Current through Register Vol. 24-18, September 15, 2024
To meet legislative requirements, the medicaid agency
includes a "hold harmless" provision for eligible hospitals participating in
certified public expenditure (CPE) payment programs under WAC
182-550-4650 and
182-550-5400. Under the provision
and subject to legislative directives and appropriations, hospitals eligible
for payments under CPE payment programs will receive no less in combined state
and federal payments than they would have received under the methodologies
otherwise in effect as described in this section. All hospital submissions
pertaining to CPE payment programs including, but not limited to, cost report
schedules, are subject to audit at any time by the agency or its
designee.
(1) The agency:
(a) Uses historical cost and payment data
trended forward to calculate prospective hold harmless grant payment amounts
for the current state fiscal year (SFY); and
(b) Reconciles these hold harmless grant
payment amounts when the actual claims data are available for the current
fiscal year.
(2) For
SFYs 2006 through 2009, the agency calculates what the hospital would have been
paid under the methodologies otherwise in effect for the SFY as the sum of:
(a) The total payments for inpatient claims
for patients admitted during the fiscal year, calculated by repricing the
claims using:
(i) For SFYs 2006 and 2007, the
inpatient payment method in effect during SFY 2005; or
(ii) For SFYs 2008 and 2009, the payment
method that would otherwise be in effect during the CPE payment program year if
the CPE payment program had not been enacted.
(b) The total net disproportionate share
hospital and state grant payments paid for SFY 2005.
(3) For SFY 2010 and beyond, the agency
calculates what the hospital would have been paid under the methodologies
otherwise in effect for the SFY as the sum of:
(a) The total of the inpatient claim payment
amounts that would have been paid during the SFY had the hospital not been in
the CPE payment program;
(b)
One-half of the indigent assistance disproportionate share hospital payment
amounts paid to and retained by each hospital during SFY 2005; and
(c) All of the other disproportionate share
hospital payment amounts paid to and retained by each hospital during SFY 2005
to the extent the same disproportionate share hospital programs exist in the
2009-2011 biennium.
(4)
For each SFY, the agency determines total state and federal payments made under
the programs, including:
(a) Inpatient claim
payments;
(b) Disproportionate
share hospital (DSH) payments;
(c)
Supplemental upper payment limit payments, as applicable; and
(d) The federal portion of medicaid program
supplemental payments received by the hospitals.
(5) A hospital may receive a hold harmless
grant, subject to legislative directives and appropriations, when the following
calculation results in a positive number:
(a)
For SFY 2006 through SFY 2009, the amount derived in subsection (4) of this
section is subtracted from the amount derived in subsection (2) of this
section; or
(b) For SFY 2010 and
beyond, the amount derived in subsection (4) of this section is subtracted from
the amount derived in subsection (3) of this section.
(6) The agency calculates interim hold
harmless and final hold harmless grant amounts as follows:
(a) An interim hold harmless grant amount is
calculated approximately ten months after the end of the SFY to include the
paid claims for the same SFY admissions. Claims are subject to utilization
review prior to the interim hold harmless calculation. Prospective grant
payments made under subsection (1) of this section are deducted from the
calculated interim hold harmless grant amount to determine the net grant
payment amount due to or due from the hospital.
(b) The final hold harmless grant amount is
calculated at such time as the final allowable federal portions of program
payments are determined. The procedure is the same as the interim grant
calculation, but it includes all additional claims that have been paid or
adjusted since the interim hold harmless calculation. Claims are subject to
utilization review and audit prior to the final calculation of the hold
harmless amount. Interim grant payments determined under (a) of this subsection
are deducted from this final calculation to determine the net final hold
harmless amount due to or due from the hospital.
11-14-075, recodified as §182-550-4670, filed 6/30/11,
effective 7/1/11. Statutory Authority: 2009 c 564 §§ 201 and 209,
RCW
74.04.050,
74.04.057,
74.08.090, and
74.09.500. 10-11-032, §
388-550-4670, filed 5/11/10, effective 6/11/10. Statutory Authority:
RCW
74.08.090 and
74.09.500. 08-20-032, §
388-550-4670, filed 9/22/08, effective 10/23/08; 07-14-090, §
388-550-4670, filed 6/29/07, effective 8/1/07. Statutory Authority:
RCW
74.08.090,
74.09.500, and 2005 c 518 §
209(9). 06-11-100, § 388-550-4670, filed 5/17/06, effective
6/17/06.
