Current through all regulations passed and filed through September 16, 2024
Effective for services or discharges on or after the effective
date of this rule, payments made to Ohio hospitals under the prospective
payment systems or non-diagnostic related groups (DRG) and non-ambulatory patient grouping (EAPG) prospective
payment systems will receive a cost coverage
add-on. The provisions of this rule do not apply to the medicaid maximum
allowed amount calculation described in rule
5160-2-25 of the Administrative
Code.
(A) Definitions.
(1) "Inpatient case mix" means the sum of the
relative weight values for all discharges during the calendar year preceding
the calendar year that precedes the state fiscal year (SFY) of the cost
coverage add-on divided by the total number of discharges during the same
calendar year.
(2) "Freestanding
psychiatric hospital" means a privately-owned psychiatric hospital with more
than sixteen beds that is eligible to provide medicaid services as described in
rule 5160-2-01 of the Administrative
Code.
(3) "Outpatient case mix"
means the sum of the relative weight values for each enhanced ambulatory
patient grouping (EAPG) detail line paid with a relative weight during the
calendar year preceding the calendar year that precedes the state fiscal year
of the cost coverage add-on divided by the total number of EAPG detail lines
paid with a relative weight during the same calendar year.
(4) "Total medicaid
inpatient discharges" for each hospital means the sum of medicaid fee for
service (FFS) discharges reported on "Ohio Medicaid Hospital Cost Report" ODM
02930, schedule C-1, section I, columns 2 and 3, line 54 for the applicable SFY
and medicaid managed care plan (MCP) discharges reported on ODM 02930, schedule
C-1, section I, columns
6 and 7, line 54.
(5) "Total medicaid
inpatient charges" for each hospital means the sum of FFS medicaid inpatient
charges reported on ODM 02930, schedule H, column 1, line 8 and MCP inpatient
charges reported on ODM 02930, schedule I, column 2, line 202.
(6)
"Total medicaid outpatient charges" for each hospital means the sum of FFS
medicaid outpatient charges reported on ODM 02930, schedule H, column 1, line
16 and MCP outpatient charges reported on ODM 02930, schedule I, column 4, line
202.
(7) "Total medicaid
inpatient costs" for each hospital means the sum of FFS medicaid inpatient
costs reported on ODM 02930, schedule H, column 1, line 1 and MCP inpatient
costs reported on ODM 02930, schedule I, column 3, line 202.
(8)
"Total medicaid outpatient costs" for each hospital means the sum of FFS
medicaid outpatient costs reported on ODM 02930, schedule H, column 1, line 10
and MCP outpatient costs reported on ODM 02930, schedule I, column 5, line
202.
(9) "Total medicaid
outpatient visits" for each hospital means the sum of medicaid FFS visits
reported on ODM 02930, schedule C-1, section I, columns 2 and 3, line 56 and
medicaid MCP visits reported on ODM 02930, schedule I, column 4, line
205.
(B) Source data for
calculations
The calculations described in this rule will be based on
cost-reporting data described in rule
5160-2-23 of the Administrative
Code, which reflects the interim settled Ohio medicaid hospital cost report
(ODM 02930) for each hospital's cost reporting period ending in the SFY prior
to the SFY that ends immediately preceding the SFY to which the cost coverage
add-on will apply. The data policies described in rules
5160-2-08 and
5160-2-09 of the Administrative
Code that use the same cost report data described in this paragraph will apply
to the data used for the cost coverage add-on, except for hospitals that have
closed or are known to be closing.
(C) The appropriations authorized by the
general assembly for each SFY will be divided into the following policy pools:
(1) Inpatient cost coverage standard pool,
which is the lesser of 259,229,112.31 dollars or 36.38 per cent of the
appropriated funds.
(2) Outpatient
cost coverage standard pool, which is the lesser of 168,054,601.29 dollars or
23.59 per cent of the appropriated funds.
(3) Cost coverage sustainability pool is the
sum of:
(a) The lesser of 233,000,000.00
dollars or 32.70 per cent of the appropriated funds; and
(b) The greater of 7.33 per cent or the
balance of the appropriated funds.
(4) Freestanding psychiatric hospitals as
described in paragraph (A)(2) of this rule will receive 1.86 per cent of the
amount described in paragraph (C)(3)(b) of this rule.
(D) Inpatient cost coverage.
(1) Cost coverage standard pool.
(a) From the amount specified in paragraph
(C)(1) of this rule, 15,939,479.00 dollars will be allocated to children's
hospitals, as defined in rule
5160-2-05 of the Administrative
Code, based on the payments made to each children's hospital from funds
specifically appropriated by Am. Sub. HB 49 of the 132nd General
Assembly.
(b) Each hospital will be
allocated from paragraph (C)(1) of this rule, an amount equal to the inpatient
non-claims specific lump sum payments not resulting from an alternative payment
model or the hospital care assurance program (HCAP) as described in rule
5160-1-70 or
5160-2-09 of the Administrative
Code, less the amount allocated in paragraph (D)(1)(a) of this rule.
(c) Any amounts in paragraph (D)(1)(b) of
this rule allocated to a closed hospital are reallocated to the remaining
hospitals based on the ratio of each hospital's allocation in paragraph
(D)(1)(b) of this rule to the sum of the allocation for all remaining
hospitals.
(d) For each hospital,
sum the amount allocated in paragraphs (D)(1)(a) to (D)(1)(c) of this
rule.
(2) Divide ten per
cent of the cost coverage sustainability pool described in paragraph (C)(3) of
this rule by the total medicaid discharges for all hospitals, then multiply the
resulting quotient by the number of total medicaid discharges for each
hospital.
(3) For freestanding
psychiatric hospitals, divide the amount described in paragraph (C)(4) of this
rule by the total medicaid discharges for all freestanding psychiatric
hospitals, then multiply the resulting quotient by the number of medicaid
discharges for each freestanding psychiatric hospital.
(E) Outpatient cost coverage.
(1) Cost coverage standard pool.
(a) Each hospital will be allocated from
paragraph (C)(2) of this rule an amount equal to the outpatient non-claims
specific lump sum payments not resulting from an alternative payment model or
HCAP as described in rule
5160-1-70 or
5160-2-09 of the Administrative
Code.
(b) Any amounts in paragraph
(E)(1)(a) of this rule allocated to a closed hospital are reallocated to the
remaining hospitals based on the ratio of each hospital's allocation in
paragraph (E)(1)(a) of this rule to the sum of the allocation for all remaining
hospitals.
(c) For each hospital,
sum the amount allocated in paragraph (E)(1)(a) of this rule and the amount
calculated in paragraph (E)(1)(b) of this rule.
(2) Divide ninety per cent of the cost
coverage sustainability pool described in paragraph (C)(3) of this rule less
the amount described in paragraph (C)(4) of this rule by the total medicaid
visits for all hospitals, then multiply the resulting quotient by the number of
total medicaid visits for each hospital.
(F)
Inpatient cost coverage add-on amount per discharge for hospitals paid in
accordance with rule
5160-2-65 of the Administrative
Code.
(1) For each hospital, divide the sum of
paragraphs (D)(1) to (D)(3) of this rule by the total medicaid
discharges used in the inpatient case-mix calculation as described in paragraph
(A)(1) of this rule.
(2) For
each hospital, divide the results in paragraph (F)(1) of this rule by the
inpatient case-mix as defined in paragraph (A)(1) of this rule.
(3) The cost coverage add-on per discharge
amount is equal to the amount calculated in paragraph (F)(2) of this rule,
rounded to two decimal places.
(4)
The amount calculated in paragraph (F)(3) of this rule will be added to the
hospital's inpatient base rate.
(G) Outpatient cost coverage add-on amount
per detail for hospitals paid in accordance with rule
5160-2-75 of the Administrative
Code.
(1) For each hospital, divide the sum of
paragraphs (E)(1) and (E)(2) of this rule by the total EAPG detail lines used
in the outpatient case-mix calculation as described in paragraph (A)(3) of this
rule.
(2) For each hospital, divide
the results in paragraph (G)(1) of this rule by the outpatient case-mix as
defined in paragraph (A)(3) of this rule.
(3) The cost coverage add-on per detail
amount is equal to the amount calculated in paragraph (G)(2) of this rule,
rounded to two decimal places.
(4)
The amount calculated in paragraph (G)(3) of this rule will be added to the
hospital's outpatient base rate.
(H) Inpatient cost coverage add-on for
hospitals paid in accordance with rule
5160-2-22 of the Administrative
Code.
(1) For each hospital, calculate total
inpatient payments by multiplying total medicaid inpatient charges as described
in paragraph (A)(5) of this rule by the inpatient cost-to-charge ratio
described in rule
5160-2-22 of the Administrative
Code calculated from the source data described in paragraph (B) of this
rule.
(2) For each hospital, divide
the amount in paragraph (H)(1) of this rule by the total medicaid inpatient
costs as described in paragraph (A)(7) of this rule.
(3) For each hospital, sum the inpatient
payments calculated in paragraph (H)(1) of this rule and the amounts
distributed in paragraphs (D)(1) to (D)(3) of this rule.
(4) For each hospital, divide the result in
paragraph (H)(3) of this rule by the total medicaid inpatient costs as
described in paragraph (A)(7) of this rule.
(5) For each hospital, calculate the
inpatient cost coverage increase by subtracting the result in paragraph (H)(2)
of this rule from the result in paragraph (H)(4) of this rule and dividing the
result by paragraph (H)(2) of this rule, rounded to four decimal
places.
(6) For each hospital,
multiply the result in paragraph (H)(5) of this rule by the inpatient
cost-to-charge ratio calculated in paragraph (H)(1) of this rule.
(7) Apply the amount calculated in paragraph
(H)(6) of this rule as an increase to the hospital's inpatient cost-to-charge
ratio as follows:
(a) For each July first, the
hospital's inpatient cost-to-charge ratio calculated the previous January in
accordance with rule
5160-2-22 of the Administrative
Code.
(b) For each January first,
the hospital's inpatient cost-to-charge ratio as calculated in rule
5160-2-22 of the Administrative
Code.
(I)
Outpatient cost coverage add-on for hospitals paid in accordance with rule
5160-2-22 of the Administrative
Code.
(1) For each hospital, calculate total
outpatient payments by multiplying total medicaid outpatient charges as
described in paragraph (A)(6) of this rule by the outpatient cost-to-charge
ratio described in rule
5160-2-22 of the Administrative
Code calculated from the source data described in paragraph (B) of this
rule.
(2) For each hospital, divide
the amount in paragraph (I)(1) of this rule by the total medicaid outpatient
costs as described in paragraph (A)(8) of this rule.
(3) For each hospital, sum the outpatient
payments calculated in paragraph (I)(1) of this rule and the distribution pools
in paragraphs (E)(1) and (E)(2) of this rule.
(4) For each hospital, divide the result in
paragraph (I)(3) of this rule by the total medicaid outpatient costs as
described in paragraph (A)(8) of this rule.
(5) For each hospital, calculate the
outpatient cost coverage increase by subtracting the result in paragraph (I)(2)
of this rule from the result in paragraph (I)(4) of this rule and dividing the
result by paragraph (I)(2) of this rule, rounded to four decimal
places.
(6) For each hospital,
multiply the result in paragraph (I)(5) of this rule by the outpatient
cost-to-charge ratio calculated in paragraph (I)(1) of this rule.
(7) Apply the amount calculated in paragraph
(I)(6) of this rule as an increase to the hospital's outpatient cost-to-charge
ratio as follows:
(a) For each July first, the
hospital's outpatient cost-to-charge ratio calculated the previous January in
accordance with rule
5160-2-22 of the Administrative
Code.
(b) For each January first,
the hospital's outpatient cost-to-charge ratio as calculated in rule
5160-2-22 of the Administrative
Code.
(J) To
ensure that funds appropriated for the cost coverage add-on are fully expended
in support of the intended purpose, the department may make short term
adjustments to increase or decrease hospital-specific rates. Such adjustments
will be calculated in accordance with the cost coverage sustainability pool as
described in paragraphs (D)(2) and (E)(2) of this rule. The number of
discharges or visits used to establish a case-mix adjusted hospital-specific
rate, may be adjusted to reflect the time period for which the rate will be in
effect. Any such adjustments will be developed in consultation with the
department's actuary and approved by the medicaid director.
