13 CSR 70-15.220 - Disproportionate Share Hospital (DSH) Payments
PUBLISHER'S NOTE: The secretary of state has determined that publication of the entire text of the material that is incorporated by reference as a portion of this rule would be unduly cumbersome or expensive. This material as incorporated by reference in this rule shall be maintained by the agency at its headquarters and shall be made available to the public for inspection and copying at no more than the actual cost of reproduction. This note applies only to the reference material. The entire text of the rule is printed here.
(1) General Reimbursement Principles.
(A) In order to receive federal financial
participation (FFP), disproportionate share hospital (DSH) payments are made in
compliance with federal statutes and regulations. Section 1923 of the Social
Security Act (42 U.S. Code) describes the hospitals that must be paid DSH
payments and those that the state may elect to pay DSH payments.
(B) Federally deemed DSH hospitals. The state
must pay disproportionate share payments to hospitals that meet the specific
obstetric requirements set forth below in paragraph (1)(B)1. and have either a
Medicaid inpatient utilization rate (MIUR) at least one (1) standard deviation
above the state mean or a low-income utilization rate (LIUR) greater than
twenty-five percent (25%). The state shall not make DSH payments in excess of
each hospital's estimated hospital-specific DSH limit.
1. Obstetrics requirements and exemptions.
A. Hospitals must have two (2) obstetricians,
with staff privileges, who agree to provide non-emergency obstetric services to
Medicaid eligibles. Rural hospitals, as defined by the federal Executive Office
of Management and Budget, may qualify any physician with staff privileges as an
obstetrician.
B. Hospitals are
exempt from the obstetric requirements if the facility did not offer
non-emergency obstetric services as of December 22, 1987.
C. Hospitals are exempt if inpatients are
predominantly under eighteen (18) years of age.
(C) State-elected DSH payments. The state may
elect to make disproportionate share payments to hospitals that meet the
obstetric requirements set forth in paragraph (1)(B)1. and have a MIUR of at
least one percent (1%).
(D) Section
1923(g) of the Social Security Act (Act) limits the amount of DSH payments
states can pay to each hospital and earn FFP. To be in compliance with the Act,
DSH payments shall not exceed one hundred percent (100%) of the uncompensated
care costs of providing hospital services to Medicaid and uninsured
individuals. Hospital-specific DSH limit calculations must comply with the
federal DSH rules ( 42 CFR 447, Subpart E and 42 CFR 455, Subpart D). If the
disproportionate share payments exceed the hospital-specific DSH limit, the
difference shall be deducted from disproportionate share payments or recouped
from future payments.
(E) All DSH
payments in the aggregate shall not exceed the federal DSH allotment within a
state fiscal period. The DSH allotment is the maximum amount of DSH payments a
state can distribute each year and receive FFP.
(F) The state must submit an annual
independent audit of the state's DSH program to the Centers for Medicare &
Medicaid Services (CMS). FFP is not available for DSH payments that are found
to exceed the hospital-specific eligible uncompensated care cost limit. All
hospitals that receive DSH payments are subject to the independent federal DSH
audit.
(G) Hospitals qualify for
DSH for a period of one (1) state fiscal year and must requalify at the
beginning of each state fiscal year to continue to receive disproportionate
share payments.
(2)
Definitions.
(A) Annual independent DSH audit.
The annual independent DSH audit is the annual independent certified audit of
the state DSH payments as required by the federal DSH audit rule
42 CFR
455.301 through
42 CFR
455.304. The annual independent DSH audit
also includes the reporting requirements of
42 CFR
447.299. The annual independent DSH audit may
also be referred to as the federally mandated annual independent DSH audit or
independent federal DSH audit.
(B)
Division. Unless otherwise specified, division refers to the MO HealthNet
Division, the division of the Department of Social Services charged with the
administration of Missouri's MO HealthNet Program.
(C) Estimated Medicaid net cost. Estimated
Medicaid net cost is defined per the annual state DSH survey, as defined in
subsection (2)(X), and related training documents and instructions provided to
the hospitals by the division or its authorized contractor. The estimated
Medicaid net cost is determined by using Medicare cost reporting methodologies
described in this rule and is calculated using data reported on the state DSH
survey.
1. The estimated Medicaid net cost is
determined from the state DSH survey, as defined in subsection (2)(X), and is
calculated as follows:
A. Total cost of care
for Medicaid IP/OP services;
B.
Less regular IP/OP Medicaid FFS rate payments (excluding any other Medicaid
payments as defined in subsection (2)(T));
C. Less IP/OP Medicaid MCO
payments;
D. Equals the estimated
Medicaid net cost; and
E. The
estimated Medicaid net cost shall be trended as set forth in subsection
(2)(Z).
(D)
Estimated uninsured net cost. Estimated uninsured net cost is the cost of
providing inpatient and outpatient hospital services to individuals without
health insurance or other third-party coverage for the hospital services they
receive during the year less uninsured payments received on a cash basis for
the applicable Medicaid state plan year. The costs are to be calculated using
Medicare cost report costing methodologies described in this rule and should
not include costs for services that were denied for reasons other than the
patient's benefits were exhausted at the time of admittance, or the patient's
benefit package did not cover the inpatient or outpatient hospital service(s)
received.
1. The estimated uninsured net cost
is determined from the state DSH survey and is calculated as follows:
A. Total IP/OP uninsured cost of
care;
B. Less total IP/OP indigent
care/self-pay revenues;
C. Equals
the estimated uninsured net cost.
(E) Estimated uninsured uncompensated care
cost (UCC).
1. The estimated uninsured
uncompensated care cost is determined from the state DSH survey and is
calculated as follows:
A. Estimated uninsured
net cost, as defined in subsection (2)(D);
B. Less total applicable section 1011
payments;
C. Equals the estimated
uninsured uncompensated care cost; and
D. The estimated uninsured uncompensated care
cost shall be trended as set forth in subsection (2)(Z).
(F) Federal DSH allotment. The
maximum amount of DSH a state can distribute each year and receive federal
financial participation (FFP) in the payments in accordance with
42 CFR
447.297 and
42 CFR
447.298.
(G) Hospital DSH liability. The hospital DSH
liability is the amount of DSH overpayments subject to recoupment as determined
from the final annual independent DSH audit. It is the lesser of the total
longfall or the DSH payments paid for the SFY.
(H) Hospital-specific DSH limit. The
hospital-specific DSH limit is the sum of the Medicaid uncompensated care cost
plus the uninsured uncompensated care cost and is calculated each year. The
source for this calculation is as follows:
1.
Actual hospital-specific DSH limit. The actual hospitalspecific DSH limit is
determined from the final annual independent DSH audit; and
2. Estimated hospital-specific DSH limit. The
estimated hospital-specific DSH limit is calculated by the state using data
from the state DSH survey, other Medicaid payments, and data provided in the
most recent independent DSH audit, if applicable, which is used in determining
the interim DSH payments.
(I) Incorporation by reference. This rule
incorporates by reference the following:
1.
42 CFR 447, which is incorporated by reference and made a part of this rule as
published by the U.S. Government Publishing Office, and available at its
website at
https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-C/part-447?toc=1,
June 9, 2022. This rule does not incorporate any subsequent amendments or
additions;
2. 42 CFR 455, which is
incorporated by reference and made a part of this rule as published by the U.S.
Government Publishing Office, and available at its website at
https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-C/part-455?toc=1,
June 9, 2022. This rule does not incorporate any subsequent amendments or
additions;
3. The state DSH survey
template and instructions are incorporated by reference and made a part of this
rule as published by the Department of Social Services, MO HealthNet Division,
615 Howerton Court, Jefferson City, MO 65109, at its website at
https://dss.mo.gov/mhd/providers/fee-for-service-providers.htm,
June 16, 2022. This rule does not incorporate any subsequent amendments or
additions; and
4. This alternate
state DSH survey supplemental template and instructions are incorporated by
reference and made a part of this rule as published by the Department of Social
Services, MO HealthNet Division, 615 Howerton Court, Jefferson City, MO 65109,
at its website at https://dss.mo.gov/mhd/providers/
fee-for-service-providers.htm, June 16, 2022. This rule does not incorporate
any subsequent amendments or additions.
(J) Individuals without health insurance or
other third-party coverage for the services received.
1. Individuals who have no health insurance
or other source of third-party coverage for the specific inpatient or
outpatient hospital services they received during the year are considered
uninsured. As set forth in CMS' final rule published in the Federal
Register, December 3, 2014, for
42 CFR
447.295, a service-specific approach must be
used to determine whether an individual is uninsured. The service-specific
coverage determination can occur only once per individual per service provided
and applies to the entire service, including all elements as that service, or
similar services, would be defined by MO HealthNet. Determination of an
individual's third-party coverage status is not dependent on receipt of payment
by the hospital from the third party.
2. The costs for inpatient and outpatient
hospital services provided to individuals without health insurance or other
third-party coverage for the inpatient or outpatient hospital services they
received during the year are considered uninsured and included in calculating
the hospital-specific DSH limit.
3.
The following costs shall be considered uninsured and included in calculating
the hospital-specific DSH limit:
A. Costs for
services provided to individuals whose benefit package does not cover the
hospital service received. If the service is not included in an individual's
health benefits coverage through a group health plan or health insurer, and
there is no other legally liable third party, the hospital services are
considered uninsured costs; and
B.
Costs for services provided to individuals who have reached lifetime insurance
limits for certain services or with exhausted insurance benefits at the time of
service. When a lifetime or annual coverage limit is imposed by a third-party
payer, specific services beyond the limit would not be within the individual's
health benefit package from that third-party payer and would be considered
uninsured costs, as long as the benefits were exhausted when the patient was
admitted; and
C. For American
Indians/Alaska Natives, Indian Health Services (IHS) and tribal coverage is
only considered third-party coverage when services are received directly from
IHS or tribal health programs or when IHS or a tribal health program has
authorized coverage through the contract health service program.
4. The costs associated with the
following shall not be included as uninsured costs:
A. Bad debts or unpaid
coinsurance/deductibles for individuals with third-party coverage.
Administrative denials of payment or requirements for satisfaction of
deductible, copayment, or coinsurance liability do not affect the determination
that a specific service is included in the health benefits coverage;
and
B. Unpaid balances due for
claims denied by the third-party payer for billing discrepancies, which include
but are not limited to denials due to lack of pre-authorization, denials due to
timely filing, denials due to lack of medical necessity, etc.; and
C. Prisoners. Individuals who are inmates in
a public institution or are otherwise involuntarily in secure custody as a
result of criminal charges are considered to have a source of third-party
coverage. However, an individual can be included as uninsured if a person has
been released from secure custody and is referred to the hospital by law
enforcement or corrections authorities and is admitted as a patient rather than
an inmate to the hospital.
5. These definitions, and the resulting
uninsured costs includable in calculating the hospital-specific DSH limit, are
subject to change based on any federal DSH audit regulation changes. The
division reserves the right to determine whether changes in federal DSH audit
regulation will be applied to the interim DSH payment calculations.
(K) Institution for Mental
Diseases (IMD) DSH allotment. The IMD DSH allotment is a portion of the
state-wide DSH allotment and is the maximum amount set by the federal
government that may be paid to IMD hospitals. Any unused IMD DSH allotment not
paid to IMD hospitals for any plan year may be paid to hospitals that are under
their projected hospital-specific DSH limit.
(L) Inpatient and outpatient hospital
services. For purposes of determining the estimated hospital-specific DSH limit
and the actual hospital-specific DSH limit, the inpatient and outpatient
hospital services are limited to inpatient and outpatient hospital services
included in the approved Missouri Medicaid State Plan.
(M) Lifetime or annual health insurance
coverage limit. An annual or lifetime limit, imposed by a third-party payer,
that establishes a maximum dollar value, or maximum number of specific services
on a lifetime or annual basis, for benefits received by an
individual.
(N) Longfall. The
longfall is the total amount a hospital has been paid for inpatient and
outpatient hospital services (including all DSH payments) in excess of their
hospital-specific DSH limit. The source for this calculation is as follows:
1. Actual longfall. The actual longfall is
based on the annual independent DSH audit; and
2. Estimated longfall. The estimated longfall
is calculated by the state using data from the state DSH survey, other Medicaid
payments, and data provided in the most recent independent DSH audit, if
applicable.
(O) Low
income utilization rate (LIUR). The LIUR shall be calculated as follows:
1. As determined from the third prior year
audited Medicaid cost report, the LIUR shall be the sum (expressed as a
percentage) of the fractions, calculated as follows:
A. Total MO HealthNet patient revenues (TMPR)
paid to the hospital for patient services under a state plan plus the amount of
the cash subsidies (CS) directly received from state and local governments,
divided by the total net revenues (TNR) (charges, minus contractual allowances,
discounts, and the like) for patient services plus the CS; and
B. The total amount of the hospital's charges
for patient services attributable to charity care (CC) less CS directly
received from state and local governments in the same period, divided by the
total amount of the hospital's charges (THC) for patient services. The total
patient charges attributed to CC shall not include any contractual allowances
and discounts other than for indigent patients not eligible for MO HealthNet
under a state plan.
LIUR = ((TMPR + CS) / (TNR + CS)) + ((CC - CS) / (THC))
(P) Medicaid inpatient utilization rate
(MIUR). The MIUR shall be calculated as follows:
1. As determined from the third prior year
audited Medicaid cost report, the MIUR will be expressed as the ratio of total
Medicaid eligible hospital days (TMD) provided under a state plan divided by
the provider's total number of inpatient hospital days (TNID); and
2. The state's mean MIUR will be expressed as
the ratio of the sum of the total number of the Medicaid days for all Missouri
hospitals divided by the sum of the total patient days for the same Missouri
hospitals. Data for hospitals no longer participating in the program will be
excluded.
MIUR = TMD / TNID
(Q) Medicaid state plan year. Medicaid state
plan year coincides with the twelve- (12-) month period for which a state
calculates DSH payments. For Missouri, the Medicaid state plan year coincides
with its state fiscal year (SFY) and is July 1 through June 30.
(R) Medicare cost reporting methodologies.
Medicaid and uninsured costs will be determined utilizing Medicare Cost Report
(form CMS 2552) methodologies. The Medicaid Cost Report is completed using the
Medicare Cost Report form CMS 2552, using the Medicare cost reporting
methodologies. Based on these methodologies, the costs included in the DSH
payment calculation will reflect the Medicaid and uninsured portion of total
allowable hospital costs from the Medicare Cost Report or the Medicaid Cost
Report, as applicable. Costs such as the Missouri Medicaid hospital provider
tax FRA are recognized as allowable costs for Medicaid and DSH program purposes
and apportioned to Medicaid, uninsured, Medicare, and other payers following
the cost finding principles included in the cost report, applicable
instructions, regulations, and governing statutes.
(S) New facility. A new hospital determined
in accordance with 13 CSR 70-15.010 without a base
year cost report.
(T) Other
Medicaid payments. For purposes of determining estimated hospital-specific DSH
limits, the other Medicaid payments include any non-claim specific Medicaid
payment made to a hospital for inpatient or outpatient hospital services
including but not limited to Direct Medicaid, acuity adjustment payment, poison
control payment, stop loss payment, graduate medical education (GME),
children's outliers, cost settlements, and upper payment limit (UPL) payments,
if applicable, will be included in the annual independent DSH audit. Any other
payments made with state only funds are not required to be offset in
determining the hospital-specific DSH limit.
(U) Out-of-state DSH payments. DSH payments
received by a Missouri hospital from a state other than Missouri.
(V) Section 1011 payments. Section 1011
payments are made to a hospital for costs incurred for the provision of
specific services to specific aliens to the extent that the provider was not
otherwise reimbursed for such services. Because a portion of the Section 1011
payments are made for uncompensated care costs that are also eligible under the
hospital-specific DSH limit, a defined portion of the Section 1011 payments
must be recognized as an amount paid on behalf of those uninsured.
(W) Shortfall. The shortfall is the
hospital-specific DSH limit in excess of the total amount a hospital has been
paid for inpatient and outpatient hospital services (including all DSH
payments). The source for this calculation is as follows:
1. Actual shortfall. The actual shortfall is
based on the annual independent DSH audit; and
2. Estimated shortfall. The estimated
shortfall is calculated by the state using data from the state DSH survey, and
other Medicaid payments.
(X) State DSH survey. The state DSH survey
was designed to reflect the standards of calculating uncompensated care cost
established by the federal DSH rules in determining hospitalspecific DSH
limits. The DSH survey is also similar to, or the same as, the DSH survey that
is utilized by the independent auditor during the annual independent DSH audit
performed in accordance with the federally mandated DSH audit rules. The blank
state DSH survey is referred to as the state DSH survey template.
1. Beginning with SFY 2017, the state DSH
survey shall be the most recent DSH survey collected during the independent DSH
audit of the fourth prior SFY (i.e., the most recent survey collected by the
independent DSH auditor for the SFY 2019 independent DSH audit will also be
used to calculate the interim DSH payment for SFY 2023). The survey shall be
referred to as the SFY to which payments will relate.
(Y) Taxable revenue. Taxable revenue is the
hospital's total inpatient adjusted net revenues plus outpatient adjusted net
revenues determined in accordance with
13 CSR
70-15.110, paragraph (1)(A)13.
(Z) Trends. A trend of one and a half percent
(1.5%) will be applied to the hospital's estimated Medicaid net cost and the
estimated uninsured uncompensated care cost (UCC) from the year subsequent to
the state DSH survey period to the current SFY (i.e., the SFY for which the
interim DSH payment is being determined). The first year's trend shall be
adjusted to bring the facility's cost to a common fiscal year end of June 30
and the full trends shall be applied for the remaining years. The trends shall
be compounded each year to determine the total cumulative trend.
(AA) Uncompensated care costs (UCC). The
uncompensated care costs are those set forth in subsection (2)(H).
(BB) Uninsured revenues. Payments received on
a cash basis that are required per
42 CFR
455.301 through
42 CFR
455.304 and
42 CFR
447.299 to be offset against the uninsured
cost to determine the uninsured net cost include any amounts received by the
hospital, by or on behalf of either self-pay or uninsured individuals during
the SFY under audit.
(3)
Interim DSH Payments.
(A) Beginning with SFY
2013, interim DSH payments shall be calculated on an annual basis and will be
based on the state's calculations using data provided in the state DSH survey
for the applicable SFY, and estimated other Medicaid payments calculated by the
division in accordance with
13 CSR
70-15.010,
13 CSR
70-15.015, and
13 CSR
70-15.230 for the applicable SFY.
(B) The interim DSH payments will be
calculated as follows:
1. The estimated
hospital-specific DSH limit is calculated as follows:
A. Estimated Medicaid net cost from the state
DSH survey calculated in accordance with subsection (2)(C);
B. Less estimated other Medicaid payments
calculated by the division in accordance with
13 CSR
70-15.010,
13 CSR
70-15.015, and
13 CSR
70-15.230;
C. Equals estimated Medicaid uncompensated
care cost;
D. Plus estimated
uninsured uncompensated care cost from the state DSH survey calculated in
accordance with subsection (2)(E);
E. Equals estimated hospital-specific DSH
limit;
2. The estimated
uncompensated care costs potentially eligible for MHD interim DSH payments
excludes out-of-state DSH payments and is calculated as follows:
A. Estimated hospital-specific DSH
limit;
B. Less estimated
out-of-state (OOS) DSH payments;
C.
Equals estimated uncompensated care cost (UCC) net of OOS DSH
payments;
3. Hospitals
determined to have a negative estimated UCC net of OOS DSH payments (payments
exceed costs) will not receive interim DSH payments because their estimated
payments for the SFY are expected to exceed their estimated hospital-specific
DSH limit; and
4. Qualified DSH
hospitals determined to have a positive estimated UCC net of OOS DSH payments
(costs exceed payments) will receive interim DSH payments. The interim DSH
payments are subject to the federal DSH allotment, the availability of state
funds, and the estimated hospital-specific DSH limits less estimated OOS DSH
payments. The interim DSH payments will be calculated as follows:
A. Interim DSH payments to qualified DSH
hospitals determined to have a positive estimated UCC net of OOS DSH payments
will be calculated as follows:
(I) Up to one
hundred percent (100%) of the available federal DSH allotment will be allocated
to each hospital with a positive estimated UCC net of OOS DSH payments, and the
allocation shall result in each hospital receiving the same percentage of their
estimated UCC net of OOS DSH payments. The allocation percentage will be
calculated at the beginning of the SFY by dividing the available federal DSH
allotment to be distributed by the total hospital industry's positive estimated
UCC net of OOS DSH payments; and
(II) The allocated amount will then be
reduced by one percent (1%) for hospitals that do not contribute through a plan
that is approved by the director of the Department of Health and Senior
Services to support the state's poison control center and the Primary Care
Resource Initiative for Missouri (PRIMO) and Patient Safety
Initiative.
(C) Hospitals may elect not to receive an
interim DSH payment for a SFY by completing a DSH waiver form. This includes
federally deemed hospitals that do not have uncompensated care costs to justify
the receipt of an interim DSH payment. Hospitals that elect not to receive an
interim DSH payment for a SFY must notify the division, or its authorized
agent, that it elects not to receive an interim DSH payment for the upcoming
SFY. If a hospital does not receive an interim DSH payment for a SFY, it will
not be included in the independent DSH audit related to that SFY and will not
be eligible for final DSH audit payment adjustments related to that SFY unless
it submits a request to the division to be included in the independent DSH
audit. If the request is approved by the division, the hospital must submit all
necessary data elements to the independent DSH auditor in order to be included
in the audit and eligible for final DSH payment adjustments.
(D) Hospitals, including federally deemed
hospitals, may elect to receive an upper payment limit payment as defined in
13 CSR
70-15.230 in lieu of DSH payments. Hospitals that
elect to receive an upper payment limit payment rather than a DSH payment must
submit a request to the MO HealthNet Division on an annual basis. If a hospital
does not receive an interim DSH payment for a SFY, it will not be included in
the independent DSH audit related to that SFY, and will not be eligible for
final DSH audit payment adjustments related to that SFY unless it submits a
request to the division to be included in the independent DSH audit. If the
request is approved by the division, the hospital must submit all necessary
data elements to the independent DSH auditor in order to be included in the
audit and eligible for final DSH payment adjustments.
(E) Disproportionate share payments will
coincide with the semimonthly claim payment schedule.
(F) New facilities that do not have a
Medicare/Medicaid cost report on which to base the state DSH survey will be
paid the lesser of the estimated hospital-specific DSH limit less OOS DSH
payments based on the estimated state DSH survey or the industry average
estimated interim DSH payment. The industry average estimated interim DSH
payment is calculated as follows:
1.
Hospitals receiving interim DSH payments, as determined from subsection (3)(B),
shall be divided into quartiles based on total beds;
2. DSH payments shall be individually summed
by quartile and then divided by the total beds in the quartile to yield an
average interim DSH payment per bed; and
3. The number of beds for the new facility
shall be multiplied by the average interim DSH payment per bed.
(G) Interim DSH payments for
hospital mergers.
1. Hospitals that merge
prior to the beginning of the SFY. Hospitals that merge their operations under
one (1) Medicare and MO HealthNet provider number shall have their interim DSH
payment determined based on adding each hospital's state DSH survey to yield a
combined state DSH survey and applying the same calculations in subsection
(3)(B).
2. Hospitals that merge
after the beginning of the SFY. The interim DSH payments that have been
determined separately for the hospitals will be added together and paid to the
surviving hospital effective with the approval date of the merger.
(H) Interim DSH payment
adjustments.
1. To minimize hospital
longfalls, interim DSH payments made to hospitals will be revised if changes to
federally mandated DSH audit standards are enacted during a SFY, updated for
Medicaid expansion until it is captured in the required state DSH survey, or
any changes in Medicaid reimbursement until it is captured in the required
state DSH survey. These revisions are to serve as interim adjustments until the
federally mandated DSH audits are complete. DSH audits are finalized three (3)
years following the SFY year-end reflected in the audit. For example, the SFY
2019 DSH audit will be finalized in calendar year (CY) 2022.
(4) Department of Mental
Health (DMH) Hospitals DSH Adjustments and Payments.
(A) Beginning in SFY 2012, due to structural
changes occurring at the DMH facilities, interim DSH payments will be based on
the third prior base year cost report trended to the current SFY adjusted for
the federal reimbursement allowance (FRA) assessment paid by DMH hospitals. The
interim DSH payments calculated using the third prior base year cost report may
be revised based on the results of a DMH state DSH survey. Additional
adjustments may be done based on the results of the federally mandated DSH
audits as set forth below in subsection (5)(A).
(5) Final DSH Adjustments.
(A) Final DSH adjustments will be made after
actual cost data is available and the annual independent DSH audit is
completed. Annual independent DSH audits are completed three (3) years
following the state fiscal year-end reflected in the audit. For example, final
DSH adjustments for SFY 2022 DSH payments will be made following the completion
of the annual independent DSH audit in 2025 (SFY 2026).
(B) Final DSH adjustments may result in a
recoupment for some hospitals and additional DSH payments for other hospitals
based on the results of the annual independent DSH audit as set forth below-
1. Hospital DSH liabilities are overpayments
which will be recouped. If the annual independent DSH audit reflects that a
facility has a hospital DSH liability, it is an overpayment to the hospital and
is subject to recoupment. The hospital's DSH liability shown on the final
independent DSH audit report, that is required to be submitted to CMS by
December 31 will be due to the division by October 31 of the following
year;
2. Any overpayments that are
recouped from hospitals as the result of the final DSH adjustment will be
redistributed to hospitals that are shown to have a total shortfall. These
redistributions will occur proportionally based on each hospital's total
shortfall to the total shortfall, not to exceed each hospital-specific DSH
limit less OOS DSH payments;
3.
Redistribution payments to hospitals that have a total shortfall must occur
after the recoupment of hospital DSH liabilities. However, total industry
redistribution payments may not exceed total industry recoupments collected to
date;
4. If the amount of DSH
payments to be recouped as a result of the final DSH adjustment is more than
can be redistributed, the entire amount in excess of the amount able to be
redistributed will be recouped and the federal share will be returned to the
federal government. The state share of the final DSH recoupments that has not
been redistributed to hospitals with DSH shortfalls may be used to make a
hospital upper payment limit payment and/or a state-only quality improvement
payment to all non-DMH hospitals. The state-only quality improvement payment
will be paid proportionally to non-DMH hospitals based on the number of
hospital staffed beds to total staffed beds for the same state fiscal year the
final DSH adjustment relates to. Staffed beds are reported on the Missouri
Annual Licensing Survey which is mandated by the Department of Health and
Senior Services in accordance with
19 CSR
10-33.030;
5. If the Medicaid program's original interim
DSH payments did not fully expend the federal DSH allotment for any plan year,
the remaining DSH allotment may be paid to hospitals that are under their
hospital-specific DSH limit as determined from the annual independent DSH
audit. These payments will occur proportionally based on each hospital's
shortfall to the total shortfall, not to exceed each hospital's
hospital-specific DSH limit less OOS DSH payments;
6. If the Medicaid program's original DSH
payments did not fully expend the federal Institute for Mental Disease (IMD)
DSH allotment for any plan year, the remaining IMD DSH allotment may be paid to
IMD hospitals that are under their projected hospital-specific DSH limit. These
payments will occur proportionally based on each hospital's estimated shortfall
to the total estimated shortfall, not to exceed each hospital's estimated
hospital-specific DSH limit less OOS DSH payments; and
7. Bankrupt-liquidation or closed hospitals
are not eligible for final DSH redistributions or unspent allotment
payments.
(6)
Record Retention.
(A) Records used to complete
the state's DSH survey shall be kept until the final audit is completed. For
example, the SFY 2022 state DSH survey will use 2018 cost data, which must be
maintained until the 2022 DSH audits are completed in SFY 2026.
(B) Records provided by hospitals to the
state's independent auditor shall also be maintained until the federal
independent DSH audit is complete.
(7) State DSH Survey Reporting Requirements.
(A) Beginning in SFY 2016, each hospital must
complete and submit the state DSH survey set forth in paragraph (2)(X)1. (i.e.,
required state DSH survey) to the independent DSH auditor, the MO HealthNet
Division's authorized agent, in order to be considered for an interim DSH
payment for the subsequent SFY (i.e., DSH surveys collected during SFY 2016
will be used to calculate SFY 2017 interim DSH payments). The independent DSH
auditor will distribute the state DSH survey template to the hospitals to
complete and will notify them of the due date, which shall be a minimum of
thirty (30) days from the date it is distributed. However, the state DSH survey
is due to the independent DSH auditor no later than March 1 preceding the
beginning of each state fiscal year for which the interim DSH payment is being
calculated (i.e., the state DSH survey used for SFY 2017 interim DSH payments
will be due to the independent DSH auditor no later than March 1, 2016).
Hospitals that do not submit the state DSH survey by March 1 will not be
eligible to receive an interim DSH payment for that SFY. The division may grant
an industry-wide extension on the March 1 deadline due to unanticipated
circumstances that affect the industry as a whole. The independent DSH auditor
may perform an initial review of the required state DSH survey submitted by the
hospital and make preliminary adjustments for use in calculating the interim
DSH payment. The independent DSH auditor shall provide the hospital with any
preliminary adjustments that are made for review and comment prior to the data
being provided to MHD for use in calculating the interim DSH payment for the
SFY. Additional or revised audit adjustments may be made to the DSH survey for
purposes of the independent DSH audit.
1. A
new facility that does not have cost report data for the fourth prior year may
complete the state DSH survey using actual, untrended cost and payment data
from the most recent twelve- (12-) month cost report filed with the
division.
2. A new facility that
has not yet filed a twelve- (12-) month Medicaid cost report with the division
may complete the state DSH survey using facility projections to reflect
anticipated operations for the interim DSH payment period. Trends shall not be
applied to the data used to complete the state DSH survey. Interim DSH payments
determined from this state DSH survey are limited to the industry average
estimated interim DSH payment as set forth in subsection (3)(F).
3. Hospitals may elect not to receive an
interim DSH payment for a SFY by completing a DSH waiver form. Hospitals that
elect not to receive an interim DSH payment for a SFY must notify the division,
or its authorized agent, that it elects not to receive an interim DSH payment
for the upcoming SFY. If a hospital does not receive an interim DSH payment for
a SFY, it will not be included in the independent DSH audit related to that
SFY, and will not be eligible for final DSH audit payment adjustments related
to that SFY unless it submits a request to the division to be included in the
independent DSH audit. If the request is approved by the division, the hospital
must submit all necessary data elements to the independent DSH auditor in order
to be included in the audit and eligible for final DSH payment
adjustments.
4. If a hospital
received an interim DSH payment and later determined that it did not have
uncompensated care costs for Medicaid and the uninsured to support part or all
the interim DSH payment that it received or is receiving, the hospital may
request that the interim DSH payments be stopped or it may return the entire
interim DSH payment it received.
5.
Exceptions process to use alternate data for interim DSH payment.
A. A hospital may submit a request to the
division to have its interim DSH payment based on alternate data as set forth
below rather than the state DSH survey required to be submitted for the year
(i.e., required state DSH survey) if it meets the criteria for any of the
circumstances detailed below in subparagraph (7)(A)5.D. The request must
include an explanation of the circumstance, the impact it has on the required
state DSH survey period, and how it causes the data to be materially misstated
or unrepresentative. The division shall review the facility's request and may,
at its discretion and for good cause shown, use the alternate data in
determining the interim DSH payment for the SFY. The division shall notify the
facility of its decision regarding the request.
(I) Alternate state DSH survey. A state DSH
survey completed using the actual, untrended cost and payment data from the
most recent twelve- (12-) month cost report filed with the division. Any
hospital requesting an exception must complete an alternate state DSH survey.
If the most recent full-year cost report filed with the division does not
reflect the impact of any material changes, a supplemental schedule, as defined
below, may be completed and submitted in addition to the alternate state DSH
survey. If the impact of any changes is reflected in the most recent full-year
cost report filed with the division, the facility may only use the alternate
state DSH survey.
(II) Alternate
state DSH survey supplemental schedule. A supplemental schedule developed by
the division to recognize material changes that have occurred at a hospital
that are not yet reflected in the hospital's alternate state DSH survey. The
supplemental schedule uses the data from the alternate state DSH survey as the
basis and includes additional fields to reflect changes that occurred
subsequent to the alternate state DSH survey period through the SFY for which
the interim DSH payment is being calculated. The blank alternate state DSH
survey supplemental schedule is referred to as the alternate state DSH survey
supplemental template.
B.
The provider must submit both the required state DSH survey and the alternate
data for review to determine if the facility meets the criteria set forth below
in subparagraph (7)(A)5.D.
C. The
interim DSH payment based on the applicable alternate data shall be calculated
in the same manner as the interim DSH payment based on the required state DSH
survey, except for the trends applied to the alternate data as noted below in
parts (7)(A)5.C.(I) and (II). The allocation percentage calculated at the
beginning of the SFY year as set forth in part (3)(B)4.A.(I) shall be applied
to the estimated UCC net of OOS DSH payments based on the alternate data to
determine the preliminary interim DSH payment.
(I) Alternate state DSH survey. The trends
applied to the alternate state DSH survey shall be from the year subsequent to
the alternate state DSH survey period to the current SFY for which the interim
DSH payment is being determined.
(II) Alternate state DSH survey supplemental
schedule. Trends shall not be applied to an alternate state DSH survey
supplemental schedule since it incorporates changes from the full-year cost
report period through the SFY for which the interim DSH payment is being
calculated.
D. Following
are the circumstances for which a provider may request that its interim DSH
payment be based on alternate data rather than the required state DSH survey,
including the criteria and other requirements:
(I) Twenty percent (20.00%) DSH outlier. A
provider may request that the alternate state DSH survey be used prior to the
interim DSH payment being determined for the SFY if the untrended total
estimated net cost from the alternate state DSH survey is at least twenty
percent (20.00%) higher than the trended total estimated net cost from the
required state DSH survey (i.e., the increase is at least twenty percent
(20.00%) rounded to two (2) decimal places).
(a) Both the required state DSH survey and
the alternate state DSH survey must be submitted to the independent DSH auditor
and the division, respectively, no later than March 1 preceding the beginning
of each SFY for which interim DSH payments are being made;
(II) Extraordinary circumstances. A provider
may request that alternate data be used if the facility experienced an
extraordinary circumstance during or after the required state DSH survey report
period up to the SFY for which the interim DSH payment is being calculated that
caused the required DSH survey report period to be materially misstated and
unrepresentative. If circumstances found in items (7)(A)5.D.(II) (a)I.-IV.
below are applicable, the facility may complete and submit the applicable
alternate data.
(a) Extraordinary
circumstances include unavoidable circumstances that are beyond the control of
the facility and include the following:
I. Act
of God (i.e., tornado, hurricane, flooding, earthquake, lightning, natural
wildfire, etc.);
II. War;
III. Civil disturbance; or
IV. If the data to complete the required
state DSH survey set forth in paragraph (2)(X)1. is not available due to a
change in ownership because the prior owner is out of business and is
uncooperative and unwilling to provide the necessary data.
(b) A change in hospital operations or
services (i.e., terminating or adding a service or a hospital wing; or, a
change of owner, except as noted in item (7)(A)5.D.(II)(a) IV., manager,
control, operation, leaseholder or leasehold interest, or Medicare provider
number by whatever form for any hospital previously certified at any time for
participation in the MO HealthNet program, etc.) does not constitute an
extraordinary circumstance.
(c)
Both the required state DSH survey and the alternate data must be submitted to
the independent DSH auditor and the division, respectively, no later than March
1 if the alternate data is to be used to determine the interim DSH payment at
the beginning of the SFY.
(d) A
hospital may submit a request to use alternate data due to extraordinary
circumstances after March 1, but the alternate data and the resulting interim
DSH payment will be subject to the same requirements as the interim DSH payment
adjustments noted below in subparts (7)(A)5.D.(III)(b)-(d). The requests
relating to extraordinary circumstances received after the March 1 deadline
will be included with the interim DSH payment adjustments requests in part
(7)(A)5.D.(III) in distributing the unobligated DSH allotment and available
state funds remaining for the SFY;
(III) Interim DSH payment adjustment.
(a) After the interim DSH payment has been
calculated for the current SFY based on the required state DSH survey, a
provider may request that alternate data be used if the untrended total
estimated net cost from the alternate data is at least twenty percent (20.00%)
higher than the trended total estimated net cost from the required state DSH
survey (i.e., the increase is at least twenty percent (20.00%) rounded to two
(2) decimal places).
(b) The
division will process interim DSH payment adjustments once a year. After all
requests are received, the division will determine whether revisions to the
interim DSH payments are appropriate. Any revisions to the interim DSH payments
are subject to the unobligated DSH allotment remaining for the SFY and
availability of state funds.
(c)
The request, including the alternate data, must be submitted to the division by
December 31 of the current SFY for which interim DSH payments are being
made.
(d) To the extent that state
funds are available, the DSH allotment for the SFY that has not otherwise been
obligated will be distributed proportionally to the hospitals determined to
meet the above criteria, based on the difference between the preliminary
interim DSH payment based on the alternate data and the original interim DSH
payment; and
(IV) If a
provider received an exception that allows it to use alternate data for interim
DSH payment purposes under paragraph (7)(A)5. in the prior SFY, it may continue
to use alternate data for its interim DSH payment until the required state DSH
survey reflects the annual impact of the change. The alternate state DSH survey
supplemental schedule should be used until the most recent cost report on file
with the division reflects the annual impact of the change. Both the required
state DSH survey and the applicable alternate data must be submitted to the
independent DSH auditor and the division no later than March 1 preceeding the
beginning of each SFY for which the interim DSH payment is being
made.
Notes
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