Current through September 17, 2024
A hospital qualifies as a disproportionate share hospital if
the hospital meets the definition of a disproportionate share hospital and
submits the required information completed, dated and signed as follows with
their Medicare cost report:
(A) The
names of at two obstetricians who have staff privileges at the hospital and who
have agreed to provide obstetric services to individuals who are eligible for
Medicaid. This requirement does not apply to a hospital:
(i) The inpatients of which are predominantly
individuals under 18 years of age;
(ii) Which does not offer non-emergency
obstetric services to the general population as of December 21, 1987;
or
(iii) For a hospital located in
a rural area, the term obstetrician includes any physician with staff
privileges at the hospital to perform non-emergency obstetric
procedures;
(B) Only
Nebraska hospitals which have a current enrollment with Medicaid will be
considered for eligibility as a disproportionate share hospital; and
(C) When notified by the Department that the
hospital qualifies as a disproportionate share hospital, each hospital must
certify to Medicaid that it has incurred costs for the delivery of
uncompensated care which are equal to or exceed the amount of the
disproportionate share hospital payment.
009.01
DISPROPORTIONATE SHARE
ELIGIBILITY CALCULATION. To calculate eligibility, proxy data will
be used from each hospital's fiscal year ending in the calendar year preceding
the state fiscal year. Eligibility as a disproportionate share hospital will be
calculated using the following data.
009.01(A)
MEDICAID INPATIENT
UTILIZATION RATE. To determine the Medicaid inpatient utilization
rate, the denominator will be the total days as reported on the Medicare cost
report. The numerator will be the sum of each hospital's Medicaid days, which
includes the Medicaid management information system claims file data run 150
days after each hospital's fiscal year end, managed care days, and out-of-state
days reported before the federal fiscal year for which the determination is
made. Only secondary payor days in the Medicaid management information system
claims file data will be included.
009.02(B)
LOW INCOME UTILIZATION
RATE. To determine the low-income utilization rate, data from the
Nebraska accounting system will be used to calculate the low-income utilization
rate for state-owned institutions for mental disease. For all other hospitals,
the hospital's certified report of total revenue, Medicaid inpatient revenue,
cash subsidies, uncompensated care charges, and total inpatient charges minus
any disproportionate share payment will be used.
009.02
DISPROPORTIONATE SHARE
HOSPITAL UPPER PAYMENT LIMIT AND UNCOMPENSATED CARE CALCULATION.
The Disproportionate Share Hospital upper payment limit and the uncompensated
care calculation is the sum of the Medicaid shortfall plus the cost of
uninsured care.
(A) The Department will
calculate the Medicaid shortfall as follows:
(i) The Department will determine the costs
of Medicaid fee-for-service and managed care inpatient services by:
(1) Calculating a hospital's routine cost per
day for each cost center from the Centers for Medicare and Medicaid Services
2552 cost report by dividing the total costs by the total days; and
(2) Multiplying the cost per day times the
number of Medicaid allowable days provided during the same fiscal year as the
filed cost report, and paid up to 150 days after the end of the fiscal
year.
(ii) The
Department will determine costs of Medicaid fee-for-service and managed care
outpatient services by:
(1) Calculating a
hospital's ancillary cost-to-charge ratio from the Centers for Medicare and
Medicaid Services 2552 cost report; and
(2) Multiplying the total Medicaid allowable
charges times the ancillary cost-to-charge ratio.
(iii) The total Medicaid cost is the sum of
the inpatient and outpatient costs for each hospital; and
(iv) The Medicaid shortfall is determined by
subtracting the total allowable Medicaid payments from the total Medicaid
cost.
(B) The Department
will calculate the cost of uninsured care by using each hospital's charges for
services provided to uninsured patients as filed and certified to the
Department for the same fiscal year as the Centers for Medicare and Medicaid
Services cost report used in determining costs. The Department will convert
each hospital's charges to cost for uninsured patients by multiplying the
charges by the overall cost-to-charge ratio determined using each hospital's
Centers for Medicare and Medicaid Services 2552 report for the same fiscal year
used in determining cost; and
(C)
The Medicaid upper payment limit and the uncompensated care amount shall be the
sum of the Medicaid shortfall plus the cost of uninsured care.
009.03
DISPROPORTIONATE SHARE PAYMENTS. Disproportionate
share payments will be made each federal fiscal year following receipt of all
required data by the Department. The total of all disproportionate share
payments must not exceed the limits on disproportionate share hospital funding
as established for this State by the Centers for Medicare and Medicaid Services
in accordance with the provisions of the Social Security Act, Title XIX,
Section 1923. Payments determined for each federal fiscal year will be
considered payment for that year, and not for the year from which proxy data
used in the calculation was taken. To calculate payment, proxy data will be
used from each hospital's fiscal year ending in the calendar year preceding the
state fiscal year which coincides most closely to the federal fiscal year for
which the determination will be applied.
009.03(A)
METHODS.
For federal fiscal year 2007 and succeeding years, the Department will make a
disproportionate share hospital payment to hospitals that qualify for a payment
under one of the following pool distribution methods.
009.03(A)(i)
BASIC
DISPROPORTIONATE SHARE PAYMENT POOL 1. Pool 1 consists of eligible
hospitals in peer groups 2, 3, and 6 that are not eligible under pool 6.
009.03(A)(i)(1)
POOL
1. Total funding to Pool 1 will be $1,000,000. In federal fiscal
year 2008 and following years, this amount will be increased by the percentage
change in the consumer price index for all urban consumers, all items; U.S.
city average. The Department will calculate the payment as follows. First, each
hospital's Medicaid days, which include days from the Medicaid management
information system claims file data run 150 days after each hospital's fiscal
year end, managed care days, and out-of-state days reported before the federal
fiscal year for which the determination is made, will be divided by the sum of
the Medicaid inpatient days of all hospitals which qualify for a payment in
pool 1. Second, the ratio resulting from such division will be multiplied times
the total funding for pool 1 to determine each hospital's payment. If payment
to a hospital exceeds the disproportionate share hospital payment limit, as
established under section 1923(f) of the Social Security Act, the payment will
be reduced. If payment is reduced to a hospital within pool 1, the additional
funds will be redistributed pro rata to eligible hospitals within pool
1.
009.03(A)(i)(2)
BASIC DISPROPORTIONATE SHARE PAYMENT POOL 2. Pool 2
consists of eligible hospitals in Peer Groups 1, 2, and 3 that are also
eligible under Pool 6.
009.03(A)(i)(2)(a)
POOL 2. Total funding to pool 2 will be $3,154,000 for
federal fiscal year 2007, and $2,654,000 for federal fiscal year 2008. For
federal fiscal year 2009 and following years, the total funding will be the
amount for federal fiscal year 2008 with an annual increase by the percentage
change in the consumer price index for all urban consumers, all items; U.S.
city average. The Department will calculate the payment for pool 2 as follows.
First, each hospital's Medicaid days, which include days from the Medicaid
management information system claims file data run 150 days after each
hospital's fiscal year end, managed care days, and out-of-state days reported
before the federal fiscal year for which the determination is made, will be
divided by the sum of the Medicaid inpatient days of all hospitals which
qualify for a payment in pool 2. Second, the ratio resulting from the division
will be multiplied times the total funding for Pool 2 to determine each
hospital's payment. If payment to a hospital exceeds the disproportionate share
hospital payment limit, as established under 1923 (f) of the Social Security
Act, the payment will be reduced. If payment is reduced to a hospital within
pool 2, the additional funds will be redistributed pro rata to eligible
hospitals within pool 2.
009.03(A)(i)(3)
DISPROPORTIONATE
SHARE PAYMENT FOR HOSPITALS THAT PRIMARILY SERVE CHILDREN POOL 3.
Pool 3 consists of the hospital that both primarily serves children age 20 and
under, and has the greatest number of Medicaid days.
009.03(A)(i)(3)(a)
POOL 3
FUNDING. Total funding for pool 3 will be $3,138,000 for federal
fiscal year 2007, and $3,638,000 for federal fiscal year 2008. For federal
fiscal year 2009 and following years, the total funding will be the amount for
federal fiscal year 2008 with an annual increase by the percentage change in
the consumer price index for all urban consumers, all items; U.S. city average.
A hospital eligible for payment under this pool will not be eligible for
payment under any other pool. If payment to the hospital exceeds the
disproportionate share hospital payment limit, as established under 1923(f) of
the Social Security Act, the payment will be reduced.
009.03(A)(i)(4)
DISPROPORTIONATE
SHARE PAYMENT FOR STATE OWNED INSTITUTIONS FOR MENTAL DISEASE HOSPITALS AND FOR
ELIGIBLE HOSPITALS IN PEER GROUP 4 POOL 4. Pool 4 consists of
state owned institutions for mental disease and other eligible hospitals in
peer group 4.
009.03(A)(i)(4)(a)
POOL 4 FUNDING. Total funding for Pool 4 will be
$1,811,337 annually. The Department will calculate payments as follows.
Each eligible hospitals must certify in writing to the
Nebraska Medical Assistance Program its charges for uncompensated care for the
hospital's fiscal year ending in the calendar year preceding the federal fiscal
year for which the determination is applied. Charges for uncompensated care
will be converted to cost using the hospitals cost-to-charge ratio. payment to
each hospital will be equal to the cost of its uncompensated care. If the total
of all disproportionate share payment amounts for pool 4 exceeds the federally
determined disproportionate share hospital limit for Nebraska, the will be
reduced pro rata.
009.03(A)(i)(5)
NON-PROFIT ACUTE
CARE TEACHING HOSPITAL AFFILIATED WITH A STATE-OWNED UNIVERSITY MEDICAL COLLEGE
POOL 5. Pool 5 consists of the non-profit acute care teaching
hospital, subsequently referred to as the state teaching hospital, that has an
affiliation with the University Medical College owned by the State of Nebraska.
A hospital eligible for payment under this pool may be eligible for payment
under Pool 6.
009.03(A)(i)(5)(a)
POOL 5 FUNDING. Total funding to Pool 5 will be
$15,000,000. For FFY 08 and following years the funding will be increased
annually by the percentage change in the consumer price index for all urban
consumers, all items; U.S. city average. The Department will calculate the
disproportionate share hospital payment to Pool 4 5 as an amount equal to the
cost of its uncompensated care. If the payment to the hospital exceeds the
disproportionate share payment limit, as established under 1923(f) of the
Social Security Act, the payment will be reduced.
009.03(A)(i)(6)
UNCOMPENSATED
CARE POOL. Pool 6 consists of hospitals that provide services to
low-income persons covered by a county administered general assistance program;
or hospitals that provide services to low-income persons covered by the state
administered public behavioral health system.
009.03(A)(i)(6)(a)
POOL 6
FUNDING. Total funding to Pool 6 will be the remaining balance of
the total, federal and state, disproportional share hospital funding minus the
funding for pools 1, 2, 3, 4, and 5, The Department will calculate payments as
follows. Disproportionate share hospital payments to a hospital under all other
pools will be subtracted from the hospital's disproportionate share hospital
upper payment limit before allocating payments under pool 6. The costs for
uncompensated care resulting from participation in county administered general
assistance program will be reported by the county; and costs for the state
administered public behavioral health system will be reported by each hospital.
Reported costs will be subject to audit by the Department. A ratio for each
hospital will be determined based on the uncompensated cost for each hospital
to the total of uncompensated cost for all hospitals in pool 6. The ratio for
each hospital will be multiplied times the available funding to the Pool to
yield each hospital' annual payment amount. The total computable payment will
be commensurate with the charges for uncompensated care resulting from
participation in county administered general assistance program; or the state
administered public behavioral health system. The annual payment amount will be
dispersed in twelve monthly payments. If payment to the hospital exceeds the
disproportionate share payment limit, as established under 1923(g) of the
Social Security Act, the payment will be reduced to the payment limit. If
payments to hospitals under this pool exceed the total allotment to Nebraska,
the payments will be reduced pro rata.
009.03(B)
LIMITATIONS
ON DISPROPORTIONATE SHARE PAYMENTS. No payments made under this
section will exceed any applicable limitations upon such payments established
by Section 1923(g)(1)(A) of the Social Security Act. Disproportionate Share
payments to all qualified hospitals for a year will not exceed the State
disproportionate share hospital payment limit, as established under 1923 (f) of
the Social Security Act.
009.04
REDISTRIBUTION OF
DISPROPORTIONATE SHARE HOSPITAL OVERPAYMENTS. As required by
Section 1923(j) of the Social Security Act related to auditing and reporting of
disproportionate share hospital payments, the Department will implement
procedures to comply with the Disproportionate Share Hospital Payments final
rule issued in the December 19, 2008, Federal Register, with effective date of
January 19, 2009. Beginning in disproportionate share hospital state plan rate
year 2011, if the results of audits conducted in accordance with the
disproportionate share hospital final rule indicate that a hospital has
exceeded the hospital specific disproportionate share hospital limit the amount
of disproportionate share hospital payment in excess of uncompensated care
costs will be recouped. Any funds recouped shall first be recouped from pool 1
through 5 payments and then from pool 6 payments and shall be redistributed to
other eligible hospitals within the state, provided each hospital remains below
their hospital specific disproportionate share hospital limit. Funds recouped
from pools 1 through 6 shall first be redistributed to each eligible hospital
in the pool in which the hospital payment was recouped. Any recouped funds that
are not able to be distributed within the pool will accumulate and be
redistributed to all eligible hospitals.
009.04(A)
CALCULATION. The Department will calculate the
redistribution as follows. First, for each pool in which funds were recouped
beginning with Pool 1 and proceeding in pool numerical order, each hospital's
difference between their disproportionate share hospital payment and
disproportionate share hospital limit will be calculated. The difference will
be divided by the sum of the difference between the disproportionate share
hospital payment and disproportionate share hospital limit for all hospitals in
the pool. Second, the ratio resulting from such division will be multiplied
times the total funding recouped for the pool to determine each hospital's
redistribution payment. If the sum of the original disproportionate share
hospital payment and redistribution payment exceeds the disproportionate share
hospital payment limit, the payment will be reduced. If payment is reduced to a
hospital within a pool, the additional funds will be redistributed pro rata to
eligible hospitals within the pool. If all hospitals within the Pool have
reached their disproportionate share hospital limit, the remaining funds will
be carried forward to be redistributed to all eligible hospitals. For pool 6,
each hospital's difference between their disproportionate share hospital
payment and disproportionate share hospital limit will include funds
redistributed from pools 1 through 5 above.
009.04(B)
FINAL
REDISTRIBUTION. The final redistribution will be calculated as
follows. First, for any funds that were not redistributed for each pool in
which funds were recouped, each hospitals, except for pool 4 institutions of
mental disease difference between their disproportionate share hospitals
payment and disproportionate share hospitals limit will be calculated. The
difference will be divided by the sum of the difference between the
disproportionate share hospitals payment and disproportionate share hospitals
limit for all non-institutions of mental disease hospitals. Second, the ratio
resulting from such division will be multiplied times the total recouped
funding not already distributed to determine each hospital's redistribution
payment. If the sum of the original disproportionate share hospital payment and
redistribution payment exceeds the disproportionate share hospitals payment
limit, the payment will be reduced. If payment is reduced to a hospital, the
additional funds will be redistributed pro rata to eligible non-institutions of
mental disease hospitals within the pool. If all non-institutions of mental
disease hospitals have reached their disproportionate share hospital limit, the
federal portion of remaining funds will be returned to the Centers for Medicare
and Medicaid Services.
