Current through September 21, 2024
(a) In addition to
the payment rates established pursuant to State Plan Amendments 4.19A, Part 1,
Addendum 1, and 4.19B, Addendum 1-Page 24A, a DSH shall be entitled to a
disproportionate share payment computed pursuant to this section.
(b) Determination of eligibility for
disproportionate share payment. To be eligible for disproportionate share
payment a hospital shall meet both of the following criteria:
(i) Have a Wyoming Medicaid utilization rate
of not less than five percent (5%), defined as the percentage resulting from
dividing Medicaid patient days by total patient days, based on the most current
available information; and
(ii)
Have at least two (2) obstetricians with staff privileges at the hospital who
have agreed to provide obstetric services to individuals entitled to such
services under the Medicaid State Plan. In the case of a hospital located in a
rural area (that is, an area located outside of a Metropolitan Statistical Area
as defined by the Executive Office of Management and Budget), the obstetrician
includes any physician with staff privileges at the hospital to perform
nonemergency obstetric procedures.
(c) Determination of the Medicaid payment
deficit.
(i) For each DSH, the Department
shall determine total hospital payments for covered services as follows:
(A) Calculate the hospitals inpatient and
outpatient Medicaid payments for furnishing covered services during a payment
period;
(B) Calculate any amounts
payable to the hospital by other third parties and beneficiaries for Medicaid
covered services during a payment period; and
(C) Calculate Qualified Rate Adjustment (QRA)
payments pursuant to State Plan Amendments 4.19A, Part 1, Addendum 1 and 4.19B
Addendum 1-Page 24A.
(D) The
results of paragraphs (A), (B), and (C) shall be summed to determine the total
payments for covered services for each hospital.
(ii) For each DSH, the Department shall
determine hospital Medicaid costs as follows:
(A) Calculate the hospital-specific ancillary
department cost-to-charge ratios and the ratio of Medicaid allowable costs to
billed charges using the hospitals most recently available Medicare cost
report.
(B) Inflate hospital
ancillary billed charges to the midpoint of the payment period using the
CMS-PPS Hospital Market Basket index.
(C) Multiply the cost-to-charge ratios by the
hospitals inflated billed charges reported on Medicaid claims paid during the
most recently ended State fiscal year.
(D) Calculate hospital-specific routine
department per diems using the hospitals most recently available Medicare cost
report.
(E) Inflate
hospital-specific routine department per diems to the midpoint of the payment
period using the CMS-PPS Hospital Market Basket Index.
(F) Multiply the inflated routine per diems
by the number of days reported on Medicaid claims paid during the most recently
ended State fiscal year.
(G) Sum
the product determined in subsection (c)(ii)(C) and subsection (c)(ii)(F) to
determine a hospitals allowable Medicaid costs for furnishing covered services
during the most recently completed payment period.
(iii) For each DSH, the Department shall
determine the Medicaid payment deficit as the difference between total payments
in subsection (c)(i)(D) and Medicaid costs of services in subsection
(c)(ii)(G).
(d)
Determination of hospital-specific preliminary disproportionate share payment.
For each DSH, the Department shall calculate a preliminary disproportionate
share payment as follows:
(i) Calculate the
ratio of the hospitals Medicaid payment deficit to the hospitals total payments
to determine the hospital-specific Medicaid payment deficit
percentage.
(ii) Calculate a
percentage to represent each DSHs payment deficit as a percentage of all DSHs
payment deficits by dividing the hospital-specific Medicaid payment deficit
percentage by the sum of all DSHs Medicaid payment deficit
percentages.
(iii) Multiply the
percentage obtained in subsection (d)(ii) for each DSH by Wyomings federal
fiscal year allotment to determine each hospitals preliminary disproportionate
share payment.
(e)
Determination of preliminary hospital-specific disproportionate share payment
upper limit. Disproportionate share payments shall be limited to no more than
one hundred percent (100%) of costs related to caring for Medical Assistance
patients and uncompensated costs related to caring for indigent patients. For
each DSH, the Department shall test the hospital-specific disproportionate
share payment using the hospital-specific disproportionate share hospital upper
limit as follows:
(i) Sum total payments from
subsection (c)(i)(D) and the preliminary disproportionate share payment from
subsection (d)(iii) and compare the total to Medicaid costs determined in
subsection (c)(ii)(G).
(A) If a DSHs Medicaid
costs as calculated in subsection (c)(ii)(G) are greater than the sum of total
payments as calculated in subsection (c)(i)(D) and the preliminary
disproportionate share payment for the hospital as calculated in subsection
(d)(iii), then the hospital has not exceeded the hospital-specific
disproportionate share hospital upper limit.
(B) If a DSHs Medicaid costs as calculated in
subsection (c)(ii)(G) are less than the sum of total payments as calculated in
subsection (c)(i)(D) and the preliminary disproportionate share payment for the
hospital as calculated in subsection (d)(iii), then the hospital has exceeded
the hospital-specific disproportionate share hospital upper limit.
(f) Determination of
final hospital-specific disproportionate share payments. For each DSH, the
Department shall determine the final disproportionate share payment as follows:
(i) Use the Medicaid payment deficit amount
as calculated in subsection (c)(iii) to substitute the disproportionate share
payment amount determined in subsection (d)(iii) for DSHs that reach the
hospital-specific disproportionate share hospital upper limit in subsection
(e)(i)(B).
(ii) Distribute
unallocated disproportionate share payments. The Department shall distribute
any disproportionate share hospital allotment amounts that are not allocated
due to the hospital-specific disproportionate share hospital upper limit test
to the remaining DSHs that have not exceeded the hospital-specific
disproportionate share hospital upper limit as follows:
(A) The Department shall sum the preliminary
disproportionate share payments allocated to each DSH; and
(B) Subtract the amount determined in
subsection (f)(ii)(A) from Wyomings federal fiscal year allotment for
disproportionate share payments to calculate the unallocated disproportionate
share payments.
(C) For each
hospital that has not exceeded its hospital-specific disproportionate share
hospital upper limit the Department shall allocate any remaining
disproportionate share hospital payment allotment as calculated from subsection
(f)(ii)(B) as follows:
(I) Calculate a
percentage to represent each DSHs payment deficit as a percentage of all DSHs
payment deficits by dividing the hospital-specific Medicaid payment deficit
percentage by the sum of all DSHs Medicaid payment deficit percentages,
excluding the payment deficits for each DSH that has reached the
hospital-specific disproportionate share hospital upper limit.
(II) Multiply subsection (f)(ii)(C)(I) by the
unallocated disproportionate share hospital allotment pursuant to subsection
(f)(ii)(B) to determine the additional disproportionate share hospital
allocation.
(III) Sum total
payments from subsection (c)(i)(D), the preliminary disproportionate share
payment from subsection (d)(iii), and the additional disproportionate share
hospital payment from subsection (f)(ii)(C)(II) and compare the total to
Medicaid costs from subsection (c)(ii)(G) to perform the hospital-specific
upper payment limit test described in subsection (e).
(iii) The Department shall follow
the steps outlined in subsection (f) until the entire disproportionate share
hospital allotment is distributed to DSHs or until each DSH has been allocated
disproportionate share payments up to its hospital-specific disproportionate
share hospital upper limit.
(g) In conformity with OBRA '93, the
Department shall not establish disproportionate share payments greater than
each hospitals unreimbursed costs for services rendered to Title XIX patients
and uninsured patients. The Department shall review cost and payment
information annually for each hospital receiving disproportionate share
payments. The annual review shall consist of comparing providers proposed
disproportionate share payments to their unreimbursed costs for services
rendered to Title XIX patients and uninsured patients.
(h) If a providers proposed disproportionate
share payments are less than or equal to unreimbursed costs, then the providers
disproportionate share payments conform with OBRA '93 and shall not be
adjusted. If a providers proposed disproportionate share payments are greater
than the providers unreimbursed costs, the Department shall reduce the
providers proposed disproportionate share payments to equal the unreimbursed
costs. The Department shall calculate unreimbursed costs by applying
provider-specific cost-to-charge ratios to charges for services provided to
Title XIX and uninsured patients and subtracting payments from the costs of
those services. For purposes of the cost-to-charge ratio calculation, the
Department shall use cost and charge data from the same cost reports as those
used to calculate the disproportionate share payments. This calculation shall
occur following the most recently ended state fiscal year.
(i) Disproportionate share payments for
hospitals located outside Wyoming.
(i)
Request. Hospitals certified as DSHs by the Medicaid agency in a state other
than Wyoming may submit a request for consideration for disproportionate share
payments.
(ii) Time and contents of
request. A request for disproportionate share payments shall be sent to the
Department, by certified mail, on or before October 1st of each year. The
hospital shall submit the correct cost report with the request, if it is
available. The hospital shall contact the Department before that date to
determine which fiscal years cost report to submit with the request. The
failure to timely submit a request, including the correct cost report, shall
preclude the hospital from receiving disproportionate share payment.
(iii) Determination of amount of payment. The
amount of the disproportionate share payment shall be that proportion of the
amount determined pursuant to subsection (f).
(j) Notice of disproportionate share payment.
(i) The Department shall notify all Wyoming
hospitals providing inpatient hospital services of whether they are entitled to
disproportionate share payments.
(ii) Such notice shall:
(A) Be in writing;
(B) Be mailed by certified mail, return
receipt requested; and
(C) Include
the hospitals right to request reconsideration of the determination of
disproportionate share payments or the denial of disproportionate share
payments, pursuant to Chapter 16.
