S.D. Admin. R. 67:16:03:06

Current through Register Vol. 50, page 162, June 24, 2024

Section 67:16:03:06 - Basis of reimbursement - Inpatient services - Hospitals with more than 30 Medicaid discharges

Reimbursement for services provided to a patient admitted to an in-state acute care hospital that had more than 30 Medicaid discharges during the hospital's fiscal year ending after June 30, 1996, and before July 1, 1997, is based on DRGs and weight factors, the hospital's target amount, and capital and education costs per day. A hospital's base target amount is calculated from the cost report submitted to the Medicare program for the hospital's fiscal year ending after June 30, 1996, and before July 1, 1997, and adjusted annually for inflation as appropriated by the Legislature and changes to the DRG weight factors. A list of the DRGs and their associated weight factors may be obtained on the department's fee schedule website.

The department shall use the following method to calculate the amount of reimbursement:

(1) Multiply the hospital's target amount by the weight factor of the DRG assigned to the claim;

(2) Multiply the daily capital and education cost for the hospital by the number of days the patient was in the hospital; and

(3) Add the products of subdivisions (1) and (2) of this section.

In addition to the regular DRG reimbursement, the department shall pay for a cost outlier if the claim qualifies for the cost outlier as defined in § 67:16:03:01. The amount of the cost outlier payment is equal to 90 percent of the cost outlier.

When calculating the rate of reimbursement, the department uses only those diagnosis codes adopted in § 67:16:01:26 that reflect the services furnished to or on behalf of the eligible individual and the conditions that affected the treatment or extended the length of the individual's stay.

If a patient is transferred, referred, or discharged to another hospital or another type of special care facility and the transfer, referral, or discharge is medically necessary or if a patient leaves the hospital against medical advice, reimbursement is on a per diem basis. To determine the rate of reimbursement, multiply the hospital's target amount by the weight factor of the DRG assigned to the claim, divide the result by the geometric mean length of stay, multiply the result by the number of days the individual was an inpatient, and add the hospital's daily capital and education cost. The amount paid may not exceed 100 percent of the allowed DRG reimbursement.

For inpatient costs for Medicaid Access Critical facilities the department uses the facility's cost report to determine whether any adjustment to reimbursement is necessary for amounts due the provider.

S.D. Admin. R. 67:16:03:06

SL 1975, ch 16; 42 SDR 51, effective 10/13/2015

General Authority: SDCL 28-6-1(2), 28-6-1.1.

Law Implemented: SDCL 28-6-1(2), 28-6-1.1.

Reference: South Dakota Medicaid State Plan, Attachment 4.19-A, page 1. Copies may be obtained from the Department of Social Services, Division of Medical Services, 700 Governors Drive, Pierre, South Dakota 57501. Basis of reimbursement -- Outpatient services other than outpatient laboratory and outpatient surgical procedures, § 67:16:03:06.01. Basis of payment -- Inpatient services -- Hospitals with less than 30 Medicaid discharges, § 67:16:03:06.03. Reimbursement of outpatient laboratory services, § 67:16:03:06.07.