(a) In general. Except as otherwise specified in this Chapter, the Department reimburses hospitals providing inpatient hospital services to Medicaid recipients using Medicare principles of cost reimbursement. The Medicaid allowable payment shall be the lower of the hospital's usual and customary charges and the allowable payment determined pursuant to this section.
(b) New hospitals. A new hospital shall receive an initial rate equal to the lowest cost to charge ratio for combined inpatient and outpatient services established for a hospital located in Wyoming pursuant to paragraph (e)(i) until the hospital files its first Medicare cost report and a rate is determined pursuant to paragraphs (e)(i) or (f)(i). The initial rate shall be cost settled pursuant to Section 8 unless the hospital is located outside Wyoming and the Department determines that it is not cost-effective to cost settle.
(c) Reimbursement of distinct part hospital unit. Costs associated with distinct part hospital units shall be included in the hospitals general costs and shall not be separately reimbursed. The transfer of a recipient from a unit within a hospital to another unit within the hospital or to a distinct part hospital unit in the same hospital shall not be considered a discharge.
(d) Negotiated rate. A hospital may negotiate an interim rate which is lower than the interim rate which would otherwise be in effect pursuant to this Section.
(e) Hospitals located in Wyoming. - (i) Interim rate. The Department shall establish an interim rate for inpatient hospital services for each hospital using Medicare principles of cost reimbursement, as modified by this rule, based on the most recent settled cost report submitted by the hospital to the Medicare intermediary. The interim rate shall be the cost to charge ratio established by the Department using Medicare principles of cost reimbursement as modified by this rule.
- (A) Rate effective date. The interim rate shall be effective for all inpatient services provided on or after December 1 of each year;
- (B) Rate period. The interim rate shall remain in effect for all inpatient services until redetermined pursuant to this Section.
- (C) Except as otherwise specified by this rule, the interim rate shall be applied to all claims submitted by the provider.
- (ii) Cost settlement. The Department shall cost settle Medicaid reimbursement for inpatient hospital services provided during each rate period pursuant to Section 8.
(f) Hospitals located outside Wyoming. - (i) Reimbursement rate. The Department shall determine a reimbursement rate for inpatient services provided by hospitals located outside the State of Wyoming pursuant to paragraphs (ii) and (iii). Such rate shall remain in effect for all inpatient services until redetermined pursuant to this subsection.
- (ii) Hospitals which submit cost reports. Hospitals located outside Wyoming which provide inpatient hospital services to Wyoming recipients may submit their most recently settled Medicare cost reports.
- (A) Submission and preparation of cost reports. Except as otherwise specified by this subsection, hospitals which submit cost reports shall prepare and submit them pursuant to Section 7.
- (B) Time of submission. A hospital shall submit its most recently settled Medicare cost report on or before October 31st of each year.
- (I) The cost report must not have been previously submitted or used for a previous rate period, and it must be for a year subsequent to the year reported in the hospital's most recently submitted cost report.
- (II) If the hospital cannot submit a cost report which meets the requirements of this subparagraph because of delay caused by the intermediary, the hospital must submit verification of the delay from the intermediary on or before October 31st of the relevant year. If there is a verifiable delay caused by the intermediary, the hospital shall receive a rate equal to the lowest cost to charge ratio established for a hospital located in Wyoming pursuant to paragraph (e)(i) of this Section for the current State of Wyoming fiscal year. The hospital must submit its cost report promptly after it becomes available, and in no event later than 9 months after the October 1st due date. The Department shall determine the hospitals cost to charge ratio and shall adjust the hospitals rate retroactively to the original rate effective date. A hospital which fails to submit a cost report within 9 months after the due date shall receive no retroactive adjustment to its rate.
- (C) Determination of reimbursement rate. The Department shall establish a reimbursement rate for each hospital which submits a cost report using Medicare principles of cost reimbursement, as modified by this rule, based on the most recently settled Medicare cost report submitted by the hospital to the Department. The reimbursement rate shall be the hospitals cost to charge ratio for combined inpatient and outpatient services.
- (D) Rate effective date. Reimbursement rates for hospitals which submit cost reports shall be effective for 'services provided on or after July 1, 1992. The rate shall be adjusted each December 1 thereafter, assuming the hospital submits a cost report pursuant to (B).
- (E) Duration of reimbursement rate. Rates determined pursuant to this paragraph shall remain in effect for services provided during the twelve months following the rate
- (F) Cost settlement. The Department shall cost settle pursuant to Section 8, unless the Department determines that it is not cost-effective to do so.
- (iii) Hospitals which do not submit cost reports. The reimbursement rate for hospitals which elect not to submit cost reports pursuant to (ii) shall be the lesser of the hospital's submitted charges and the lowest cost to charge ratio established for a hospital located in Wyoming pursuant to paragraph (e)(i) for the current State of Wyoming fiscal year. The rate shall be effective for all services provided on after July 1, 1992. The rate shall be adjusted each December 1 thereafter to correspond with the then current lowest cost to charge ratio established pursuant to paragraph (e)(i).
048-24 Wyo. Code R. § 24-5