048-30 Wyo. Code R. § 30-9

Current through April 27, 2019

Section 30-9 - Determination of base period allowable costs

(a) The Department shall determine base period Medicaid allowable costs for each level of care for each participating provider as specified in this Section. Base period allowable costs are the sum of routine per diem costs and ancillary service costs.

(b) Allowable Medicaid per diem costs for inpatient routine departments shall be extracted from the hospitals base period settled cost report.

(i) Medicaid per diem costs for inpatient routine departments extracted from the cost report shall exclude costs associated with capital and direct medical education.

(c) Medicaid per diem costs derived from (b)(i) shall be applied to Medicaid patient days on each base period claim to determine routine base period costs for each level of care.

(d) The Medicaid per diem costs for each level of care shall be inflated forward from the midpoint of the base period to December 31, 1997.

(e) Base period ancillary service costs.

(i) Costs for ancillary services shall be extracted from the base period cost report, grouped according to the type of service, and cost-to-charge ratios shall be established for each group of services for each provider.

(ii) The cost-to-charge ratios for each group of ancillary services for all providers shall be arrayed, from low to high, and the mean for each group shall be determined. Next, cost-to-charge ratios which are two standard deviations or more from the mean cost-to-charge ratio shall be eliminated from the array, and the mean shall be redetermined for each group.

(iii) The Medicaid allowable base period cost for ancillary services shall be determined using the lower of:
- (A) The provider's cost-to-charge ratio for ancillary services as determined pursuant to paragraph (i); and
- (B) The mean cost-to-charge ratio as determined pursuant to paragraph (ii) if the provider's cost-to-charge ratio exceeds the mean and if the mean is greater than 1.00.
- (C) If the provider does not have a cost-to-charge ratio for a service, base period costs shall be the mean cost-to-charge ratio established pursuant to paragraph (ii).

(iv) Ancillary service charges for base period claims shall be inflated forward from the date of service to December 31, 1997, using the inflation factor.

(v) The Medicaid ancillary services cost-to-charge ratios determined in paragraph (iii) shall be applied to the ancillary services charges determined pursuant to paragraph (iv).

(f) Each claim's cost in the base period is derived from subsections (d) and (e).

(g) High and low cost Medicaid outlier costs shall be identified for each level of care. For purposes of this section, the high cost outlier threshold shall be discharges with allowable costs greater than two standard deviations from the mean. For purposes of this section, low cost outliers shall be discharges with allowable costs less than two standard deviations from the mean.

(h) Costs associated with less than one day stays shall be identified for each level of care.

(i) Claims with "zero dollars" in the payment field shall be identified.

(j) Transfers shall be identified.

(k) The base period allowable Medicaid cost for each level of care shall be determined by subtracting (g), (h), (i) and (j) from (f).

(l) The base period Medicaid discharges for each level of care shall be determined by subtracting the number of outliers, less than one day stays, transfer claims, and zero payment claims from the total number of base period Medicaid discharges.

(m) The base period allowable Medicaid cost per discharge for each level of care shall be determined by dividing (k) by (l).

(n) Determination of mean.

(i) A hospital-specific mean base period cost per discharge for each level of care shall be determined by dividing the hospitals Medicaid allowable costs for each level of care by the number of discharges for that level of care.

(ii) The statewide mean base period cost per discharge for each level of care shall be determined by dividing the total Medicaid allowable costs for each level of care for all participating providers by the total number of discharges for each level of care for all participating providers.

(o) Determination of median. The median for each level of care shall be determined by taking the midpoint of the arrayed means determined pursuant to subsection (m).

(n) The level of care payment shall be:

(i) The amount determined pursuant to Sections 10 and 11;

(ii) The capital payment determined pursuant to Section 18; and

(iii) The direct medical education payment pursuant to Section 19.

048-30 Wyo. Code R. § 30-9