D.C. Mun. Regs. tit. 29, r. 29-4803

Current through Register Vol. 71, No. 43, October 25, 2024

Rule 29-4803 - INPATIENT SERVICES: CALCULATION OF THE HOSPITAL-SPECIFIC COST PER DISCHARGE

4803.1

For Medicaid reimbursement of inpatient hospital discharges, the hospital specific cost per discharge shall equal a hospital's Medicaid inpatient operating costs standardized for indirect medical education (IME) costs and variations in casemix, divided by the number of Medicaid discharges in the base year data set and adjusted for outlier reserve.

4803.2

Medicaid inpatient operating costs for the base year period shall be calculated by applying the hospital-specific CCR, as determined in Section 4802, to allowed charges from the base year claims data.

4803.3

Medicaid inpatient operating costs shall be standardized for IME costs by removing IME costs to determine the District-wide component of the base rate. IME costs shall be removed by dividing Medicaid operating costs for each hospital with IME costs by the IME factor for that hospital.

4803.4

The IME adjustment factor for each hospital shall be calculated using the Medicare algorithm for each hospital based on the hospital cost report for the base year period.

4803.5

Medicaid inpatient operating costs shall be standardized for variations in casemix by dividing Medicaid operating costs standardized for IME by the appropriate casemix adjustment factor.

4803.6

The Hospital-specific cost per discharge shall be adjusted for IME and casemix and shall be reduced by a net one percent (1%) to account for five percent (5%) of the cost reserved for payment of high-cost outlier claims and four percent (4%) of the cost restored to account for the reduction in payment for low-cost outlier claims.

D.C. Mun. Regs. tit. 29, r. 29-4803

Final Rulemaking published at 45 DCR 4141, 4146 (June 26, 1998); as Final Rulemaking published at 50 DCR 5196 (June 27, 2003); as amended by Notice of Emergency and Proposed Rulemaking published at 57 DCR 2691 (March 26, 2010) [EXPIRED]; as amended by Notice of Emergency and Proposed Rulemaking published at 57 DCR 6837 (July 10, 2010) [EXPIRED]; as amended by Notice of Final Rulemaking published at 58 DCR 4323, 4327 (May 20, 2011); as amended by Final Rulemaking published at 59 DCR 15078 (December 28, 2012); amended by Final Rulemaking published at 63 DCR 5234 (4/8/2016)

29 DCMR § 4803 is formerly entitled SAdjustment for Inflation".

Authority: The Director of the Department of Health Care Finance (DHCF), pursuant to the authority set forth in An Act to enable the District of Columbia to receive federal financial assistance under Title XIX of the Social Security Act for a medical assistance program and for other purposes, approved December 27, 1967 (81 Stat. 774; D.C. Official Code § 1-307.02 (2001; Supp. 2008)) and section 6(6) of the Department of Health Care Finance Establishment Act of 2007, effective February 27, 2008 (D.C. Law 17-109; D.C. Official Code § 7-771.05(6) (2001; Supp. 2008)).