(a) Disproportionate share payment
distributions made to general hospitals pursuant to article 28 of the Public
Health Law shall be limited in accordance with the provisions of this section.
The latest available annual cost report submitted by a hospital prior to the
disproportionate share distribution period shall be used to determine
eligibility pursuant to subdivision (b) of this section and for projected
limits pursuant to subdivision (e) of this section. Annual cost reports having
an end date in the applicable annual disproportionate share distribution
period, or for certain State-operated general hospitals, annual cost reports
having an end date in the subsequent annual disproportionate share distribution
period, shall be used to reconcile limits pursuant to subdivision (f) of this
section.
(b) General hospitals
whose inpatient Medicaid eligible patient days are less than one percent of
total inpatient patient days shall not be eligible to receive disproportionate
share distributions.
(c) No general
hospital shall receive in total from disproportionate share payment
distributions an amount which exceeds the costs incurred during the periods
described in subdivision (a) of this section for furnishing inpatient and
ambulatory hospital services to individuals who are eligible for medical
assistance benefits pursuant to title XIX of the Federal Social Security Act
(hereinafter referred to as "Medicaid cost") or to individuals who have no
health insurance for the services provided or other source of third party
coverage (hereinafter referred to as "self-pay cost"), reduced by medical
assistance payments made pursuant to title XIX of the Federal Social Security
Act (hereinafter referred to as "Medicaid revenue"), other than
disproportionate share payments, and payments by uninsured patients. For
purposes of this section, payments to a general hospital for services provided
to indigent patients made by the State or a unit of local government within the
State shall not be considered a source of third party payment.
(d) In order to ensure the continued flow of
disproportionate share payments to hospitals, the commissioner shall make
projections of each hospital's disproportionate share limitation based on the
most current data available from the hospital's annual cost reports. The
commissioner shall use annual cost reports in accordance with the provisions of
subdivision (e) of this section to estimate Medicaid and self-pay costs in the
projection methodology for a particular rate year. This shall be referred to as
the "projection methodology". Subsequent to the receipt of a hospital's annual
cost report having an end date in the applicable annual disproportionate share
distribution period, or for certain State-operated general hospitals whose
annual cost reports have an end date within the subsequent annual period, each
hospital's disproportionate share limitation shall be reconciled to the actual
rate year data. This shall be referred to as the "reconciliation
methodology".
(e)
Projection
methodology.
Each hospital's projected disproportionate share
limitation for each rate year shall be the sum of its inpatient and outpatient
Medicaid and uninsured gains/(losses) as calculated using reported base year
data and statistics from the year two years immediately preceding the rate year
and as used for projection methodology purposes for that prior
year.
(f)
Reconciliation methodology.
The commissioner shall revise the projected limitation
based on actual data reported to the commissioner for such rate year in
accordance with the following and in accordance with final regulations issued
by the Federal Department of Health and Human Services implementing
42
USC section 1396r-4. The commissioner shall
revise the projected limitations for each hospital within eight months from the
date required reports are submitted to the department, except if such reports
are determined to be unacceptable by the department. For hospitals which have
submitted unacceptable reports, the commissioner shall revise the projected
limitations within eight months from the date acceptable reports have been
resubmitted to the department.
(1)
Each hospital shall submit, by the same date the annual cost reports are
required to be filed pursuant to section
86-1.2
of this Subpart, a disproportionate share limitation schedule in a form and
manner prescribed by the commissioner within which the hospital shall
calculate, in accordance with the instructions, its inpatient and outpatient
Medicaid and self-pay gains/(losses) during the cost reporting year. The
disproportionate share limitation schedule shall be accompanied by a
certification by the hospital's independent public accountant which provides
the commissioner sufficient assurance as to the accuracy of the information
contained in such schedule.
(i) The final
limit shall be calculated by excluding inpatient and outpatient Medicaid
revenue impacts resulting from prospective adjustments to rates for periods
prior to the implementation of the Federal hospital specific disproportionate
share payment limits from the inpatient and outpatient Medicaid and self-pay
gains/(losses) reported on the disproportionate share payment limitation
schedule.
(2) Failure of
a hospital to submit the information required by this section in a form
acceptable to the commissioner shall result in the immediate withholding of all
subsequent disproportionate share distributions. Such withholding shall
continue until the hospital complies with the reporting requirements of this
subdivision.
