Current through Register 1531, September 27, 2024
The Division shall determine for FY 1996 and succeeding years
an extraordinary disproportionate share adjustment for all eligible psychiatric
hospitals, using the data and methodology described in 114.1 CMR 40.12.
(1)
Data Sources.
The Division shall use the RSC-403 report for the fiscal year two years prior
to the fiscal year of the calculation of the disproportionate share adjustment
to determine the cost, free care, charge, patient day, and net revenue amounts.
If said RSC-403 report is not available, the Division shall use the most recent
available previous RSC-403 report to estimate these variables. If the specified
data source is unavailable, then the Division shall determine and use the best
alternative data source.
(2)
Determination of Eligibility.
(a) In order to be eligible for the
extraordinary disproportionate share payment adjustment, a psychiatric hospital
must:
1. specialize in providing
psychiatric/psychological care and treatment;
2. provide for special active treatment such
as treatment of deafness, developmental disabilities, and the
elderly;
3. accept all patients
without regard to their ability to pay;
4. consist partly or wholly of locked
wards;
5. meet requirements for the
receipt of federal matching funds;
6. meet the low-income standard as set forth
in 114.1 CMR 40.12(2)(b); and
7.
meet the unreimbursed cost standard as set forth in 114.1 CMR
40.12(2)(c).
(b)
Low-income standard.
1. For each psychiatric hospital, the
Division shall calculate the hospital-specific low-income utilization rate as
follows:
a. The Division shall divide each
hospital's net Medicaid revenue by its total gross patient service
revenue.
b. The Division shall
divide each hospital's free care charges by its total charges.
c. The total of these percentages shall equal
the hospital's low-income utilization rate.
2. If the hospital-specific low-income
utilization rate exceeds 45%, then the psychiatric hospital meets the
low-income standard.
(c)
Unreimbursed cost standard.
1. For each psychiatric hospital, the
Division shall calculate the hospital-specific unreimbursed cost percentage as
follows:
a. The Division shall calculate the
costs of providing hospital services to Medicaid-eligible individuals and
uninsured individuals, by multiplying Medicaid RFR by the ratio of Medicaid
charges plus self pay charges plus free care charges to total
charges.
b. The Division shall
subtract the total of Medicaid payments (excluding any disproportionate share
payments) plus self pay payments, from the costs determined in 114.1 CMR
40.12(2)(c)1.a., to determine the amount of unreimbursed costs.
c. The Division shall divide the amount of
unreimbursed costs determined in 114.1 CMR 40.12(2)(c)1.b. by the costs
determined in 114.1 CMR 40.12(2)(c)1.a. to determine the percentage of
unreimbursed costs.
2.
If the hospital-specific percentage of unreimbursed costs exceeds 50%, then the
psychiatric hospital meets the unreimbursed cost standard.
(3)
Determination of
Payment. Except as provided in 114.1 CMR 40.10(2), for each
psychiatric hospital determined eligible for the extraordinary disproportionate
share adjustment under 114.1 CMR 40.12(2), the payment amount shall be equal to
the estimated rate year unreimbursed cost of providing hospital services to
Medicaid-eligible individuals and uninsured individuals, calculated as follows:
a. First, determine the estimated rate year
cost of providing hospital services to Medicaid-eligible individuals and
uninsured individuals as set forth in 114.1 CMR 40.12(2)(c)1.a., substituting
rate year Reasonable Financial Requirements for source data RFR.
b. Then, multiply this cost by the
unreimbursed cost percentage determined pursuant to 114.1 CMR
40.12(2)(c)1.c.
(4)
Payments made pursuant to this section are subject to Health Care Financing
Administration approval of state plan amendments incorporating this
methodology.
