Current through Register Vol. 54, No. 44, November 2, 2024
(a)
The Department will annually determine the acute care general hospitals
including their distinct part units, private psychiatric hospitals and
freestanding rehabilitation hospitals that qualify for disproportionate share
payments by the method in subsections (b)-(e). The Department will annually
determine the amount of disproportionate share payments for eligible private
psychiatric hospitals and distinct part psychiatric units of acute care general
hospitals by the method in subsections (f)-(h).
(b) A hospital that meets at least one of the
requirements in subsection (d) will qualify for disproportionate share payments
if one of the following applies:
(1) The
hospital's ratio of Title XIX inpatient days to total inpatient days is equal
to or greater than one standard deviation above the mean of the ratios for
hospitals in this Commonwealth. To determine the ratio for an acute care
general hospital, the Department will include inpatient days covered under
Chapter 1163, Subchapter A (relating to acute care general hospitals under the
prospective payment system), and days covered under Chapter 1163, Subchapter B
(relating to hospitals and units covered under cost reimbursement principles),
as well as days covered under this chapter. The Department will include in the
database MA administrative days, days of care provided to recipients in other
states' Medicaid Programs, MA health maintenance organizations (HMO) days and
MA Health Insuring Organization (HIO) days.
(2) The hospital's low income utilization
rate, as defined under section 1923(d) of the Social Security Act
(42 U.S.C.A. §
1396r-4(b)(3)) exceeds
25% under one of the following methods:
(i)
The hospital's low income utilization rate as reported on its cost report (MA
336) computation of low income utilization rate worksheet exceeds
25%.
(ii) The hospital's low income
utilization rate as determined by its ratio of Title XIX and General Assistance
inpatient days to total inpatient days exceeds 25%. To determine the ratio for
an acute care general hospital, the Department will include inpatient days
covered under Chapter 1163, Subchapter A, and days covered under Chapter 1163,
Subchapter B, as well as days covered under this chapter. The Department will
include in the database MA administrative days, days of care provided to
recipients in other states' Medicaid Programs, MA HMO days and MA HIO
days.
(3) The hospital is
an acute care general hospital which qualifies as a rural hospital or sole
community hospital under the Medicare Program, and its number of MA acute care
inpatient cases to total acute care inpatient cases is equal to or greater than
the 75th percentile of the ratios for acute care general hospitals in this
Commonwealth. The Department will not include cases for a unit covered under
Chapter 1163, Subchapter B, or under this chapter. The Department will include
in the database discharges related to other states' Medicaid
Programs.
(c) The
Department will utilize the following data sources in making disproportionate
share eligibility determinations:
(1) For
Fiscal Year 1993-94, the Department will utilize data from Fiscal Year 1991-92
Cost Reports (MA 336) and from Fiscal Year 1991-92 for services provided to
recipients enrolled in MA HMO programs and MA HIO programs. To determine the
Title XIX percentage of total MA cases or days, the Department will utilize the
most currently available data.
(2)
For Fiscal Year 1994-95, the Department will utilize data from Fiscal Year
1992-93 Cost Reports (MA 336) and from Fiscal Year 1992-93 for services
provided to recipients enrolled in MA HMO programs and MA HIO programs. To
determine the Title XIX percentage of total MA cases or days, the Department
will utilize the most currently available data.
(d) To qualify for disproportionate share
payments, a hospital shall meet at least one of the following requirements:
(1) The hospital shall be identified as a
children's hospital, as defined under §
1163.2 (relating to
definitions).
(2) The hospital
shall have at least two physicians with staff privileges who have agreed to
provide obstetric services to individuals entitled to those services under the
MA Program.
(3) The hospital has
not offered nonemergency obstetric services to the general population since
December 21, 1987.
(e) To
determine hospitals that qualify for disproportionate share payments based on
the ratio of Title XIX inpatient days to total inpatient days, the Department
will:
(1) Identify the total number of MA
inpatient days from the hospital's cost report (MA 336), including days of care
provided to recipients in other states' Medicaid Programs, and to that number:
(i) Add the hospital's number of inpatient
days for MA recipients enrolled in MA HMO programs and MA HIO
programs.
(ii) Add the hospital's
number of MA administrative days from the hospital's Cost Report (MA
336).
(iii) Subtract the hospital's
number of days of care provided to General Assistance recipients.
(2) Divide the days determined
under paragraph (1) by the total number of inpatient days from the hospital's
Cost Report (MA 336) to determine the hospital's ratio of Title XIX inpatient
days to total inpatient days.
(3)
Array the hospitals, from high to low, according to the ratios determined under
paragraph (2) and determine the mean and standard deviation of the
array.
(4) Identify as
disproportionate share providers, hospitals with a ratio of Title XIX inpatient
days to total inpatient days equal to or greater than one standard deviation
above the mean.
(f) Once
the Department determines which hospitals qualify as disproportionate share
providers under subsection (b)(1)-(3) for Fiscal Year 1993-94, the Department
will calculate disproportionate share percentages for qualifying private
psychiatric hospitals and distinct part psychiatric units of acute care general
hospitals by:
(1) Arraying qualifying
inpatient psychiatric facilities from high to low, according to each facility's
ratio of Title XIX inpatient days to total inpatient days.
(2) Assigning a disproportionate share
percentage of 10% to the qualifying inpatient psychiatric facility with the
highest ratio of Title XIX inpatient days to total inpatient days.
(3) Obtaining for other inpatient psychiatric
facilities in the array, the annual disproportionate share percentage, which is
1%, plus 8% multiplied by a fraction, the numerator of which is the ratio of
Title XIX inpatient days to total inpatient days of the qualifying facility,
minus the ratio of Title XIX inpatient days to total inpatient days of the
lowest facility in the array; and the denominator of which is the ratio of
Title XIX inpatient days to total inpatient days of the second to highest
facility in the array, minus the ratio of Title XIX inpatient days to total
inpatient days of the lowest facility in the array.
(g) The Department will determine
prospectively the annual disproportionate share payment amount for each
qualifying inpatient psychiatric facility by multiplying the following:
(1) The inpatient psychiatric facility's
disproportionate share percentage determined under subsection (f).
(2) The inpatient psychiatric facility's per
diem rate in effect on July 1 of the fiscal year, except that the Department
will use the new base per diem rate for a facility whose rate changes during
the fiscal year for any reason except for the annual inflationary
increase.
(3) The inpatient
psychiatric facility's projected number of MA inpatient psychiatric days,
determined as follows:
(i) For Fiscal Year
1993-94, the number of inpatient psychiatric days for the inpatient psychiatric
facility, as reported on the facility's Fiscal Year 1991-92 Cost Report (MA
336), increased by 3.52%, and then by 2.8%.
(ii) For Fiscal Year 1994-95, the number of
inpatient psychiatric days for the inpatient psychiatric facility, as reported
on the facility's Fiscal Year 1992-93 Cost Report (MA 336) increased by
utilization factors consistent with the Governor's Fiscal Year 1994-95 budget
proposal.
(4) For
inpatient psychiatric facilities that do not receive an inflationary increase
on July 1, the Department will inflate one-half of the amount calculated under
subsection (g)(1)-(3) by the annual inflation increase.
(h) The Department will divide the annual
disproportionate share payment amount into 12 monthly payments.
(i) The Department will publish annually, as
a notice in the Pennsylvania Bulletin, a list of the
qualifying inpatient psychiatric facilities and their annual disproportionate
share payment percentages.
The provisions of this §1151.54 amended under sections 201
and 443.1(1) of the Public Welfare Code (62 P. S.
§§
201 and
443.1(1)).
