10 Colo. Code Regs. § 2505-10-8.3004
Current through Register Vol. 47, No. 18, September 25, 2024
Section 10 CCR 2505-10-8.3004 - [Effective until 10/12/2024] SUPPLEMENTAL MEDICAID AND DISPROPORTIONATE SHARE HOSPITAL PAYMENTS8.3004.A.CONDITIONS APPLICABLE TO ALL SUPPLEMENTAL PAYMENTS1. All Supplemental Medicaid Payments are prospective payments subject to the Inpatient Upper Payment Limit and Outpatient Upper Payment Limit, calculated using historical data, with no reconciliation to actual data for the payment period. In the event that data entry or reporting errors, or other unforeseen payment calculation errors are realized after a supplemental payment has been made, reconciliations and adjustments to impacted hospital payments may be made retroactively, as determined by the Enterprise.2. No hospital shall receive a DSH Payment exceeding its Hospital-Specific Disproportionate Share Hospital Limit. If upon review, the Disproportionate Share Hospital Payment, described in 10 CCR 2505-10, Section 8.3004.D, exceeds the Hospital-Specific Disproportionate Share Hospital Limit for any qualified hospital, the hospital's payment shall be reduced to the Hospital-Specific Disproportionate Share Hospital Limit retroactively. The amount of the retroactive reduction shall be retroactively distributed to other qualified hospitals by each hospital's percentage of Uninsured Costs compared to total Uninsured Costs for all qualified hospitals not exceeding their Hospital-Specific Disproportionate Share Hospital Limit.3. In order to receive a Supplemental Medicaid Payment or Disproportionate Share Hospital Payment, hospitals must meet the qualifications for the payment in the year the payment is received as confirmed by the hospital during the data confirmation report. Payments will be prorated and adjusted for the expected volume of services for hospitals that open, close, relocate or merge during the payment year.8.3004.B.OUTPATIENT HOSPITAL SUPPLEMENTAL MEDICAID PAYMENT1. Qualified hospitals. Hospitals providing outpatient hospital services to Medicaid clients are qualified to receive this payment except as provided below.2. Excluded hospitals. Psychiatric Hospitals are not qualified to receive this payment.3. Calculation methodology for payment. For each qualified hospital, the annual payment shall equal outpatient billed costs, adjusted for utilization and inflation, multiplied by a percentage adjustment factor. Outpatient billed costs equal outpatient billed charges multiplied by the Medicare cost-to-charge ratio. The percentage adjustment factor may vary for State-Owned Government Hospitals, Non-State-owned Government Hospitals, Privately-Owned Hospitals, for urban and rural hospitals, for State University Teaching Hospitals, for Pediatric Specialty Hospitals, for Urban Center Safety Net Specialty Hospitals, or for other hospital classifications, except that the adjustment factor for a Safety Net Metropolitan Hospital shall be equal to the adjustment factor for a Privately-Owned Independent Metropolitan Hospital. Total payments to qualified hospitals shall not exceed the Outpatient Upper Payment Limit. The percentage adjustment factor for each qualified hospital shall be published annually in the Colorado Medicaid Provider Bulletin.8.3004.C.INPATIENT HOSPITAL SUPPLEMENTAL MEDICAID PAYMENT1. Qualified hospitals. Hospitals providing inpatient hospital services to Medicaid clients are qualified to receive this payment, except as provided below.2. Excluded hospitals. Psychiatric Hospitals are not qualified to receive this payment.3. Calculation methodology for payment. For each qualified hospital, the annual payment shall equal Medicaid Non-Managed Care Days multiplied by an adjustment factor. The adjustment factor may vary for State-Owned Government Hospitals, Non-State-owned Government Hospitals, Privately-Owned Hospitals, for urban and rural hospitals, for State University Teaching Hospitals, for Pediatric Specialty Hospitals, for Urban Center Safety Net Specialty Hospitals, or for other hospital classifications, except that the adjustment factor for a Safety Net Metropolitan Hospital shall be at least equal to the adjustment factor for a Privately-Owned Independent Metropolitan Hospital. Total payments to qualified hospitals shall not exceed the Inpatient Upper Payment Limit. The adjustment factor for each qualified hospital shall be published annually in the Colorado Medicaid Provider Bulletin.8.3004.D.DISPROPORTIONATE SHARE HOSPITAL SUPPLEMENTAL PAYMENT1. Qualified hospitals.a. Hospitals that are Colorado Indigent Care Program providers and have at least two obstetricians who have staff privileges at the hospital and who have agreed to provide obstetric care for Medicaid clients or are exempt from the obstetrician requirement pursuant to 42 U.S.C. § 1396r-4(d)(2)(A) are qualified to receive this payment.b. Hospitals with a MIUR equal to or greater than the mean plus one standard deviation of all MIURs for Colorado hospitals and have at least two obstetricians who have staff privileges at the hospital and who have agreed to provide obstetric care for Medicaid clients or are exempt from the obstetrician requirement pursuant to 42 U.S.C. § 1396r-4(d)(2)(A) are qualified to receive this payment.c. Critical Access Hospitals with at least two obstetricians who have staff privileges at the hospital and who have agreed to provide obstetric care for Medicaid clients or are exempt from the obstetrician requirement pursuant to 42 U.S.C. § 1396r-4(d)(2)(A) are qualified to receive this payment2. Excluded hospitals. Psychiatric Hospitals are not qualified to receive this payment.3. Calculation methodology for payment. a. Total funds for the payment shall equal $257,231,668.b. No qualified hospital shall receive a payment greater than 100% of their Hospital-Specific DSH Limit.c. Certain qualified hospitals shall receive a payment equal to a percentage of their Hospital-Specific DSH Limit.i. A qualified hospital with CICP write-off costs greater than 700% of the state-wide average shall receive a payment equal to a minimum of 96.00% of their Hospital-Specific DSH Limit. ii. A qualified Critical Access Hospital or Rural Hospital shall receive a payment equal to a minimum of 86.00% of their Hospital Specific DSH Limit. iii. A qualified hospital not owned/operated by a healthcare system network within a Metropolitan Statistical Area and having less than 2,700 Medicaid Days shall receive a payment equal to a minimum of 80.00% of their Hospital-Specific DSH Limit.iv. The payment percentages for these qualified hospitals shall be published in the Colorado Medicaid Provider Bulletin.d. All remaining qualified hospitals shall receive a payment calculated as the percentage of uninsured costs to total uninsured costs for all remaining qualified hospitals, multiplied by the remaining funds.e. A Low MIUR hospital shall have their Hospital-Specific DSH Limit equal 10.00%.i. A low MIUR hospital is a hospital with a MIUR less than or equal to 22.50%.8.3004.E.ESSENTIAL ACCESS HOSPITAL SUPPLEMENTAL MEDICAID PAYMENT1. Qualified hospitals. Essential Access Hospitals are qualified receive this payment.2. Calculation methodology for payment. For each qualified hospital, the annual payment shall equal the available Essential Access funds divided by the total number of qualified Essential Access Hospitals.8.3004.F.HOSPITAL QUALITY INCENTIVE PAYMENT1. Qualified hospitals. Hospitals providing hospital services to Medicaid clients are qualified to receive this payment except as provided below.2. Excluded hospitals. Psychiatric Hospitals are not qualified to receive this payment.3. Calculation methodology for payment. For each qualified hospital, the annual payment shall equal adjusted discharge points multiplied by dollars per-adjusted discharge point. a. Adjusted discharge points equal normalized points awarded multiplied by adjusted Medicaid discharges. Normalized points awarded equals the sum of points awarded, normalized to a 100-point scale for measures a hospital is not eligible to complete. The measures and measure groups are published annually in the Colorado Medicaid Provider Bulletin. Adjusted Medicaid Discharges equal inpatient Medicaid discharges multiplied by a discharge adjustment factor.
i. The discharge adjustment factor equals total Medicaid charges divided by inpatient Medicaid charges. The discharge adjustment factor is limited to 5.ii. For qualified hospitals with less than 200 inpatient Medicaid discharges, inpatient Medicaid discharges shall be multiplied by 125%.b. Dollars per-adjusted discharge point are determined using a qualified hospital's normalized points awarded. Dollars per-adjusted discharge point are tiered so that qualified hospitals with more normalized points awarded receive more dollars per-adjusted discharge point. There are five tiers delineating the dollars per-adjusted discharge point with each tier assigned a certain normalized points awarded range. For each tier the dollars per-adjusted discharge point increase by a multiplier. The multiplier and normalized points awarded for each tier are:
Tier | Normalized Points Awarded | Dollars Per-Adjusted Discharge Point |
1 | 1-19 | 0(x) |
2 | 20-39 | 1(x) |
3 | 40-59 | 2(x) |
4 | 60-79 | 3(x) |
5 | 80-100 | 4(x) |
The dollars per discharge point shall equal an amount such that the total quality incentive payments made to all qualified hospitals shall equal seven percent (7.00%) of total hospital payments in the previous state fiscal year.
4. A hospital shall have the opportunity to request a reconsideration of points awarded that are provided with the preliminary scoring letter. a. To be considered for payment, a hospital shall submit a survey through the data collection tool on or before May 31 of each year.b. A preliminary scoring letter containing the scores and scoring rationale shall be provided to a hospital that submits a survey within ninety calendar days of May 31. The preliminary scoring letter will be delivered to each hospital that submitted a survey via the data collection tool.c. A hospital that believes a measure in the preliminary scoring letter was inaccurately scored may submit a reconsideration request within ten business days of delivery of the preliminary scoring letter. The request must be made by electronic notice. i. The reconsideration request must be provided following the process established through the HQIP scoring review and reconsideration period user guide. Reconsideration requests may not be accepted if they are not provided through this process.d. A response to the reconsideration request shall be provided within ten business days upon receipt of the reconsideration request via electronic notice. The response shall provide whether a change to a measure score was made or if the reconsideration request was denied.e. If a hospital is not satisfied with the reconsideration response, the hospital may request the reconsideration be escalated to the Special Financing Division Director within five business days of delivery of the reconsideration response. Any escalations must be provided to the Department via electronic notice.i. The escalation request must be provided following the process established through the HQIP scoring review and reconsideration period user guide. Escalation requests may not be accepted if they are not provided through this process.f. A response to the escalation request shall be provided to the hospital within ten business days via electronic notice. The response shall provide whether a change to a measure score was made or if the escalation request was denied. The escalation response is final, and points awarded may not be reconsidered further.g. No other reconsiderations of points awarded, both preliminary and final, may be accepted by the Department outside of this process. The Department's decision is not an adverse action subject to administrative or judicial review under the Colorado Administrative Procedure Act (ACA).8.3004.G.RURAL SUPPORT PROGRAM HOSPITAL SUPPLEMENTAL MEDICAID PAYMENT1. Qualified hospitals. Hospitals that meet all the following criteria:a. Is state licensed as a Critical Access Hospital or is a Rural Hospital, participating in Colorado Medicaid,b. Is a nonprofit hospital, andc. Meets one of the below: i. Their average net patient revenue for the three-year 2016, 2017, and 2018 cost report period is in the bottom ten percent (10%) for all Critical Access Hospitals and Rural Hospitals, orii. Their funds balance for the 2019 cost report period is in the bottom two and one-half percent (2.5%) for all Critical Access Hospitals and Rural Hospitals not in the bottom 10% of the three-year average net patient revenue for all Critical Access Hospitals and Rural Hospitals,2. Calculation methodology for payment. For a qualified hospital, the annual payment shall equal twelve million dollars ($12,000,000) divided by the number of qualified hospitals.3. The payment shall be calculated once and reimbursed in monthly installments over the subsequent five federal fiscal years.4. A qualified hospital must submit an attestation form every year to receive the available funds. If a qualified hospital does not submit the required attestation form their funds for the year shall be redistributed to other requalified hospitals.8.3004.H.REIMBURSEMENT OF SUPPLEMENTAL MEDICAID PAYMENTS AND DISPROPORTIONATE SHARE HOSPITAL PAYMENT1. The Enterprise shall calculate the Supplemental Medicaid Payments and DSH Payment under this section on an annual basis in accordance with the Act. Upon receiving a favorable recommendation by the Enterprise Board, the Supplemental Medicaid Payments and DSH Payment shall be subject to approval by the CMS and the Medical Services Board. Following these approvals, the Enterprise shall notify hospitals, in writing or by electronic notice, of the annual payment made each year, the methodology to calculate such payment, and the payment reimbursement schedule. Hospitals shall be notified, in writing or by electronic notice, at least thirty calendar days prior to any change in the dollar amount of the Supplemental Medicaid Payments or the DSH Payment to be reimbursed.8.3004.I.HOSPITAL TRANSFORMATION PROGRAMQualified hospitals shall participate in the Hospital Transformation Program (HTP). The HTP leverages supplemental payments as incentives designed to improve patient outcomes and lower Medicaid cost. Qualified hospitals are required to complete certain reporting activities. Qualified hospitals not completing a reporting activity shall have their supplemental Medicaid payments reduced. The reduced supplemental Medicaid payments shall be paid to qualified hospitals completing the reporting activity. The HTP is a multi-year program with a program year (PY) being on a federal fiscal year (October 1 through September 30) basis.
1. Qualified hospitals. Hospitals providing hospital services to Medicaid clients shall participate in the HTP except as provided below.2. Excluded hospitals. Psychiatric Hospitals, Rehabilitation Hospitals, or Long-Term Care Hospitals shall not participate in the HTP.3. Calculation methodology for payment. a. Each program year includes reporting activities that a qualified hospital is required to complete. A qualified hospital not completing a reporting activity shall have their HTP Supplemental Medicaid Payments reduced by a designated percent.b. The dollars not paid to those qualified hospitals shall be redistributed to qualified hospitals completing the reporting activity. A qualified hospital's distribution shall equal their percent of HTP Supplemental Medicaid Payments to the total HTP Supplemental Medicaid Payments for all qualified hospitals completing the reporting activity, multiplied by the total reduced dollars for qualified hospitals not completing the reporting activity.c. The reduction and redistribution shall be calculated using the HTP Supplemental Medicaid Payments effective during the reporting activity period. The reduction and redistribution for reporting activities shall occur at the same time during the last quarter of the subsequent program year. e. There are five HTP reporting activities. The reporting activities are listed below, along with the total percent at-risk associated with each reporting activity. i. Application (1.5% at-risk total) - Qualified hospitals must provide interventions and measures focusing on improving processes of care and health outcomes and reducing avoidable utilization and cost. The percent at-risk shall be scored on timely and satisfactory submission.ii. Implementation Plan (1.5% at-risk total) - Qualified hospitals must submit a plan to implement interventions with clear milestones that shall impact their measures. The percent at-risk shall be scored on timely and satisfactory submission.iii. Quarterly Reporting (0.5% at-risk per report) - Qualified hospitals must report quarterly on the different activities that occurred in that quarter. For any given quarter, this includes interim activity reporting, milestone reporting, self-reported data associated with the measures, and Community and Health Neighborhood Engagement (CHNE) reporting. The percent at-risk shall be scored on timely and satisfactory submission.iv. Milestone Report (2.0% at-risk per report in PY 2, 4.0% at-risk per report in PY 3) - Qualified hospitals must report on achieved/missed milestones over the previous two quarters. The percent at-risk shall be scored on timely and satisfactory submission and for achievement of milestones. Qualified hospitals that miss a milestone can have the reduction for the milestone reduced by 50% if they submit a course correction plan with the subsequent Milestone Report. A course correction reduction for a missed milestone can only be done once per intervention.v. Sustainability Plan (8.0% at-risk total) - Qualified hospitals must submit a plan demonstrating how the transformation efforts will be maintained after the HTP is over. The percent at-risk shall be scored on timely and satisfactory submission. f. A qualified hospital not participating in the HTP may have the entirety of their HTP Supplemental Medicaid Payments withheld.4. A hospital shall have the opportunity to request a reconsideration of scores for reporting compliance, milestone completion (including milestone amendments and course corrections), and performance measure data accuracy. a. The scoring review and reconsideration period begins when the Department notifies hospitals of initial scores. This period consists of multiple steps that will span 45 business days. i. The Department completes initial review of reports within 20 business days of report due date.ii. The Department notifies hospital of scores available for viewing and the scoring review and reconsideration period begins within 21 business days of report due date.iii. The hospital request for reconsideration is due within 10 business days of release of initial scores.iv. The Department issues final scores and reconsideration decisions within 14 business day of the scoring review and reconsideration period close date.b. All hospitals will receive electronic notification when initial scores are released to the Department's web portal.c. To submit a request for reconsideration of an initial score, a hospital must utilize the scoring review and reconsideration form available on the Department's web portal. It must identify the specific scoring elements the hospital would like reconsidered and the rationale for the reconsideration request. The form must be emailed following the proper guidelines as mentioned on the form. i. Late report submissions and report revisions are not accepted through the reconsideration process.ii. The hospital will receive an electronic notification of the outcome of the reconsideration request.d. If a hospital is not satisfied with the reconsideration response, the hospital may request the reconsideration be escalated to the Project Manager or the Special Financing Division Director. Initial escalations to the Project Manager must be made within five business days of delivery of the reconsideration response. Final escalations to the Special Financing Division Director must be made within 15 business days of delivery of the reconsideration response. Any escalations must be provided to the Department via electronic notice.i. The escalation request must be provided following the process established through the HTP scoring review and reconsideration period user guide. Escalation requests may not be accepted if they are not provided through this process. e. A response to the initial escalation request shall be provided to the hospital within ten business days via electronic notice. A response to the final escalation request shall be provided to the hospital within 20 business days via electronic notice. Any response shall provide whether a change to a measure score was made or if the escalation request was denied. The escalation response is final, and points awarded may not be reconsidered further.f. No other reconsiderations of scores, both preliminary and final, may be accepted by the Department outside of this process. The Department's decision is not an adverse action subject to administrative or judicial review under the Colorado Administrative Procedure Act (ACA).46 CR 15, August 10, 2023, effective 7/14/2023 (EMERGENCY)46 CR 19, October 10, 2023, effective 10/30/202347 CR 14, July 25, 2024, effective 7/1/2024, exp. 10/12/2024 (Emergency)