Current through Register Vol. 24-18, September 15, 2024
This section does not apply to out-of-state hospitals unless
they are border hospitals (critical or noncritical).
(1) The medicaid agency:
(a) Pays for services provided to a client
eligible for a state-administered program (SAP) based on SAP rates;
(b) Establishes SAP rates independently from
the process used in setting the medicaid payment rates;
(c) Calculates a ratable each year to adjust
each hospital's SAP rates for their percentage of community-based dollars to
the total revenues for all hospitals;
(d) Calculates an equivalency factor (EF) to
keep the SAP payment rates at the same level before and after the medicaid
rates were rebased.
(2)
The agency has established the following:
(a)
SAP diagnosis-related group (DRG) conversion factor (CF) for claims grouped
under DRG classifications services;
(b) SAP per diem rates for claims grouped
under the following specialty service categories:
(i) Chemical-using pregnant (CUP) women;
(ii) Detoxification;
(iii) Physical medicine and rehabilitation
(PM&R); and
(iv)
Psychiatric.
(c) SAP
ratio of costs-to-charges (RCC) for claims grouped under transplant
services.
(3) This
subsection describes the SAP DRG CF and payment calculation processes used by
the agency to pay claims using the DRG payment method. The agency pays for
services grouped to a DRG classification provided to clients eligible for a SAP
based on the use of a DRG CF, a DRG relative weight, and a maximum service
adjustor. This process is similar to the payment method used to pay for
medicaid and CHIP services grouped to a DRG classification.
(a) The agency's SAP DRG CF calculation
process is as follows:
(i) The hospital's
specific DRG CF used to calculate payment for a SAP claim is the medicaid DRG
CF multiplied by the applicable EF multiplied by the ratable;
(ii) For hospitals that do not have a ratable
or an EF, the SAP CF is the hospital's specific medicaid CF multiplied by the
average EF and the average ratable; and
(iii) For noncritical border hospitals, the
SAP DRG CF is the lowest in-state medicaid DRG CF multiplied by the average
ratable and the average EF.
(b) The agency calculates the SAP DRG EF as
follows:
(i) The hospital-specific current
SAP DRG CF is divided by the rebased medicaid DRG CF and then divided by the
ratable factor to compute the preliminary EF.
(ii) The current SAP DRG payment is
determined by multiplying the hospital-specific SAP DRG CF by the APR-DRG
relative weight.
(iii) The current
aggregate DRG payment is determined by summing the current SAP DRG payments for
all hospitals.
(iv) The hospital
projected SAP DRG payment is determined by multiplying the hospital-specific
current SAP DRG CF by the APR-DRG relative weights and the maximum service
adjustor.
(v) The projected
aggregate DRG payment is determined by summing the projected SAP program DRG
payments for all hospitals.
(vi)
The aggregate amounts derived in (b)(iii) and (v) of this subsection are
compared to identify a neutrality factor that keeps the projected aggregate SAP
DRG payment (based on APR-DRG relative weights) at the same level as the
previous aggregate SAP DRG payment (based on APR-DRG relative weights
.
(vii) The neutrality factor is
multiplied by the hospital-specific preliminary EF to determine the
hospital-specific final EF that is used to determine the SAP DRG conversion
factors for the rebased system implementation.
(c) The agency calculates the DRG payment for
services paid under the DRG payment method as follows:
(i) The agency calculates the allowed amount
for the inlier portion of the SAP DRG payment by multiplying the SAP DRG CF by
the DRG relative weight and the maximum service adjustor.
(ii) SAP claims are also subject to outlier
pricing. See WAC
182-550-3700
for details on outlier pricing.
(4) This subsection describes how the agency
calculates the SAP per diem rate and payment for CUP, detoxification, PM&R,
and psychiatric services.
(a) The agency
calculates the SAP per diem rate for instate and critical border hospitals by
multiplying the hospital's specific medicaid per diem by the ratable and the
per diem EF.
(b) The agency
calculates the SAP per diem rate for non-critical border hospitals by
multiplying the lowest in-state medicaid per diem rate by the average ratable
and the average per diem EF.
(c)
For hospitals with more than twenty nonpsychiatric SAP per diem paid services
during SFY 2011, the agency calculates a per diem EF for each hospital using
the individual hospital's claims as follows:
(i) The agency calculates a SAP average
payment per day by dividing the total current SAP per diem payments by the
total number of days associated with the payments.
(ii) The agency calculates a medicaid average
payment per day by dividing the aggregate payments based on the rebased
medicaid rates by the total number of days associated with the aggregate
payments (same claims used in (c)(i) of this subsection).
(iii) The agency divides the hospital
estimated SAP average payment per day in (a) of this subsection by the hospital
medicaid average payment per day in (b) of this subsection.
(iv) The agency divides the result of
(c)(iii) of this subsection by the hospital-specific ratable factor to
determine the EF.
(d)
For hospitals with twenty or less nonpsychiatric SAP per diem paid services
during SFY 2011, the EF is an average for all hospitals. The agency uses the
following process to determine the average EF:
(i) The agency calculates a SAP average
payment per day by dividing the total current SAP per diem payments for all
hospitals by the total number of days associated with the aggregate
payments.
(ii) The agency
calculates a medicaid average payment per day by dividing the aggregate
payments based on the rebased medicaid rates by the total number of days
associated with the aggregate payment (same claims used in (d)(i) of this
subsection).
(iii) The agency
divides the SAP average per day in (a) of this subsection by the medicaid
average payment per day in (b) of this subsection.
(iv) The agency divides the result of
(d)(iii) of this subsection by the hospital-specific ratable factor to
determine the EF. The EF is an average based on claims for all the hospitals in
the group.
(e) The
agency uses a psychiatric EF to keep SAP psychiatric rates at the level
required by the Washington state legislature. The agency's SAP psychiatric
rates are eighty-five and four one hundredths of a percent (85.04%) of the
agency's medicaid psychiatric rates. The factor is applied to all
hospitals.
(f) The agency
calculates the SAP per diem allowed amount for CUP, detoxification, PM&R,
and psychiatric services by multiplying the hospital's SAP per diem rate by the
agency's allowed patient days.
(g)
The agency does not apply the high outlier or transfer policy to the payment
calculations for CUP, detoxification, PM&R, and psychiatric
services.
(5) The agency
calculates the SAP RCC by multiplying the medicaid RCC by the hospital's
ratable.
(6) The agency annually
establishes the hospital-specific ratable factor used in the calculation of SAP
payment rate based on the most current hospital revenue data available from the
department of health (DOH). The agency uses the following process to determine
the hospital ratable factor:
(a) The agency
adds the hospital's medicaid revenue, medicare revenue, charity care, and bad
debts as reported in DOH data.
(b)
The agency determines the hospital's community care dollars by subtracting the
hospital's low-income disproportionate share hospital (LIDSH) payments from the
amount derived in (a) of this subsection.
(c) The agency calculates the hospital net
revenue by subtracting the hospital-based physician revenue (based on
information available from the hospital's medicare cost report or provided by
the hospitals) from the DOH total hospital revenue report.
(d) The agency calculates the preliminary
hospital-specific ratable by dividing the amount derived in (b) of this
subsection by the amount derived in (c) of this subsection.
(e) The agency determines a neutrality factor
by comparing the hospital-specific medicaid revenue (used in (a) of this
subsection) multiplied by the preliminary ratable to the hospital-specific
medicaid revenue (used in (a) of this subsection) multiplied by the prior year
ratable. The neutrality factor is used to keep the projected SAP payments at
the same current payment level.
(f)
The agency determines the final hospital-specific ratable by multiplying the
hospital-specific preliminary ratable by the neutrality factor.
(g) The agency applies to the allowable for
each SAP claim all applicable adjustments for client responsibility, any
third-party liability, medicare payments, and any other adjustments as
determined by the agency.
(7) The agency does not pay a SAP claim paid
by the DRG method at greater than the billed charges.
(8) SAP rates do not apply to the critical
access hospital (CAH) program's weighted cost-to-charges, to the long-term
acute care (LTAC) program's per diem rate, or to the certified public
expenditure (CPE) program's RCC (except as the RCC applies to the CPE hold
harmless described under WAC
182-550-4670
).
11-14-075, recodified as §182-550-4800, filed 6/30/11,
effective 7/1/11. Statutory Authority:
RCW
74.08.090,
74.09.500 and 2005 c 518.
07-14-051, § 388-550-4800, filed 6/28/07, effective 8/1/07. Statutory
Authority:
RCW
74.04.050,
74.08.090. 05-12-132, §
388-550-4800, filed 6/1/05, effective 7/1/05. Statutory Authority:
RCW
74.08.090 and
74.09.500. 04-19-113, §
388-550-4800, filed 9/21/04, effective 10/22/04. Statutory Authority:
RCW
74.08.090,
74.09.500,
74.09.035(1), and
43.88.290. 02-21-019, §
388-550-4800, filed 10/8/02, effective 11/8/02. Statutory Authority:
RCW
74.08.090 and
42 U.S.C.
1395 x(v),
42 C.F.R.
447.271, .11303, and .2652. 01-16-142, §
388-550-4800, filed 7/31/01, effective 8/31/01. Statutory Authority:
RCW
74.09.080,
74.09.730,
42 U.S.C.
1395 x(v) and 1396r-4,
42 C.F.R.
447.271 and 2652. 99-14-026, §
388-550-4800, filed 6/28/99, effective 7/1/99. Statutory Authority:
RCW
74.08.090,
42 USC
1395 x(v),
42 C.F.R.
447.271, 447.11303, and 447.2652. 99-06-046,
§ 388-550-4800, filed 2/26/99, effective 3/29/99. Statutory Authority:
RCW
74.08.090,
74.09.730,
74.04.050,
70.01.010,
74.09.200, [74.09.]500,
[74.09.]530 and43.20B.020 . 98-01-124, § 388-550-4800, filed 12/18/97,
effective 1/18/98.
