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
freestanding rehabilitation hospitals and distinct part rehabilitation units of
acute care general hospitals by the method in subsections (f)- (i).
(b) A hospital that meets at least one of the
requirements under subsection (d) qualifies 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
Subchapter A and Chapter 1151 (relating to acute care general hospitals under
the prospective payment system; and inpatient psychiatric services), as well as
days covered under this subchapter. The Department will include in the database
MA administrative days, days of care provided to recipients in other states'
Medicaid Programs, MA Health Maintenance Organization (HMO) days and MA Health
Insuring Organization (HIO) days.
(2) The hospital's low income utilization
rate, as defined under section 1923 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 Subchapter A and Chapter 1151, as well as days covered under this
subchapter. 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.
(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
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
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 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 since December 21, 1987, offered nonemergency obstetric services to the
general population.
(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 determines 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 this section, the Department will calculate annual payments to
qualifying freestanding rehabilitation hospitals and distinct part
rehabilitation units of acute care general hospitals by:
(1) Arraying the qualifying rehabilitation
hospitals and units from high to low according to each hospital's ratio of
Title XIX inpatient days to total inpatient days.
(2) For Fiscal Years 1990-91-1992-93, for
each hospital or unit covered by this subchapter and included in the array,
prospectively calculating the annual disproportionate share percentage, which
is 0.5%, plus 8.0% multiplied by a fraction, the numerator of which is the
ratio of Title XIX inpatient days to total inpatient days of the qualifying
hospital or unit, minus the ratio of Title XIX inpatient days to total
inpatient days of the lowest hospital in the array; and the denominator of
which is the ratio of Title XIX inpatient days to total inpatient days of the
highest hospital in the array, minus the ratio of Title XIX inpatient days to
total inpatient days of the lowest hospital in the array.
(3) For Fiscal Years 1993-94 and 1994-95, for
each hospital or unit covered by this subchapter and included in the array,
prospectively calculating the annual disproportionate share percentage which is
1.0%, plus 9.0% multiplied by a fraction, the numerator of which is the ratio
of Title XIX inpatient days to total inpatient days of the qualifying hospital
or unit, minus the ratio of Title XIX inpatient days to total inpatient days of
the lowest hospital in the array; and the denominator of which is the ratio of
Title XIX inpatient days to total inpatient days of the highest hospital in the
array, minus the ratio of Title XIX inpatient days to total inpatient days of
the lowest hospital in the array.
(4) Multiplying the following:
(i) The facility's disproportionate share
percentage determined under paragraph (2) or (3).
(ii) The facility's base per diem rate in
effect on July 1 of the fiscal year, except that the Department will use the
new base rate for a hospital whose rate changes during the fiscal year for any
reason except for the annual inflationary increase.
(iii) The facility's projected Title XIX
inpatient days determined as follows:
(A) For
Fiscal Year 1993-94, the number of Title XIX inpatient days based on the
hospital's Fiscal Year 1991-92 Cost Report (MA 336) increased by 3.52% and then
by 2.8%.
(B) For Fiscal Year
1994-95, the number of Title XIX inpatient days based on the hospital's Fiscal
Year 1992-93 Cost Report (MA 336) increased by utilization increase factors
consistent with the Governor's Fiscal Year 1994-95 budget proposal.
(5) For Fiscal Years
1993-94 and 1994-95 for hospitals that do not receive an inflationary increase
on July 1, further inflating one-half of the amount calculated under paragraph
(4) by the annual inflation increase.
(g) Effective with Fiscal Year 1993-94, the
Department will pay the interim disproportionate share amounts, determined
under subsection (f)(4), in equal monthly installments.
(h) The Department will determine final
semiannual disproportionate share amounts for hospitals and units under this
subchapter by multiplying the following:
(1)
The facility's disproportionate share percentage determined under subsection
(f)(2) or (3).
(2) The facility's
final audited per diem rate for the period.
(3) The facility's final audited Title XIX
inpatient days for the period.
(i) The Department will add the semiannual
disproportionate share payments calculated under subsection (h) and reconcile
any difference between the final payment and the interim payment determined
under subsection (f)(4) at cost settlement for the fiscal year.
(j) The Department will publish annually a
notice in the Pennsylvania Bulletin listing the qualifying
hospitals and their annual disproportionate share payment
percentages.
The provisions of this §1163.459 amended under sections
201 and 443.1(1) of the Public Welfare Code (62 P. S. §§
201 and
443.1(1)).
This section cited in 55 Pa. Code §
1163.452 (relating to payment
methods and rates).
