(a) Generally.
Payment to facilities for outpatient hospital services shall be provided
pursuant to
42
C.F.R. §
413.65. State-developed fee
schedule rates for services described in this section shall be the same for
public and private providers. The fee schedule and any periodic adjustments to
the fee schedule shall be published at the Department's fiscal agent's website.
Medicaid allowable payments for outpatient hospital services shall be made
according to one of the following fee schedules depending on the type of
service:
(i) Medicaid Ambulatory Payment
Classification (APC) fee schedule. The APC fee schedule shall be based on
services that are included and excluded in Medicare's outpatient prospective
payment system pursuant to
42
C.F.R. §§
419.21 and
419.22.
(A) Services included under the APC fee
schedule:
(I) Significant outpatient
procedures, e.g., a procedure or surgery provided to a patient that constitutes
the primary reason for the visit to the hospital;
(II) Ancillary Services;
(III) Emergency Services;
(IV) Observation;
(V) Drugs;
(VI) Laboratory services not included in
Medicare's clinical laboratory fee schedule;
(VII) Durable medical equipment, prosthetics
and orthotics;
(VIII) Radiology;
and
(IX) Vaccines and
immunizations.
(B)
Ambulatory Payment Classification relative weights. The Department shall use
Medicare's APC relative weights.
(C) Wyoming-specific Medicaid conversion
factors. The Department shall use a Wyoming-specific Medicaid conversion factor
for each of the following three (3) hospital groups: children's hospitals,
critical access hospitals, and general acute care hospitals as follows:
(I) For each group of hospitals, the
Wyoming-specific Medicaid conversion factor shall be the result after dividing
the estimated costs of APC-based services by the sum of the relative weights
for the hospital group.
(1.) For each
hospital, the calculated estimated cost-to-charge ratios shall be determined by
dividing state fiscal year (SFY) 2005 estimated Medicaid costs by SFY 2005
Medicaid billed charges (paid claims).
(2.) The Department shall calculate estimated
SFY 2005 Medicaid costs by multiplying SFY 2005 billed charges by
hospital-specific outpatient hospital cost-to-charge ratios calculated from
provider fiscal year end 2004 as-filed cost reports.
(II) For each group of hospitals, the
Department shall calculate the conversion factor percentage of Medicare's final
calendar year (CY) 2006 conversion factor as published in the Federal Register
Vol. 70, No. 217 (November 10, 2005). The Department divided the
Wyoming-specific Medicaid conversion factor by Medicare's final CY 2006
conversion factor as follows:
(1.) The
Wyoming-specific Medicaid conversion factor for children's hospitals shall be
one hundred seventy-one percent (171%) of Medicare's final CY 2006 conversion
factor.
(2.) The Wyoming-specific
Medicaid conversion factor for critical access hospitals shall be one hundred
ninety-six percent (196%) of Medicare's final CY 2006 conversion
factor.
(3.) The Wyoming-specific
Medicaid conversion factor for general acute care hospitals shall be
seventy-five percent (75%) of Medicare's final CY 2006 conversion
factor.
(D)
Fee schedule payment calculation. The fee schedule shall be established by
multiplying the Wyoming-specific Medicaid conversion factor by the Medicare APC
relative weight.
(E) Discounting.
Payment amounts for certain multiple, bilateral or discontinued procedures,
reimbursed using the Medicaid APC fee schedule, shall be discounted. The
Department shall use the discount formulas that are included in Medicare's
Integrated Outpatient Code Editor (I/OCE) with the exception of discount
formula 8 (used for bilateral procedures). For discount formula 8, the
Department shall use one hundred fifty percent (150%) rather than Medicare's
two hundred percent (200%). Medicare outlines its discount formulas in the
I/OCE Quarterly Transmittal, Appendix D, which is incorporated
herein.
(F) Medicaid physician fee
schedule. The Medicaid allowable payment shall be based on the reported
procedure code and shall be the lesser of charges or the fee schedule amount.
The following outpatient hospital services shall be reimbursed using the
physician fee schedule:
(I) Physical,
occupational, and speech therapy;
(II) Radiology, including mammography
screening and diagnostic mammography; and
(III) Vaccines and immunization.
(G) Medicaid durable medical
equipment, prosthetics and orthotics fee schedule. For those durable medical
equipment, prosthetics and orthotics not included in the APC fee schedule, the
Medicaid allowable payment shall be based on the reported procedure code and
shall be the lesser of billed charges or the fee schedule amount.
(H) The Medicaid laboratory fee schedule. For
those laboratory services not included in the APC fee schedule, the Medicaid
allowable payment shall be based on the reported procedure code and shall be
the lesser of billed charges or the fee schedule amount. The laboratory fee
schedule is described in detail in State Plan Attachment 4.19 B, Policy and
Methods of Establishing Payment Rate for Each Type of Care Provided, (3) Other
Laboratory and X-ray Services.
(I)
Percent of charges. The following services shall be reimbursed based on a
percent of allowed charges. These services include the following:
(I) Transplants shall be reimbursed at
fifty-five percent (55%) of billed charges, not to exceed the upper payment
limits described in Section 1903(i) of the Social Security Act;
(II) Corneal tissue shall be reimbursed using
the hospital-specific Medicaid cost-to-charge ratio calculated annually for
inpatient level of care participating providers and may not exceed one hundred
percent (100%). Non-participating hospitals shall be reimbursed using the
average Medicaid cost-to-charge ratio for their provider type (children's
hospital, critical access hospital and general acute care hospital);
(III) Medical devices that are paid
transitional pass-through payments under Medicare's outpatient prospective
payment system pursuant to Social Security Act § 1833(t)(6) shall be
reimbursed using the hospital-specific Medicaid cost-to-charge ratios used in
Section 5(a)(i)(C)(I) of this Chapter;
(IV) Dental shall be reimbursed using the
hospital-specific Medicaid cost-to-charge ratios used in Section 5(a)(i)(C)(I)
of this Chapter.
(ii) Qualified Rate Adjustment payments. The
Department shall annually reimburse non-State government owned and operated
hospitals that qualify for Qualified Rate Adjustment payments pursuant to State
Plan Attachment 4.19B, Part 1, Addendum 1, by the end of the first quarter of
each federal fiscal year.
(iii)
Private Hospital Supplemental payments. The Department shall quarterly
reimburse privately owned and operated hospitals that are providing services as
of July 1 of each year and that qualify for a private hospital supplemental
payment pursuant to State Plan Attachment 4.19B, Part 1, Addendum 2, by the end
of each quarter. For each year, the first private hospital supplemental payment
shall be made by December 31.
