Current through Register Vol. 54, No. 49, December 7, 2024
Section 1151.54 - Disproportionate share payments(a) The Department will annually determine the acute care general hospitals including their distinct part units, private psychiatric hospitals and freestanding rehabilitation hospitals that qualify for disproportionate share payments by the method in subsections (b)-(e). The Department will annually determine the amount of disproportionate share payments for eligible private psychiatric hospitals and distinct part psychiatric units of acute care general hospitals by the method in subsections (f)-(h).(b) A hospital that meets at least one of the requirements in subsection (d) will qualify for disproportionate share payments if one of the following applies:(1) The hospital's ratio of Title XIX inpatient days to total inpatient days is equal to or greater than one standard deviation above the mean of the ratios for hospitals in this Commonwealth. To determine the ratio for an acute care general hospital, the Department will include inpatient days covered under Chapter 1163, Subchapter A (relating to acute care general hospitals under the prospective payment system), and days covered under Chapter 1163, Subchapter B (relating to hospitals and units covered under cost reimbursement principles), as well as days covered under this chapter. The Department will include in the database MA administrative days, days of care provided to recipients in other states' Medicaid Programs, MA health maintenance organizations (HMO) days and MA Health Insuring Organization (HIO) days.(2) The hospital's low income utilization rate, as defined under section 1923(d) of the Social Security Act (42 U.S.C.A. § 1396r-4(b)(3)) exceeds 25% under one of the following methods: (i) The hospital's low income utilization rate as reported on its cost report (MA 336) computation of low income utilization rate worksheet exceeds 25%.(ii) The hospital's low income utilization rate as determined by its ratio of Title XIX and General Assistance inpatient days to total inpatient days exceeds 25%. To determine the ratio for an acute care general hospital, the Department will include inpatient days covered under Chapter 1163, Subchapter A, and days covered under Chapter 1163, Subchapter B, as well as days covered under this chapter. The Department will include in the database MA administrative days, days of care provided to recipients in other states' Medicaid Programs, MA HMO days and MA HIO days.(3) The hospital is an acute care general hospital which qualifies as a rural hospital or sole community hospital under the Medicare Program, and its number of MA acute care inpatient cases to total acute care inpatient cases is equal to or greater than the 75th percentile of the ratios for acute care general hospitals in this Commonwealth. The Department will not include cases for a unit covered under Chapter 1163, Subchapter B, or under this chapter. The Department will include in the database discharges related to other states' Medicaid Programs.(c) The Department will utilize the following data sources in making disproportionate share eligibility determinations:(1) For Fiscal Year 1993-94, the Department will utilize data from Fiscal Year 1991-92 Cost Reports (MA 336) and from Fiscal Year 1991-92 for services provided to recipients enrolled in MA HMO programs and MA HIO programs. To determine the Title XIX percentage of total MA cases or days, the Department will utilize the most currently available data.(2) For Fiscal Year 1994-95, the Department will utilize data from Fiscal Year 1992-93 Cost Reports (MA 336) and from Fiscal Year 1992-93 for services provided to recipients enrolled in MA HMO programs and MA HIO programs. To determine the Title XIX percentage of total MA cases or days, the Department will utilize the most currently available data.(d) To qualify for disproportionate share payments, a hospital shall meet at least one of the following requirements: (1) The hospital shall be identified as a children's hospital, as defined under § 1163.2 (relating to definitions).(2) The hospital shall have at least two physicians with staff privileges who have agreed to provide obstetric services to individuals entitled to those services under the MA Program.(3) The hospital has not offered nonemergency obstetric services to the general population since December 21, 1987.(e) To determine hospitals that qualify for disproportionate share payments based on the ratio of Title XIX inpatient days to total inpatient days, the Department will:(1) Identify the total number of MA inpatient days from the hospital's cost report (MA 336), including days of care provided to recipients in other states' Medicaid Programs, and to that number: (i) Add the hospital's number of inpatient days for MA recipients enrolled in MA HMO programs and MA HIO programs.(ii) Add the hospital's number of MA administrative days from the hospital's Cost Report (MA 336).(iii) Subtract the hospital's number of days of care provided to General Assistance recipients.(2) Divide the days determined under paragraph (1) by the total number of inpatient days from the hospital's Cost Report (MA 336) to determine the hospital's ratio of Title XIX inpatient days to total inpatient days.(3) Array the hospitals, from high to low, according to the ratios determined under paragraph (2) and determine the mean and standard deviation of the array.(4) Identify as disproportionate share providers, hospitals with a ratio of Title XIX inpatient days to total inpatient days equal to or greater than one standard deviation above the mean.(f) Once the Department determines which hospitals qualify as disproportionate share providers under subsection (b)(1)-(3) for Fiscal Year 1993-94, the Department will calculate disproportionate share percentages for qualifying private psychiatric hospitals and distinct part psychiatric units of acute care general hospitals by:(1) Arraying qualifying inpatient psychiatric facilities from high to low, according to each facility's ratio of Title XIX inpatient days to total inpatient days.(2) Assigning a disproportionate share percentage of 10% to the qualifying inpatient psychiatric facility with the highest ratio of Title XIX inpatient days to total inpatient days.(3) Obtaining for other inpatient psychiatric facilities in the array, the annual disproportionate share percentage, which is 1%, plus 8% multiplied by a fraction, the numerator of which is the ratio of Title XIX inpatient days to total inpatient days of the qualifying facility, minus the ratio of Title XIX inpatient days to total inpatient days of the lowest facility in the array; and the denominator of which is the ratio of Title XIX inpatient days to total inpatient days of the second to highest facility in the array, minus the ratio of Title XIX inpatient days to total inpatient days of the lowest facility in the array.(g) The Department will determine prospectively the annual disproportionate share payment amount for each qualifying inpatient psychiatric facility by multiplying the following: (1) The inpatient psychiatric facility's disproportionate share percentage determined under subsection (f).(2) The inpatient psychiatric facility's per diem rate in effect on July 1 of the fiscal year, except that the Department will use the new base per diem rate for a facility whose rate changes during the fiscal year for any reason except for the annual inflationary increase.(3) The inpatient psychiatric facility's projected number of MA inpatient psychiatric days, determined as follows:(i) For Fiscal Year 1993-94, the number of inpatient psychiatric days for the inpatient psychiatric facility, as reported on the facility's Fiscal Year 1991-92 Cost Report (MA 336), increased by 3.52%, and then by 2.8%.(ii) For Fiscal Year 1994-95, the number of inpatient psychiatric days for the inpatient psychiatric facility, as reported on the facility's Fiscal Year 1992-93 Cost Report (MA 336) increased by utilization factors consistent with the Governor's Fiscal Year 1994-95 budget proposal.(4) For inpatient psychiatric facilities that do not receive an inflationary increase on July 1, the Department will inflate one-half of the amount calculated under subsection (g)(1)-(3) by the annual inflation increase.(h) The Department will divide the annual disproportionate share payment amount into 12 monthly payments.(i) The Department will publish annually, as a notice in the Pennsylvania Bulletin, a list of the qualifying inpatient psychiatric facilities and their annual disproportionate share payment percentages.The provisions of this § 1151.54 adopted June 1, 1990, effective retroactively to July 1, 1988, 20 Pa.B. 2913; amended June 18, 1993, effective 7/1/1993, 23 Pa.B. 2917; amended October 29, 1993, effective 7/1/1993, 23 Pa.B. 5241.The provisions of this § 1151.54 amended under sections 201 and 443.1(1) of the Public Welfare Code (62 P. S. §§ 201 and 443.1(1)).