Nebraska Administrative Code
Topic - HEALTH AND HUMAN SERVICES SYSTEM
Title 471 - NEBRASKA MEDICAL ASSISTANCE PROGRAM SERVICES
Chapter 46 - RATES FOR HOSPITAL SERVICES
Section 471-46-002 - DEFINITIONS

Universal Citation: 471 NE Admin Rules and Regs ch 46 ยง 002

Current through September 17, 2024

The following definitions apply:

002.01 ALLOWABLE COSTS. Those costs as provided in the Medicare statutes and regulations for routine service costs, inpatient ancillary costs, capital-related costs, medical education costs, and malpractice insurance cost.

002.02 ALL PATIENT REFINED-DIAGNOSIS RELATED GROUP ALL PATIENT REFINED DIAGNOSIS RELATED GROUP. A diagnosis related group classification system.

002.03 BASE YEAR. The period covered by the most recent settled Medicare cost report, which will be used for purposes of calculating prospective rates.

002.04 BUDGET NEUTRALITY. Payment rates are adjusted for budget neutrality such that estimated expenditures for the current rate year are not greater than expenditures for the previous rate year, trended forward.

002.05 CAPITAL-RELATED COSTS. Those costs, excluding tax-related costs, as provided in the Medicare regulations and statutes in effect for each facility's base year.

002.06 CASE-MIX INDEX. An arithmetical index measuring the relative average resource use of discharges treated in a hospital compared to the statewide average.

002.07 COST OUTLIER. Cases which have an extraordinarily high cost as established in this chapter so as to be eligible for additional payments above and beyond the initial diagnosis related group payment.

002.08 CRITICAL ACCESS HOSPITAL. A hospital certified for participation by Medicare as a Critical Access Hospital.

002.09 DIAGNOSIS-RELATED GROUP. A group of similar diagnoses combined based on patient age, procedure coding, comorbidity, and complications.

002.10 DIRECT MEDICAL EDUCATION COST PAYMENT. An add-on to the operating cost payment amount to compensate for direct medical education costs associated with approved intern and resident programs. Costs associated with direct medical education are determined from the hospital base year cost reports, and are limited to the maximum per intern and resident amount allowed by Medicare in the base year.

002.11 DISPROPORTIONATE SHARE HOSPITAL. A hospital located in Nebraska is deemed to be a disproportionate share hospital by having:

(A) A Medicaid inpatient utilization rate equal to or above the mean Medicaid inpatient utilization rate for hospitals receiving Medicaid payments in Nebraska; or

(B) A low-income utilization rate of 25 percent or more.

002.12 DISTINCT PART UNIT. A Medicare-certified hospital-based substance abuse, psychiatric, or physical rehabilitation unit that is certified as a distinct part unit for Medicare.

002.13 DIAGNOSIS RELATED GROUP Weight. A number that reflects relative resource consumption as measured by the relative costs by hospitals for discharges associated with each diagnosis related group and severity of illness.

002.14 HOSPITAL MERGERS. Hospitals that have combined into a single corporate entity, and have applied for and received a single inpatient Medicare provider number and a single inpatient Medicaid provider number.

002.15 HOSPITAL-SPECIFIC BASE YEAR OPERATING COST. Hospital specific operating allowable cost associated with treating Medicaid patients. Operating costs include the major moveable equipment portion of capital-related costs, but exclude the building and fixtures portion of capital-related costs, direct medical education costs, and indirect medical education costs.

002.16 HOSPITAL-SPECIFIC COST-TO-CHARGE RATIO. Hospital-specific cost-to-charge ratio is based on total hospital aggregate costs divided by total hospital aggregate charges. Hospital-specific cost-to-charge ratios used for outlier cost payments and transplant diagnosis related group cost-to-charge ratios payments are derived from the outlier cost-to-charge ratios in the Medicare inpatient prospective payment system.

002.17 INDIRECT MEDICAL EDUCATION COST PAYMENT. Payment for costs that are associated with maintaining an approved medical education program, but that are not reimbursed as part of direct medical education payments.

002.18 LOW-INCOME UTILIZATION RATE. For the cost reporting period ending in the calendar year preceding the Medicaid rate period, the sum, expressed as a percentage, of the fractions, calculated from acceptable data submitted by the hospital as follows:

(A) Total Medicaid inpatient revenues including fee-for-service, managed care, and primary care case management payments, excluding payments for disproportionate share hospitals, paid to the hospital, plus the amount of cash subsidies received directly from state and local governments in a cost reporting period, divided by the total amount of revenues of the hospital for inpatient services including fee-for-service, managed care, and primary care case management payments, including the amount of cash subsidies received directly from state and local governments and excluding payments for disproportionate share hospitals, in the same cost reporting period; and

(B) The total amount of the hospital's charges for hospital inpatient services attributable to indigent care in ending in the calendar year preceding the Medicaid rate period, less the amount of any cash subsidies identified in item 1 of this definition in the cost reporting period reasonably attributable to hospital inpatient services, divided by the total amount of the hospital's charges for inpatient services in the hospital for the same period. The total inpatient charges attributed to indigent care does not include contractual allowances and discounts, other than for indigent patients not eligible for Medicaid, that is, reductions in charges given to other third-party payors, such as health maintenance organizations, Medicare, or Blue Cross.

002.19 MEDICAID ALLOWABLE INPATIENT CHARGES. Total claim submitted charges less claim non-allowable amount.

002.20 MEDICAID ALLOWABLE INPATIENT DAYS. The total number of covered Medicaid inpatient days.

002.21 MEDICAID INPATIENT UTILIZATION RATE. The ratio of allowable Medicaid inpatient days, as determined by Nebraska Medicaid, to total inpatient days, as reported by the hospital on its Medicare cost report ending in the calendar year preceding the Medicaid rate period. Inpatient days for out-of-state Medicaid patients for the same time period will be included in the computation of the ratio if reported to the Department prior to the beginning of the Medicaid rate period.

002.22 MEDICAID RATE PERIOD. The period of July 1 through the following June 30.

002.23 MEDICAL REVIEW. Review of Medicaid claims, including validation of hospital diagnosis and procedure coding information; continuation of stay, completeness, adequacy, and quality of care; appropriateness of admission, discharge and transfer; and appropriateness of prospective payment outlier cases.

002.24 MEDICARE COST REPORT. The report filed by each facility with its Medicare fiscal intermediary.

002.25 NATIONAL WEIGHTS. The 3M APR-DRG National Weights are calculated using the Nationwide Inpatient Sample released by the Healthcare Cost and Utilization Project. A hospital that does not participate in the Medicare program shall complete the Medicare Cost Report in compliance with Medicare principles and supporting rules, regulations, and statutes. The hospital shall file the completed form with the Department within five months after the end of the hospital's reporting period. A 30-day extension of the filing period may be granted if requested in writing before the end of the five-month period. Completed Medicare Cost Reports are subject to audit by the Department or its designees. If a nursing facility is affiliated with the hospital, the nursing facility cost report must be filed according to this chapter. Note specifically that time guidelines for filing nursing facility cost reports differ from those for hospitals.

002.26 NEW OPERATIONAL FACILITY. A facility providing inpatient hospital care which meets one of the following criteria:

(A) A licensed newly constructed facility, which either totally replaces an existing facility or which is built at a site where hospital inpatient services have not previously been provided;

(B) A licensed facility which begins providing hospital inpatient services in a building at a site where those services have not previously been provided; or

(C) A licensed facility which is reopened at the same location where hospital inpatient care has previously been provided but not within the previous 12 months. A new operational facility is created neither by virtue of a change in ownership nor by the construction of additional beds to an existing facility.

002.27 OPERATING COST PAYMENT AMOUNT. The calculated payment that compensates hospitals for operating cost, including the major moveable equipment portion of capital-related costs, but excluding the building and fixtures portion of capital-related costs, direct medical education costs, and indirect medical education costs.

002.28 PEER GROUP. A grouping of hospitals or distinct part units with similar characteristics for the purpose of determining payment amounts. Hospitals are classified into one of six peer groups:

(A) Metro acute care hospitals: Peer Group 1: Hospitals located in metropolitan statistical areas as designated by Medicare;

(B) Other urban acute care hospitals: Peer Group 2: Hospitals that have been redesignated to a metropolitan statistical area by Medicare for federal fiscal year 1995 or 1996 or hospitals designated by Medicare as regional rural referral centers;

(C) Rural acute care hospitals: Peer Group 3: All other acute care hospitals;

(D) Psychiatric hospitals and distinct part units in acute care hospitals: Peer Group 4: Hospitals that are licensed as psychiatric hospitals by the licensing agency of the state in which they are located and distinct parts as defined in these regulations;

(E) Rehabilitation hospitals and distinct part units in acute care hospitals: Peer Group 5: Hospitals that are licensed as rehabilitation hospitals by the licensing agency of the state in which they are located and distinct parts as defined in these regulations; and

(F) Critical access hospital: Peer Group 5: Hospitals that are certified as critical access hospitals by Medicare.

002.29 PEER GROUP BASE PAYMENT AMOUNT. A base payment per discharge or per diem amount used to calculate the operating cost payment amount. The base payment amount is the same for all hospitals in a peer group except Peer Group 1, Children's Hospitals, Peer Group 5 and Peer Group 6.

002.30 REPORTING PERIOD. Same reporting period as that used for its Medicare cost report.

002.31 RESOURCE INTENSITY. The relative volume and types of diagnostic, therapeutic and bed services used in the management of a particular disease.

002.32 RISK OF MORTALITY (ROM). The likelihood of dying.

002.33 SEVERITY OF ILLNESS LEVEL (SOI). The extent of physiologic decompensation or organ system loss of function.

002.34 TAX-RELATED COSTS. Any real or personal property tax, sales tax, excise tax, tax enacted pursuant to the Medicaid Voluntary Contribution Provider Specific Tax Amendment of 1991 (P.L. 102-234) or any amendments thereto, franchise fee, license fee, or hospital specific tax, fee or assessment imposed by the local, state or federal government, but not including income taxes.

002.35 UNCOMPENSATED CARE. Uncompensated care includes the difference between costs incurred and payments received in providing services to Medicaid patients and uninsured.

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