Current through all regulations passed and filed through September 16, 2024
This rule is applicable for each program year for all
medicaid-participating providers of hospital services included in the
definition of "hospital" as described under section
5168.01 of the Revised
Code.
(A) Definitions.
(1) "Total fee for service (FFS) medicaid
costs" for each hospital means the sum of inpatient program costs reported on
ODM 02930, schedule H, section I, columns 1 and 3, line 1 and outpatient
medicaid program costs as reported on ODM 02930, "Ohio Medicaid Hospital Cost
Report," section II, column 1, line 10 for the applicable state fiscal
year.
(2) "Total medicaid managed
care plan (MCP) inpatient costs" for each hospital means the amount on ODM
02930 schedule I, column 3, line 202.
(3)
"Total medicaid MCP outpatient costs" for each hospital means the amount on ODM
02930 schedule I, column 5, line 202.
(4)
"Total Title V costs" for each hospital means the sum of the inpatient and
outpatient program costs as reported on ODM 02930, schedule H, section I,
column 2, line 1 and section II, column 2, line 10.
(5)
"Total inpatient uncompensated care costs for people without insurance" for
each hospital means the sum of the inpatient uncompensated care
costs below the poverty level and
inpatient uncompensated care costs above the poverty level amounts as totaled
on ODM 02930, schedule F, column 5.
(6) "Total inpatient
uncompensated care costs under one hundred per cent" for each hospital means
the sum of the inpatient uncompensated care costs under one hundred per cent
for patients with and without insurance as reported on the ODM 02930, schedule
F, columns 4 and 5.
(7) "Total inpatient
uncompensated care costs above one hundred per cent without insurance" for each
hospital means the sum of the inpatient uncompensated care costs over one
hundred per cent for patients without insurance as reported on the ODM 02930,
schedule F, column 5.
(8)
"Total outpatient uncompensated care costs under one hundred per cent" for each
hospital means the sum of the outpatient care costs under one hundred per cent
for patients with and without insurance as on the ODM 02930, schedule F,
columns 4 and 5.
(9) "Total outpatient
uncompensated care costs above one hundred per cent without insurance" for each
hospital means the sum of the outpatient uncompensated care costs above one
hundred per cent for patients without insurance as reported on the ODM 02930,
schedule F, column 5.
(10) "Total
uncompensated care costs under one hundred per cent" for each hospital means
the sum of total inpatient uncompensated care costs under one hundred per cent
as described in paragraph (A)(6) of this rule, and total outpatient uncompensated
care costs under one hundred per cent as described in paragraph (A)(8) of this
rule.
(11) "Total
uncompensated care costs above one hundred per cent without insurance" for each
hospital means the sum of total inpatient uncompensated care costs above one
hundred per cent without insurance as described in paragraph (A)(7) of this rule,
and total outpatient uncompensated care costs above one hundred per cent
without insurance as described in paragraph (A)(9) of this
rule.
(12) "Total outpatient
uncompensated care costs for people without insurance" for each hospital means
the sum of the outpatient uncompensated care costs below the poverty
level and outpatient uncompensated care
costs above the poverty level as represented on the ODM 02930, schedule F.
(13) "Total
uncompensated care costs for patients without insurance" for each hospital
means the sum of the total inpatient uncompensated care costs for people
without insurance in paragraph (A)(5) of this rule and the total outpatient
uncompensated care costs for people without insurance in paragraph (A)(12) of this
rule.
(14) "Total FFS
medicaid days" means, for each hospital, the amount on the ODM 02930, schedule
C, column 6, line 49 .
(15)
"MCP days" mean for each hospital, the
amount on the ODM 02930, schedule I, column 2, line 204.
(16) "Total
medicaid days" for each hospital means the sum of total medicaid FFS days as
defined in paragraph (A)(14) of this rule and MCP days as defined in
(A)(15)
of this rule.
(17) "High federal
disproportionate share hospital" means a hospital with a ratio of total
medicaid days as defined in paragraph (A)(16) of this rule
to total facility days as defined in paragraph (A)(19) of this rule
greater than the statewide mean ratio of the sum of total medicaid days to the
sum of total facility days plus one standard deviation.
(18)
"Total medicaid FFS payments" for each hospital means the sum
of the total medicaid inpatient payments, total medicaid outpatient payments, and
the medicaid
settlement amounts as reported on the ODM 02930, schedule H, column 1, lines 7,
15, and 26.
(19) "Total facility
days" means for each hospital the amount reported on the ODM 02930, schedule C,
column 4, line 49.
(20) "Medicaid
utilization rate" for each hospital means the rate calculated by dividing the
sum of total medicaid days as defined in paragraph (A)(16) of this rule
by the total facility days as defined in paragraph (A)(19) of this
rule.
(21) "Total medicaid
MCP costs" for each hospital means the actual cost to the hospital of care
rendered to medical assistance recipients enrolled in a MCP that has entered
into a contract with the department of medicaid and is the amount on ODM 02930,
schedule I, column 3, line 202 and column 5, line 202.
(22)
"Medicaid MCP inpatient payments" for each hospital means the amount on ODM
02930 schedule I, column 2, line 208.
(23) "Medicaid MCP
outpatient payments" for each hospital means the amount on ODM 02930 schedule
I, column 4, line 208.
(24) "Total medicaid
MCP payments" for each hospital is the sum of the amount calculated in
paragraph (A)(22) of this rule, and the amount calculated in
paragraph (A)(23) of this rule.
(25) "Adjusted total
facility costs" for each hospital means the amount described in paragraph (A)
of rule 5160-2-08 of the Administrative
Code.
(26) "Rural
Hospital (RH)"
means a
hospital geographically located in an Ohio county that
is not
classified
into a
core based statistical area (CBSA) as designated in the
inpatient prospective payment system (IPPS) case-mix and wage index table as
published October first of each program year
by the centers for medicare and
medicaid services (CMS).
(27) "Critical Access
Hospital (CAH)" means a hospital that is certified as a critical access
hospital by CMS and that has notified the Ohio department of health and the
Ohio department of medicaid of such certification.
The Ohio department of
medicaid must receive notification of critical access hospital certification by
the first day of October, the start of the program year, in order for the
hospital to be considered a critical access hospital for disproportionate share
payment purposes. Hospitals shall notify the Ohio department of medicaid of any
change in their critical access hospital status, including continued CAH
designations, immediately following notification from CMS.
(28)
"Hospital-specific disproportionate share limit" for each hospital means the
limit on disproportionate share and indigent care payments made to a specific
hospital as defined in paragraph (J)(2) of this rule.
(29)
"Children's hospitals" are those hospitals that meet the definition in
paragraph (A)(3) of rule 5160-2-05 of the Administrative
Code.
(30) "Inpatient upper
limit payment" for each hospital means the amount reported on ODM 02930,
schedule H, section I, column 1, line 5.
(31)
"Outpatient upper limit payment" for each hospital means the amount reported on
ODM 02930, schedule H, section II, column 1, line 14.
(32)
"Total program amount" means the sum of the amounts in paragraphs (K) (2) and
(K)(3) of this rule.
(33) "Obstetric
services requirements (OSR)" means for each hospital that satisfies the federal
statute of having at least two obstetricians who have staff privileges at the
hospital that agreed to provide obstetric services to medicaid eligible
individuals during the cost-reporting year as defined in paragraph (B) of rule
5160-2-08 of the Administrative
Code. For rural hospitals as defined in paragraph (A))(26) of this
rule, this requirement includes any physician with staff privileges at the
hospital to perform non-emergency obstetric procedures. This requirement shall
not apply to a hospital whose inpatients are predominantly individuals under
eighteen years of age or a hospital which did not offer non-emergency obstetric
services to the general population as of December 22, 1987, the date the
federal statute was enacted.
(C) Source data for calculations.
(1) The calculations described in this rule
will be based on cost-reporting data described in paragraph (B)(1) of rule
5160-2-08 of the Administrative
Code.
(2) For new hospitals, the
first available cost report filed with the department in accordance with rule
5160-2-23 of the Administrative
Code will be used until a cost report that meets the requirements of this
paragraph is available. If, for a new hospital, there is no available or valid
cost report filed with the department, the hospital will be excluded until
valid data is available.
Cost reports for hospitals involved in mergers during the
program year that result in the hospitals using one provider number will be
combined and annualized by the department to reflect one full year of
operation.
(3) Closed
hospitals with unique medicaid provider numbers.
For a hospital facility, identifiable to a unique medicaid
provider number, that closes during the program year defined in paragraph (A)
of rule 5160-2-08 of the Administrative
Code, the cost report data used shall be adjusted to reflect the portion of the
year the hospital was open during the current program year. That partial year
data shall be used to determine the distribution to that closed hospital. The
difference between the closed hospital's distribution based on the full year
cost report and the partial year cost report shall be redistributed to the
remaining hospitals in accordance with paragraph (G) of this rule.
For a hospital facility identifiable to a unique medicaid
provider number that closed during the immediate prior program year, the cost
report data shall be used to determine the distribution that would have been
made to that closed hospital. This amount shall be redistributed to the
remaining hospitals in accordance with paragraph (G) of this rule.
(4) Replacement hospital
facilities.
If a new hospital facility is opened for the purpose of
replacing an existing (original) hospital facility identifiable to a unique
medicaid provider number and the original facility closes during the program
year defined in paragraph (A) of rule
5160-2-08 of the Administrative
Code, the cost report data from the original facility shall be used to
determine the distribution to the new replacement facility if the following
conditions are met:
(a) Both
facilities have the same ownership,
(b) There is appropriate evidence to indicate
that the new facility was constructed to replace the original
facility,
(c) The new replacement
facility is so located as to serve essentially the same population as the
original facility, and
(d) The new
replacement facility has not filed a cost report for the current program year.
For a replacement hospital facility that opened in the
immediate prior program year, the distribution for that facility will be based
on the cost report data for that facility and the cost report data for the
original facility, combined and annualized by the department to reflect one
full year of operation.
(5) Hospitals that have changed ownership.
For a change of ownership that occurs during the program year,
the cost reporting data filed by the previous owner that reflects that
hospital's most recent completed interim settled medicaid cost report shall be
annualized to reflect one full year of operation. The data will be allocated to
each owner based on the number of days in the program year the hospital was
owned.
For a change of ownership that occurred in the previous program
year, the cost reporting data filed by the previous owner that reflects that
hospital's most recent completed interim settled medicaid cost report and the
cost reporting data filed by the new owner that reflects that hospital's most
recent completed interim settled medicaid cost report, will be combined and
annualized by the department to reflect one full year of operation. If there is
no available or valid cost report from the previous owner, the department shall
annualize the cost report from the new owner to reflect one full year of
operation.
(6) Cost report
data used in the calculations described in this rule will be the cost report
data described in this paragraph subject to any adjustments made upon
departmental review prior to final determination that is completed each year
and subject to the provisions of rule
5160-2-08 of the Administrative
Code.
(D) Determination
of indigent care pool.
(1) The "indigent care
pool" means the sum of the following:
(a) The
total assessments paid by all hospitals less the assessment deposited into the
health care services administration fund described in rule
5160-2-08 of the Administrative
Code.
(b) The total amount of
intergovernmental transfers required to be made by governmental hospitals less
the amount of the transfer deposited into the health care services
administration fund described in rule
5160-2-08 of the Administrative
Code.
(c) The total amount of
federal matching funds that will be made available to general acute care
hospitals in the same program year as a result of the state's disproportionate
share limit payment allotment determined by the CMS for that program
year.
(2) The funds
available in the indigent care pool shall be distributed through policy payment
pools in accordance with paragraphs (E) to (I) of this rule. Policy payment
pools shall be allocated a percentage of the indigent care pool as described in
paragraphs (D)(2)(a) to (D)(2)(e) of this rule.
(a) High federal disproportionate share
hospital pool: 12.00 per cent.
(b)
Medicaid indigent care pool: 77.26 per cent .
(c)
Uncompensated care pool below one hundred per cent of
poverty: zero per cent .
(d)
Critical access and rural hospitals: 8.76 per cent.
(e) Children's hospitals: 1.98 per
cent.
(E)
Distribution of funds through the indigent care payment pools.
The funds are distributed among the hospitals according to
indigent care payment pools described in paragraphs (E)(1) to (E)(3) of this
rule.
(1) Hospitals meeting the high
federal disproportionate share hospital definition described in paragraph
(A)(17)
of this rule shall receive funds from the high federal disproportionate share
indigent care payment pool.
(a) For each
hospital that meets the high federal disproportionate share definition,
calculate the ratio of the hospital's total FFS medicaid costs and total
medicaid MCP costs to the sum of total FFS medicaid costs and total medicaid
MCP costs for all hospitals that meet the high federal disproportionate share
definition.
(b) For each hospital
that meets the high federal disproportionate share definition, multiply the
ratio calculated in paragraph (E)(1)(a) of this rule by the amount allocated in
paragraph (D)(2)(a) of this rule to determine each hospital's high federal
disproportionate share hospital payment amount, subject to the following
limitations:
(i) If the hospital's payment
amount calculated in paragraph (E)(1) (b) of this rule is greater than or equal
to its hospital-specific disproportionate share limit defined in paragraph
(A)(28)
of this rule, the hospital's high federal disproportionate share hospital
payment is the amount defined in paragraph (A)(28).
(ii) If the hospital's payment amount
calculated in (E)(1)(b) of this rule is less than its hospital-specific
disproportionate share limit defined in paragraph (A)(28) of this
rule, the hospital's high federal disproportionate share hospital payment is
equal to the amount in paragraph (E)(1)(b) of this rule and any additional
amount provided by paragraph (E)(1)(b)(iv) of this rule.
(iii) If the hospital-specific
disproportionate share limit defined in paragraph (A)(28) of this rule
is equal to or less than zero, the hospital's high federal disproportionate
share hospital payment is equal to zero.
(iv) For hospitals whose high federal
disproportionate share hospital payment is set at the disproportionate share
limit defined in paragraph (A)(28) of this rule, calculate each hospital's limited
payment by subtracting the amount defined in paragraph (A)(28) of this rule
from the amount determined in paragraph (E)(1)(b) of this rule and sum these
amounts for all limited hospital(s). Subtract the sum of the limited payments
from the amount allocated in paragraph (D)(2)(a) of this rule and repeat the
distribution described in paragraph (E)(1) of this rule until all remaining
funds for this pool are expended.
(2) Hospitals shall receive funds from the
medicaid indigent care payment pool.
(a) For
each hospital, subtract the amount distributed in paragraph (E)(1) of this rule
from the hospital-specific disproportionate share limit defined in paragraph
(A)(28)
of this rule.
(b) For all
hospitals, sum the amounts calculated in paragraph (E)(2)(a) of this
rule.
(c) For each hospital,
calculate the ratio of the amount in paragraph (E)(2)(a) of this rule to the
amount in paragraph (E)(2)(b) of this rule.
(d) For each hospital, multiply the ratio
calculated in paragraph (E)(2)(c) of this rule by the amount allocated in
paragraph (D)(2)(b) of this rule to determine each hospital's medicaid indigent
care payment amount subject to the following limitations:
(i) If the sum of a hospital's payment
amounts calculated in paragraph (E)(1) of this rule is greater than or equal to
its hospital-specific disproportionate share limit defined in paragraph
(A)(28)
of this rule, the hospital's medicaid indigent care payment pool amount is
equal to zero.
(ii) If the sum of a
hospital's payment amounts calculated in paragraphs (E)(1) and (E)(2)(d) of
this rule is less than its hospital-specific disproportionate share limit
defined in paragraph (A)(28) of this rule, then the payment is equal to the
amount in paragraph (E) (2)(d) of this rule and any amount provided by
paragraph (E)(2)(d) (iv) of this rule.
(iii) If the sum of a hospital's payment
amounts calculated in paragraphs (E)(1) and (E)(2)(d) of this rule is greater
than its hospital-specific disproportionate share limit defined in paragraph
(A)(28)
of this rule, then the payment is equal to the difference between the
hospital-specific disproportionate share limit defined in paragraph (A)(28) of this rule
and the amount calculated in paragraph (E) (1) of this rule.
(iv) If any hospital is limited as described
in paragraph (E)(2)(d)(iii) of this rule, calculate each hospital's limited
payment by subtracting the amount defined in paragraph (A)(28) of this rule
from the amount determined in paragraph (E)(2)(d) of this rule and sum these
amounts for all limited hospital(s). Subtract the sum of the limited payments
from the amount allocated in paragraph (D)(2)(b) of this rule and repeat the
distribution described in paragraph (E)(2) of this rule until all remaining
funds for this pool are expended.
(v) For all hospitals, sum the amounts
calculated in paragraph (E)(2)(d) of this rule. This amount is the hospital's
medicaid indigent payment amount.
(3) Hospitals shall receive funds from the
uncompensated care indigent care payment pool.
(a) For each hospital, sum
total inpatient uncompensated care costs under one hundred
per cent defined in paragraph (A)(6) of this rule and total
outpatient uncompensated care costs under one hundred per cent defined in
paragraph (A)(8) of this rule. For hospitals with total negative
uncompensated
care costs, the resulting sum is equal to zero.
(b) For all hospitals, sum the amounts
calculated in paragraph (E)(3)(a) of this rule.
(c) For each hospital, calculate the ratio of
the amount in paragraph (E)(3)(a) of the rule to the amount in paragraph
(E)(3)(b) of this rule.
(d) For
each hospital, multiply the ratio calculated in paragraph (E)(3)(c) of this
rule by the amount allocated in paragraph (D)(2)(c) of this rule to determine
each hospital's uncompensated care under one hundred per cent payment, subject to the
following limitations:
(i) If the sum of a
hospital's payment amounts calculated in paragraphs (E)(1) and (E)(2) of this
rule is greater than or equal to its hospital-specific disproportionate share
limit defined in paragraph (A)(28) of this rule, the hospital's
uncompensated care under one hundred per cent payment amount is equal to
zero.
(ii) If the sum of a
hospital's payment amount calculated in paragraphs (E)(1) and (E)(2) of this
rule and the amount calculated in paragraph (E)(3)(d) of this rule is less than
its hospital-specific disproportionate share limit defined in paragraph
(A)(28)
of this rule, the hospital's uncompensated care under one hundred per cent payment amount is
equal to the amount calculated in paragraph (E)(3)(d) of this rule and any
amount provided by paragraph (E)(3)(d)(iv) of this rule.
(iii) If a hospital does not meet the
condition described in paragraph (E)(3)(d)(i) of this rule, and the sum of its
payment amounts calculated in paragraphs (E)(1) and (E)(2) of this rule and the
amount calculated in paragraph (E)(3)(d) of this rule is greater than its
hospital-specific disproportionate share limit defined in paragraph (A)(28) of this
rule, the hospital's uncompensated care under one hundred per cent payment amount is equal
to the difference between the hospital's disproportionate share limit and the
sum of the payment amounts calculated in paragraphs (E)(1) and (E)(2) of this
rule.
(iv) If any hospital is
limited as described in paragraph (E)(3)(d)(iii) of this rule, calculate each
hospital's limited payment by subtracting the amount defined in paragraph
(A)(28)
of this rule from the amount determined in paragraph (E)(3)(d) of this rule and
sum these amounts for all limited hospital(s). Subtract the sum of the limited
payments from the amount allocated in paragraph (D)(2)(c) of this rule and
repeat the distribution described in paragraph (E)(3) of this rule until all
funds for this pool are expended.
(e) For each hospital, sum the amount
calculated in paragraph (E)(3)(d) of this rule. This amount is the hospital's
uncompensated care indigent care payment amount.
(F) Distribution of funds through
the rural and critical access payment pools.
The funds are distributed among the hospitals according to
rural and critical access payment pools described in paragraphs (F)(1) to
(F)(2) of this rule.
(1) Hospitals
meeting the definition described in paragraph (A)(27) of this
rule, shall receive funds from the critical access hospital (CAH) payment pool.
(a) For each hospital with CAH certification,
calculate the remaining hospital-specific disproportionate share limit by
subtracting the amounts calculated in paragraphs (E)(1), (E)(2) and (E)(3) of
this rule from the amount described in paragraph (A)(28) of this
rule.
(b) For each hospital with
CAH certification:
(i) Calculate the ratio of
each CAH hospital's remaining hospital-specific disproportionate share limit as
described in paragraph (F)(1)(a) of this rule to the total remaining
hospital-specific disproportionate share limit for all CAH hospitals.
(ii) For each CAH hospital, multiply the
ratio calculated in paragraph (F)(1)(b)(i) of this rule by 38.81 per cent of
the amount allocated in paragraph (D)(2)(d) of this rule to determine each
hospital's CAH payment amount.
(c) For all hospitals with CAH certification,
sum the amounts calculated in paragraph (F)(1)(b) of this rule.
(d) For each hospital with CAH certification,
if the amount described in paragraph (F)(1)(a) of this rule is equal to zero,
the hospital shall be included in the
RH payment pool described in paragraph (F)(2)(a)
of this rule.
(2)
Hospitals meeting the definition described in paragraph (A)(26) of this rule
but do not meet the definition described in paragraph (A)(27) of this
rule, shall receive funds from the rural hospital
RH payment pool.
(a) For each hospital with
RH
classification, as qualified by paragraphs (F)(2) and (F)(1)(d) of this rule,
sum the hospital's total payments allocated in paragraphs (E)(1)(b), (E)(2)(d),
and (E)(3)(e) of this rule.
(b)
For each hospital with
RH classification, as qualified by paragraphs
(F)(2) and (F)(1)(d) of this rule subtract the amount calculated in paragraph
(F)(2)(a) of this rule, from the amount calculated in paragraph (A)(28) of this
rule. If this difference for the hospital is negative, then for the purpose of
this calculation set the difference equal to zero.
(c) For all hospitals with
RH
classification, as qualified by paragraphs (F)(2) and (F)(1)(d) of this rule,
sum the amounts calculated in paragraph (F)(2)(b) of this rule.
(d) For each hospital with
RH
classification, as qualified by paragraphs (F)(2) and (F)(1)(d) of this rule,
determine the ratio of the amounts in paragraphs (F)(2)(b) and (F)(2)(c) of
this rule.
(e) Subtract the amount
calculated in paragraph (F)(1)(c) of this rule from the amount allocated in
paragraph (D)(2)(d) of this rule.
(f) For each hospital with
RH
classification, as qualified by paragraphs (F)(2) and (F)(1)(d) of this rule,
multiply the ratio calculated in paragraph (F)(2)(d) of this rule, by the
amount calculated in paragraph (F)(2)(e) of this rule, to determine each
hospital's rural hospital payment
pool amount.
(g) For each
hospital, sum the amount calculated in paragraph (F)(1)(b) of this rule, and
the amount calculated in paragraph (F)(2)(f) of this rule. This amount is the
hospital's rural and critical access payment amount.
(G) Distribution of funds through
the county redistribution of closed hospitals payment pools.
If funds are available in accordance with paragraph (C) of this
rule, the funds are distributed among the hospitals according to the county
redistribution of closed hospitals payment pools described in paragraphs (G)(1)
to (G)(3) of this rule.
(1) If a
hospital facility that is identifiable to a unique medicaid provider number
closes during the current program year, the payments that would have been made
to that hospital under paragraphs (E), (F), (H), and (I) of this rule for the
portion of the year it was closed, less any amounts that would have been paid
by the closed hospital under provisions of rules
5160-2-08 and
5160-2-08.1 of the
Administrative Code for the portion of the year it was closed, shall be
distributed to the remaining hospitals in the county where the closed hospital
is located. If another hospital does not exist in such a county, the funds
shall be distributed to hospitals in bordering counties within the state.
For each hospital identifiable to a unique medicaid provider
number that closed during the immediate prior program year, the payments that
would have been made to that hospital under paragraphs (E), (F), (H), and (I)
of this rule, less any amounts that would have been paid by the closed hospital
under provisions of rules
5160-2-08 and
5160-2-08.1 of the
Administrative Code, shall be distributed to the remaining hospitals in the
county where the closed hospital was located. If another hospital does not
exist in such a county, the funds shall be distributed to hospitals in
bordering counties within the state.
If the closed hospital's payments under paragraphs (E), (F),
(H), and (I), of this rule does not result in a net gain, nothing shall be
redistributed under paragraphs (G)(2) and (G)(3) of this rule.
(2) Redistribution of closed
hospital funds within the county of closure.
(a) For each hospital within a county with a
closed hospital as described in paragraph (G)(1) of this rule, sum the amount
calculated in paragraph (E)(3)(a) of this rule, if the sum of a hospital's
total payments calculated in paragraphs (E)(1), (E)(2), (E)(3), (F)(1), and
(F)(2) of this rule does not exceed the hospital's disproportionate share limit
defined in paragraph (A)(28) of this rule.
(b) For all hospitals within a county with a
closed hospital, sum the amounts calculated in paragraph (G)(2)(a) of this
rule.
(c) For each hospital within
a county with a closed hospital, determine the ratio of the amounts in
paragraphs (G)(2)(a) and (G)(2)(b) of this rule.
(d) For each hospital within a county with a
closed hospital, multiply the ratio calculated in paragraph (G)(2)(c) of this
rule, by the amount calculated in paragraph (G)(1) of this rule, to determine
each hospital's county redistribution of closed hospitals payment amount,
subject to the following limitation:
If the sum of a hospital's payment amounts calculated in
paragraphs (E)(1), (E)(2), (E)(3), (F)(1), and (F)(2) of this rule is less than
the hospital's disproportionate share limit defined in paragraph (A)(28) of this
rule, then the hospital's redistribution of closed hospital funds amount is
equal to the amount in paragraph (G)(2)(d) of this rule, not to exceed the
amount defined in paragraph (A)(28) of this rule.
(3) Redistribution of closed hospital funds
to hospitals in a bordering county.
(a) For
each hospital within a county that borders a county with a closed hospital
where another hospital does not exist, as described in paragraph (G)(1) of this
rule, sum the amount calculated in paragraph (E)(3)(a) of this rule, if the sum
of a hospital's total payments calculated in paragraphs (E)(1), (E)(2), (E)(3),
(F)(1) and (F)(2) of this rule does not exceed the hospital's disproportionate
share limit defined in paragraph (A)(28) of this
rule.
(b) For all hospitals within
counties that border a county with a closed hospital where another hospital
does not exist, sum the amounts calculated in paragraph (G)(3)(a) of this
rule.
(c) For each hospital within
a county that borders a county with a closed hospital where another hospital
does not exist, determine the ratio of the amounts in paragraphs (G)(3)(a) and
(G)(3)(b) of this rule.
(d) For
each hospital within a county that borders a county with a closed hospital
where another hospital does not exist, multiply the ratio calculated in
paragraph (G)(3)(c) of this rule, by the amount calculated in paragraph (G)(1)
of this rule, to determine each hospital's county redistribution of closed
hospitals payment amount subject to the following limitation:
If the sum of a hospital's payment amounts calculated in
paragraphs (E)(1), (E)(2), (E)(3), (F)(1), and (F)(2) of this rule is less than
the hospital-specific disproportionate share limit defined in paragraph
(A)(28)
of this rule, the hospital's redistribution of closed hospital funds amount is
the amount defined in paragraph (G)(3)(d) of this rule, not to exceed the
amount defined in paragraph (A)(28) of this rule.
(H) Distribution of funds through
the children's hospital pool.
(1) For each
hospital meeting the children's hospital definition described in paragraph
(A)(29)
of this rule, sum the payment amounts as calculated in paragraphs (E), (F), and
(G) of this rule. This is the hospital's calculated payment amount.
(2) For each hospital meeting the children's
hospital definition described in paragraph (A)(29) of this
rule, with a calculated payment amount that is not greater than the
disproportionate share limit, as described in paragraph (A)(28) of this
rule, subtract the amount in paragraph (H)(1) of this rule from the
disproportionate share limit, as described in paragraph (A)(28) of this
rule.
(3) For hospitals meeting
the children's hospital definition described in paragraph (A)
(29) of
this rule, with calculated payment amounts that are not greater than the
disproportionate share limit, as described in paragraph (A)(28) of this
rule, sum the amounts calculated in paragraph (H)(2) of this rule.
(4) For each hospital meeting the children's
hospital definition described in paragraph (A) (29) of this
rule, with a calculated payment amount that is not greater than the
disproportionate share limit, as described in paragraph (A)(28) of this
rule, determine the ratio of the amounts in paragraphs (H)(2) and (H)(3) of
this rule.
(5) For each hospital
meeting the children's hospital definition described in paragraph (A)
(29) of
this rule, with a calculated payment that is not greater than the
disproportionate share limit, as described in paragraph (A)(28) of this
rule, multiply the ratio calculated in paragraph (H)(4) of this rule by the
amount allocated in paragraph (D)(2)(e) of this rule. This amount is the
children's hospital payment pool payment amount, subject to the following
limitation.
If the sum of the hospital's payment amounts calculated in
paragraphs (E)(1), (E)(2), (E)(3), (F)(1), (F)(2), and (G) of this rule is less
than the hospital's disproportionate share limit defined in paragraph
(A)(28)
of this rule, then the hospital's children's hospital pool payment amount is
equal to the amount calculated in paragraph (H)(5) of this rule, not to exceed
the amount defined in paragraph (A)(28) of this rule.
If any hospital is limited as described in paragraph (H)(5) of
this rule, calculate each hospital's limited payment by subtracting the amount
defined in paragraph (A)(28) of this rule from the amount determined in
paragraph (H)(5) of this rule and sum these amounts for all limited
hospital(s). Subtract the sum of the limited payments from the amount in
paragraph (D)(2)(e) of this rule and repeat the distribution described in
paragraph (H) of this rule until all funds for this pool are expended.
(I) Distribution model
adjustments and limitations through the statewide residual pool.
(1) For each hospital, sum the payment
amounts as calculated in paragraphs (E), (F), (G), and (H), of this rule. This
is the hospital's calculated payment amount.
(2) For each hospital, calculate the
hospital's specific disproportionate share limit as defined in paragraph
(A)(28)
of this rule.
(3) For each
hospital, subtract the hospital's disproportionate share limit as calculated in
paragraph (I)(2) of this rule from the payment amount as calculated in
paragraph (I)(1) of this rule to determine if a hospital's calculated payment
amount is greater than its disproportionate share limit. If the hospital's
calculated payment amount as calculated in paragraph (I)(1) of this rule is
greater than the hospital's disproportionate share limit calculated in
paragraph (I)(2) of this rule, then the difference is the hospital's residual
payment funds.
(4) If a hospital's
calculated payment amount, as calculated in paragraph (I)(1) of this rule, is
greater than its disproportionate share limit defined in paragraph (I)(2) of
this rule, then the hospital's payment is equal to the hospital's
disproportionate share limit.
(a) The
hospital's residual payment funds as calculated in paragraph (I)(3) of this
rule is subtracted from the hospital's calculated payment amount as calculated
in paragraph (I)(1) of this rule and is applied to and distributed as the
statewide residual payment pool as described in paragraph (I)(5) of this
rule.
(b) The total amount
distributed through the statewide residual pool will be the sum of the hospital
care assurance fund described in paragraph (K)(4) minus the sum of the lessor
of each hospital's calculated payment amount calculated in paragraph (I)(1) of
this rule or the hospital's disproportionate share limit calculated in
paragraph (I)(2) of this rule.
(5) Redistribution of residual payment funds
in the statewide residual payment pool.
(a)
For each hospital with a calculated payment amount that is not greater than the
disproportionate share limit, as described in paragraph (I)(4) of this rule,
subtract the amount in paragraph (I)(1) of this rule from the amount in
paragraph (I)(2) of this rule.
(b)
For hospitals with calculated payment amounts that are not greater than the
disproportionate share limit, sum the amounts calculated in paragraph (I)
(5)(a) of this rule.
(c) For each
hospital with a calculated payment amount that is not greater than the
disproportionate share limit, determine the ratio of the amounts in paragraphs
(I)(5)(a) and (I)(5)(b) of this rule.
(d) For each hospital with a calculated
payment amount that is not greater than the disproportionate share limit,
multiply the ratio calculated in paragraph (I)(5)(c) of this rule by the total
amount distributed through the statewide residual pool described in paragraph
(I)(4)(b) of this rule. This amount is the hospital's statewide residual
payment pool payment amount subject to the following limitation:
If the sum of the hospital's payment amounts calculated in
paragraphs (E), (F), (G), and (H) of this rule is less than the amount of the
hospital's disproportionate share limit defined in paragraph (A)(28) of this
rule, then hospital's residual pool payment amount is equal to the amount
defined in paragraph (I)(5)(d) of this rule, not to exceed the amount defined
in paragraph (A)(28) of this rule.
(J) Disproportionate share
adjustment.
(1) Determination of
disproportionate share qualification.
(a) For
each hospital, calculate the medicaid utilization rate as defined in paragraph
(A)(20)
of this rule.
(b) Each hospital
with a medicaid utilization rate greater than or equal to one per cent and
meets the obstetric services requirements as defined in paragraph (A)
(33) of
this rule qualifies as a disproportionate share hospital for the purposes of
this rule.
(c) Each hospital with
a medicaid utilization rate less than one per cent or does not meet the
obstetric services requirements as defined in paragraph (A)(33) of this rule
qualifies as a nondisproportionate share hospital for the purposes of this
rule.
(2) Limitations on
disproportionate share and indigent care payments made to hospitals.
(a) For each hospital, calculate medicaid fee
for service (FFS) shortfall by subtracting from total medicaid FFS costs, as
defined in paragraph (A) (1) of this rule, total medicaid FFS payments, as
described in paragraph (A)(18) of this rule.
(b) For each hospital, calculate medicaid MCP
shortfall by subtracting from total medicaid MCP costs, as defined in paragraph
(A)(21)
of this rule, the total medicaid MCP payments, as described in paragraph
(A)(24)
of this rule.
(c) For each
hospital, calculate the total medicaid shortfall by adding the medicaid FFS
shortfall as defined in paragraph (J)(2)(a) of this rule to the medicaid MCP
shortfall as defined in paragraph (J)(2)(b) of this rule.
(d) For each hospital, determine the total
cost of uncompensated care for people without insurance by taking the sum of
the amounts described in paragraphs (A)(5) and (A)(12) of this
rule.
(e) For each hospital,
determine the amount received under section 1011 - federal reimbursement of
emergency health services furnished to undocumented aliens from the ODM 02930,
schedule E, line 7b.
(f) For each
hospital, calculate the hospital disproportionate share limit by adding the
total medicaid shortfall as described in paragraph (J)(2)(c) of this rule and
total uncompensated care costs for people without insurance as described in
paragraph (J)(2)(d) of this rule and subtracting section 1011 payments as
described in paragraph (J)(2)(e) of this rule.
(g) The hospital will receive the lesser of
the disproportionate share limit as described in paragraph (J)(2)(f) of this
rule or the sum of disproportionate share and indigent care payments as
calculated in paragraphs (E) to (I) of this rule.
(K) Payments and adjustments.
(1) Every hospital that must make payments of
assessments and/or intergovernmental transfers to the department of medicaid
under the provisions of rule
5160-2-08.1 of the
Administrative Code shall make the payments in accordance with the payment
schedule as described in this rule. If the final determination that the
hospital must make payments was made by the department, the hospitals shall
meet the payment schedule developed by the department after consultation with
the hospitals or a designated representative thereof.
If the final determination that the hospital must make payments
was made by the court of common pleas of Franklin county, the hospital shall
meet the payment schedule developed by the department after consultation with
the hospital or a designated representative thereof. Delayed payment schedules
for hospitals that are unable to make timely payments under this paragraph due
to financial difficulties will be developed by the department.
The delayed payments shall include interest at the rate of ten
per cent per year on the amount payable from the date the payment would have
been due had the delay not been granted until the date of payment.
(2) Except for the provisions of
paragraphs (E) and (F) of rule
5160-2-08.1 of the
Administrative Code, all payments of assessments and intergovernmental
transfers, when applicable, from hospitals under rule
5160-2-08 of the Administrative
Code shall be deposited to the credit of the hospital care assurance program
fund. All investment earnings of the fund shall be credited to the fund. The
department shall maintain records that show the amount of money in the fund at
any time that has been paid by each hospital and the amount of any investment
earnings on that amount. All moneys credited to the hospital care assurance
program fund shall be used solely to make payments to hospitals under the
provisions of this rule.
(3) All
federal matching funds received as a result of hospital payments of assessments
and intergovernmental transfers the department makes to hospitals under
paragraph (K)(4) of this rule shall be credited to the hospital care assurance
match fund. All investment earnings of the fund shall be credited to the fund.
All money credited to the hospital care assurance match fund shall be used
solely to make payments to hospitals under the provisions of this
rule.
(4) The department shall make
payments to each medicaid participating hospital meeting the definition of
hospital as described under section
5168.01 of the Revised Code. The
payments shall be based on amounts that reflect the sum of amounts in the
hospital care assurance program fund described in paragraph (K)(2) of this rule
and the hospital care assurance match fund described in paragraph (K)(3) of
this rule. Payments to each hospital shall be calculated as described in
paragraphs (E), (F), (G), (H), and (I) of this rule. For purposes of this
paragraph, the value of the hospital care assurance match fund is calculated
as:
Sum of hospital care assurance program fund/{1-(federal medical
assistance percentage/100)}
The payments shall be made solely from the hospital care
assurance program fund and the hospital care assurance match fund. If amounts
in the funds are insufficient to make the total amount of payments for which
hospitals are eligible, the department shall reduce the amount of each payment
by the percentage by which the amounts are insufficient. Any amounts not paid
at the time they were due shall be paid to hospitals as soon as moneys are
available in the funds.
(5)
All payments to hospitals under the provisions of this rule are conditional on:
(a) Expiration of the time for appeals under
the provisions of rule
5160-2-08.1 of the
Administrative Code without the filing of an appeal, or on court
determinations, in the event of appeals, that the hospital is entitled to the
payments;
(b) The availability of
sufficient moneys in the hospital care assurance program fund and the hospital
care assurance match fund to make payments after the final determination of any
appeals;
(c) The hospital's
compliance with the provisions of rule
5160-2-07.17 of the
Administrative Code; and
(d) The
payment made to hospitals does not exceed the hospital's disproportionate share
limit as calculated in paragraph (J)(2) of this rule.
(6) If an audit conducted by the department
of the amounts of payments made and received by hospitals under the provisions
of this rule identifies amounts that, due to errors by the department, a
hospital should not have been required to pay but did pay, should have been
required to pay but did not pay, should not have received but did receive, or
should have received but did not receive, the department shall:
(a) Make payments to any hospital that the
audit reveals paid amounts it should not have been required to pay but did pay
or did not receive amounts it should have received; and
(b) Take action to recover from a hospital
any amounts that the audit reveals it should have been required to pay but did
not pay or that it should not have received but did receive.
(7) Payments made under paragraph
(K)(6)(a) of this rule shall be made from the hospital care assurance program
fund. Amounts recovered under paragraph (K)(6)(b) of this rule shall be
deposited to the credit of the hospital care assurance program fund. Any
hospital may appeal the amount the hospital is to be paid under paragraph
(K)(6)(a) of this rule or the amount to be recovered from the hospital under
paragraph (K)(6)(b) of this rule to the court of common pleas of Franklin
county.
(N) Payment schedule.
The assessments, intergovernmental transfers and payments made
under the provisions of this rule will be made in installments.
(1) On or before the fourteenth day after the
department mails the final determination as described in rule
5160-2-08.1 of the
Administrative Code, the hospital must submit its first assessment to the
department.
All subsequent assessments and intergovernmental transfers,
when applicable, must be made on or before the fifth working day after the date on the warrant or
electronic funds transfer (EFT) issued as payment by the department as
described in paragraph (N)(2) of this rule.
Each hospital shall submit its
assessment amount to the Ohio department of medicaid via EFT.
(2) On or before the tenth
working day after the department's deadline for
receiving assessments and intergovernmental transfers, the department must make
a payment to each hospital. However, the department shall make no payment to
any hospital that has not paid assessments or made intergovernmental transfers
that are due until the assessments and transfers are paid in full or a final
determination regarding amounts to be paid is made under any request for
reconsideration or appeal.
(3) If a
hospital closes after the date of the public hearing held in accordance with
rule 5160-2-08.1 of the
Administrative Code, and before the last payment is made, as described in this
paragraph, the payments to the remaining hospitals will be adjusted in
accordance with paragraphs (E) to (K)(7) of this rule.
