hospitals, Medicare
Dependent Rural Hospitals, and Sole Community Hospitals are priced in
accordance with
101
CMR 614.06(2)(b).
(a)
Inpatient Medical Pricing -
Standard. The Health Safety Net Office uses Medicare pricing data
and the most current version of the Medicare severity diagnostic related group
(MS-DRG) weights to calculate the inpatient medical pricing according to the
IPPS for all Acute Hospitals except other Acute Hospitals in accordance with
101
CMR 614.06(2)(b). The Health
Safety Net Office may update values as needed to conform to changes implemented
by the Medicare program during the Fiscal Year. The pricing calculation
includes Medicare adjustments for items such as high-cost outliers, transfer
cases, special pay post-acute DRGs, partially eligible stays, and participation
in the Acute Hospital Inpatient Quality Reporting program.
(b)
Inpatient Medical Pricing -
Other Acute Hospitals.
1.
Critical Access Hospitals and PPS-exempt Hospitals.
The Health Safety Net Office calculates a per discharge payment for discharges
occurring at Medicare Critical Access Hospitals and PPS-exempt cancer and
Pediatric Hospitals as follows.
a. The Health
Safety Net Office determines the average charge per discharge using adjudicated
and eligible Health Safety Net claims data from the Source Year that is
available at the time of rate calculation.
b. The Health Safety Net Office determines an
average cost per discharge by multiplying the average charge per discharge by
an inpatient cost to charge ratio using data as reported on the Hospital Cost
Report for the Source Year.
c. The
average cost per discharge is increased by a cost adjustment factor determined
by the percent change from the IPPS index level for the Source Year and the
IPPS index level forecast for the Fiscal Year, as calculated by the Health
Safety Net Office as of October 1st of the Fiscal
Year, and an additional factor of 1%. The product of this calculation is the
per discharge payment applicable to all discharges occurring during the current
Fiscal Year, except that partially eligible stays are paid pursuant to
101
CMR 614.06(2)(b)3.
d. If the Acute Hospital has fewer than 20
discharges in the Source Year, the Health Safety Net Office sets a payment on
account factor for the Acute Hospital.
e. If a case qualifies as a transfer case
under Medicare rules, the Health Safety Net Office calculates a per
diem rate, capped at the full discharge payment. The per
diem rate is the hospital-specific payment calculated under
101
CMR 614.06(2)(b)1., divided
by the Acute Hospital's average length of stay.
2.
Sole Community
Hospitals. The Health Safety Net Office calculates a
hospitalspecific per discharge amount for Acute Hospitals classified as Sole
Community Hospitals, rather than the adjusted standardized amount. This amount
is based on the hospital-specific rate provided by the Medicare fiscal
intermediary, adjusted for inflation. The payments may include transfer,
outlier, and special pay amounts, using the hospital-specific rate in these
calculations, for qualifying cases. Partially eligible stays are paid pursuant
to 101 CMR
614.06(2)(b)3.
3.
Medicare Dependent Rural
Hospitals. The Health Safety Net Office calculates a blended
payment consisting of 75% of a hospital-specific payment and 25% of the
Operating DRG Payment for Acute Hospitals classified by Medicare as Medicare
Dependent Rural Hospitals. The payments may include transfer, outlier, and
special pay amounts, using the hospital-specific blended rate in these
calculations, for qualifying cases. Partially eligible stays are paid pursuant
to 101 CMR
614.06(2)(b)3.
(c)
Inpatient
Psychiatric Pricing.
1.
Psychiatric Case. A case is classified as psychiatric
if
a. the Acute Hospital has a Medicare
psychiatric unit;
b. the primary
diagnosis is related to a psychiatric disorder; and
c. the claim includes psychiatric
accommodation charges.
2.
Psychiatric Pricing. The Health Safety Net Office uses
Medicare pricing data to calculate a per diem price according
to the IPF-PPS. The Health Safety Net Office may update values as needed to
conform to changes implemented by the Medicare Program during the Fiscal Year.
The pricing calculation includes Medicare adjustments such as a teaching
hospital adjustment, electroconvulsive therapy (ECT) adjustment, high-cost
outliers, adjustments for participation in the Inpatient Psychiatric Facilities
Quality Reporting program, and any other adjustments in accordance with
Medicare pricing provisions pursuant to
42 CFR
412.424, including adjustments for specific
DRGs, the presence of comorbidities, Patient age, and length of stay.
(d)
Inpatient
Rehabilitation Pricing.
1.
Rehabilitation Case. A case is classified as
rehabilitation if
a. the Acute Hospital has a
Medicare rehabilitation unit; and
b. the claim includes rehabilitation
accommodation charges.
2.
Payment. Rehabilitation cases are paid on a
per diem basis. The payment is determined using the Acute
Hospital's most recently filed CMS-2552 Cost Report. The rate is the sum of
total rehabilitation PPS payments and reimbursable bad debts, divided by total
rehabilitation days.
(e)
Hospital-acquired Conditions.
1. All Acute Hospitals, including but not
limited to PPS-exempt Acute Hospitals, are required to report the present on
admission indicator for all diagnosis codes on inpatient claims.
2. The Health Safety Net Office does not
assign an inpatient case to a higher paying MS-DRG if a hospital-acquired
condition that was not present on admission occurs during the stay. For
Hospital Services paid pursuant to
101
CMR 614.06(2)(a) and (b),
the DRG payment is reduced in accordance with Medicare principles.
(f)
Serious Reportable
Events. The Health Safety Net does not pay for services related to
Serious Reportable Events as defined in
105
CMR 130.332(A):
Definitions Applicable to
105
CMR 130.332 based on standards by
the National Quality Forum. The Health Safety Net Office may issue
administrative bulletins clarifying billing requirements and payment
specifications for such services.
(g)
Administrative
Days. The Health Safety Net pays Administrative Days at the
per diem rate established by MassHealth pursuant to the Acute
Hospital Request for Applications for the current Fiscal Year when the Health
Safety Net is the primary payer. When the Health Safety Net is not the primary
payer, Administrative Days are paid per
101
CMR 614.06(8).
(3)
Pricing for
Outpatient Services. The Health Safety Net pays a per visit amount
for each outpatient visit that exceeds $20.00. An outpatient visit includes all
outpatient services, excluding hospital-based physician services provided in a
single day, except for dental and pharmacy services, as described in
101
CMR 614.06(5) and (6). The
outpatient per visit amount is determined as follows.
(a) For each Acute Hospital, the Health
Safety Net Office calculates an average outpatient charge per visit, using such
adjudicated and eligible Health Safety Net claims data from the Source Year as
of June 15, 2016. Charges for dental claims, charges for claims that are $20.00
or below, and charges for outpatient claims within 72 hours of an inpatient
admission are excluded. For Critical Access Hospitals and PPS-exempt Hospitals,
only charges for claims within 24 hours of an inpatient admission are
excluded.
(b) The Health Safety Net
Office determines a hospital-specific Medicare payment on account factor (PAF),
defined as the percent of Medicare outpatient charges that are paid on average.
The PAF is calculated using the best available data and subject to review and
adjustment by the Health Safety Net Office.
(c) The Health Safety Net Office determines
an outpatient payment per visit by multiplying the average outpatient charge
per visit by the Medicare PAF. This product is further increased by a cost
adjustment factor as calculated in
101
CMR
614.06(2)(b)1.c.
(d) Disproportionate Share Hospitals and
non-teaching Acute Hospitals receive a transitional add-on of 25% of the
outpatient per visit payment rate.
(e) The per visit payment for PPS-exempt
cancer and Pediatric Hospitals and Medicare Critical Access Hospitals are
determined using the ratio of costs to charges as reported on the Hospital Cost
Report for the Source Year rather than the Medicare payment on account factor
data.
(f) Claims for visits that
are less than or equal to $20.00 are paid by multiplying the Medicare payment
on account factor by the billed charges.
(4)
Pricing for Physician
Services. The Health Safety Net Office prices hospital-based
physician service claims according to the Medicare Physician Fee
Schedule.
(5)
Dental
Services. The Health Safety Net Office prices claims from Acute
Hospitals for outpatient dental services provided at Acute Hospitals and
Hospital Licensed Health Centers using the lesser of the allowable charges
billed to the HSN, or the fees established in
101 CMR
314.00: DentalSer^vices. No
additional outpatient per visit payment is paid for dental services.
(6)
Acute Hospital Outpatient
Pharmacies.
(a)
Prescribed Drugs. For Acute Hospitals with outpatient
pharmacies, the Health Safety Net Office prices prescribed drugs using rates
set forth in
101 CMR
331.00: Prescribed Drugs. The rate is
reduced by the amount of Patient cost-sharing set forth in
101 CMR
613.00: Health Safety Net Eligible
Services. Claims are adjudicated by the MassHealth Pharmacy Online
Payment System.
(b)
Part B Covered Services. Medical supplies normally
covered by the Medicare Part B program that are dispensed by Acute Hospital
outpatient pharmacies that are not Part B Providers are priced at 20% of the
rates set forth in
101 CMR
322.00: Durable Medical Equipment, Oxygen, and
Respiratory Therapy Equipment and
101 CMR
331.00: Prescribed Drugs.
(7)
Vaccine
Administration. The Health Safety Net Office allows for separate
payment for a vaccine administration and an individual medical visit only if
the vaccine administration is not occurring on the same day as the office
visit. A separate fee for the administration of vaccines is payable only when
the sole purpose for a visit is vaccine administration. The fee is priced in
accordance with the provisions of
101 CMR
317.00: Rates for Medicine
Services.
(8)
Secondary Payer. The Health Safety Net pays claims for
which it is not the primary payer as follows.
(a)
95% Rule. If a
claim billed to the Health Safety Net has a ratio of total billed net charges
to total claim charges that is greater than 95%, the Health Safety Net pays the
claim in accordance with the applicable primary payment rules.
(b)
Medicare as Primary
Payer. For any allowable claim for which Medicare or a Medicare
Advantage plan (as defined in the Medicare Prescription Drug, Improvement, and
Modernization Act of 2003) is the primary payer, the Health Safety Net pays in
accordance with
101
CMR 613.03(1)(c)8. If
Medicare or a Medicare Advantage plan denied services on a claim as non-covered
services and those services are Eligible Services, the payment for the services
is the product of the net billed charges and the Medicare payment on account
factor as defined in
101
CMR 614.06(3)(b), except as
provided at
101
CMR 614.06(8)(e).
(c)
MassHealth as Primary
Payer. Health Safety Net pays allowable claims with MassHealth as
the primary payer in accordance with
101
CMR 613.03(1)(c).
(d)
Premium Assistance Payment
Program Operated by the Health Connector as the Primary Payer.
Health Safety Net pays allowable claims with Premium Assistance Payment Program
Operated by the Health Connector as the primary payer in accordance with
101
CMR 613.03(1)(c).
(e)
Private Insurance and Other
Primary Payers. For any allowable claim for which a payer other
than the payers discussed in
101
CMR 614.06(8)(b) through (d)
is the primary payer, the Health Safety Net pays claims in accordance to
101
CMR 613.03(1)(c)4. The
payment is the product of the net billed charges and the Medicare payment on
account factor as defined in
101
CMR 614.06(3)(b). For
inpatient services, the payment will not exceed the amount the Health Safety
Net Office would have paid if it were the primary payer.
(9)
Bad Debt
Pricing. Except as provided at
101
CMR 614.06(9)(a), the Health
Safety Net Office calculates Emergency Bad Debt payments for inpatient,
psychiatric, and outpatient Eligible Services, using the methodology in
101
CMR 614.06(2) and (3),
except that the Emergency Bad Debt outpatient rate does not include the
transitional add-on cited in
101
CMR 614.06(3)(d).
(a) If an Acute Hospital has fewer than 20
Emergency Bad Debt claims during the Source Year, the Health Safety Net Office
sets the Emergency Bad Debt rate as the outpatient primary per visit rate
established in
101
CMR 614.06(3), excluding the
transitional add-on under
101
CMR 614.06(3)(d).
(b) The Health Safety Net Office pays
Hospital Licensed Health Centers 75% of the PPS Rate as published by Medicare
for Bad Debt claims for Urgent Care Services that meet the requirements in
101 CMR
613.00: Health Safety Net Eligible
Services.
(10)
Medical Hardship. The Health Safety Net pays for
claims for Patients deemed eligible for Medical Hardship pursuant to
101 CMR
613.00: Health Safety Net Eligible
Services. The Health Safety Net Office reduces the amount of the
billed charges by any third-party payments, third-party contractual discounts,
Patient payments, and the amount of the Medical Hardship contribution. If the
adjusted charges are less than the total claim charges, the claim is paid as a
secondary claim in accordance with the provisions of
101
CMR 614.06(8). If the billed
charges are not reduced, the Health Safety Net pays the claim as if it were a
primary Health Safety Net claim.
(11)
Other. The
Health Safety Net makes an additional payment of $3.85 million to freestanding
Pediatric Hospitals with more than 1,000 Medicaid discharges during the Source
Year for which a standard payment amount per discharge was paid by MassHealth
pursuant to the Acute Hospital Request for Applications, as determined by paid
claims in the Medicaid Management Information System as of June 15, 2016, and
for which MassHealth was the primary payer. The Health Safety Net may make an
additional payment adjustment for the two Disproportionate Share Hospitals with
the highest relative volume of free care costs in FY2006.
(12)
Remediated
Claims. Remediated claims include claims that were paid or voided
during a prior Fiscal Year, but due to hospital resubmission or actions of the
Health Safety Net Office were remediated by a payment or void during the
current Fiscal Year. The Health Safety Net Office adjusts the payment or void
amounts to reflect the applicable payment methods that would have been in use
at the time of the original claim payment.
