5101:3-2-50 Supplemental inpatient hospital upper limit payments for public hospitals.

(A) Definitions.

(1) “Public hospital” means an Ohio hospital owned and operated by a governmental entity other than the state.

(2) “Available inpatient payment gap” means the difference between what is estimated using the methodology described in paragraph (C) of this rule that medicare would have paid for medicaid consumers and actual medicaid payments made in accordance with Chapter 5101:3-2 of the Administrative Code.

(3) “Intergovernmental transfer” means any transfer of money by a governmental hospital to the department.

(4) “Total medicaid inpatient payments” for each hospital means the amount paid by the medicaid program for services rendered to eligible medicaid patients, excluding supplemental payments, as reported on the medicaid cost report, as specified in paragraph (B) of this rule.

(5) “Total medicaid inpatient discharges” means for each public hospital the number of discharges from the facility for medicaid patients, as reported on the medicaid cost report, as specified in paragraph (B) of this rule.

(6) “Total medicaid inpatient charges” means for each public hospital the charges for covered medicaid inpatient services rendered, as reported on the medicaid cost report, as specified in paragraph (B) of this rule.

(7) “Medicare inpatient payments for hospitals exempt from medicare DRG payments and Medicare inpatient payments for subproviders” means the inpatient payment amount as reported on the medicare cost report, as specified in paragraph (B) of this rule.

(8) “Medicare inpatient DRG payments” means the DRG payment amount as reported on the medicare cost report, as specified in paragraph (B) of this rule.

(9) “Medicare inpatient outlier payments” means the outlier payment amount as reported on the medicare cost report, as specified in paragraph (B) of this rule.

(10) “Medicare inpatient indirect medical education” means the indirect medical education adjustment amount as reported on the medicare cost report, as specified in paragraph (B) of this rule.

(11) “Medicare inpatient disproportionate share payments” means the inpatient disproportionate share adjustment amount as reported on the medicare cost report, as specified in paragraph (B) of this rule.

(12) “Medicare inpatient hospital capital payments means” the payment for inpatient program capital as reported on the medicare cost report, as specified in paragraph (B) of this rule.

(13) “Medicare inpatient direct medical education” means the direct graduate medical education payment amount as reported on the medicare cost report, as specified in paragraph (B) of this rule.

(14) “Medicare inpatient hospital payments – other” means the sum of net organ acquisition cost, cost of teaching physicians, routine service other pass through costs, and ancillary service other pass through costs, as reported on the medicare cost report, as specified in paragraph (B) of this rule.

(15) “Total medicare inpatient charges” means the amount of inpatient charges for each hospital and subprovider, as reported on the medicare cost report, as specified in paragraph (B) of this rule.

(B) Source data for calculations. The calculations described in this rule will be based on cost reporting data described in rule 5101:3-2-23 of the Administrative Code which reflects the most recent completed interim settled medicaid cost report for all hospitals, and the medicare cost report for the corresponding cost reporting period.

(C) Calculation of available inpatient payment gap for public hospitals.

(1) For each public hospital, calculate the total medicare inpatient payment by adding the amounts described in paragraphs (A)(7) to (A)(14) of this rule.

(2) For each public hospital, calculate the medicare payment to charge ratio by dividing the amount calculated in paragraph (C)(1) of this rule by the total medicare inpatient charges as described in paragraph (A)(15) of this rule.

(3) For each public hospital, calculate the total estimated medicare inpatient payment for medicaid inpatient discharges by multiplying the amount calculated in paragraph (C)(2) of this rule by the total medicaid inpatient charges as described in paragraph (A)(6) of this rule.

(4) For each public hospital, calculate the available inpatient payment gap by taking total estimated medicare inpatient payments for medicaid inpatient discharges as calculated in paragraph (C)(3) of this rule and subtracting actual total medicaid inpatient payments as described in paragraph (A)(4) of this rule.

(5) For each public hospital that has an available inpatient payment gap greater than zero resulting from the calculations in paragraph (C)(4) of this rule, calculate the available per discharge supplemental inpatient hospital payment amount by dividing the amount in paragraph (C)(4) of this rule by the amount in paragraph (A)(5) of this rule.

(D) For each supplemental upper limit payment made after the effective date of this rule, the resulting per discharge supplemental payment amount calculated in paragraph (C) of this rule will be in effect from the first day of January through the thirty-first day of December for each supplemental upper limit payment program year.

(E) Payment of supplemental inpatient hospital upper limit payments.

(1) In January and July of each year, the department will notify public hospitals of the available per discharge supplemental inpatient hospital payment amount as described in paragraph (C)(5) of this rule, the number of actual medicaid inpatient discharges paid for through the department’s MMIS for each public hospital in the six months prior to the month of notification, and the maximum allowable supplemental payment that the public hospital is eligible to receive for the prior six months. The maximum allowable supplemental payment amount is the product of the actual number of medicaid discharges paid during the prior six months and the available per discharge supplemental inpatient hospital payment amount as described in paragraph (C)(5) of this rule, subject to the limitations described in paragraph (E)(3) of this rule.

(2) Public hospitals electing to receive supplemental inpatient hospital payments must notify the department within fourteen days of the date of the notice described in paragraph (E)(1) of this rule of their intent to participate. public hospitals that elect to participate and have notified the department of that intent shall provide an intergovernmental transfer, via electronic funds transfer, up to but not to exceed an amount that equals the maximum allowable supplemental payment amount as described in paragraph (E)(1) of this rule multiplied by [1-(federal medical assistance percentage)] by no later than thirty days from the date of the notice described in paragraph (E)(1) of this rule. Failure to submit the intergovernmental transfer by this deadline will preclude the hospital from receiving the supplemental payment for the six-month payment period.

(3) The total funds that will be paid to each public hospital electing to receive supplemental inpatient hospital payments from the department shall be the amount supplied by each hospital in paragraph (E)(2) of this rule, divided by [1-(federal medical assistance percentage)]. If the total of the funds that will be paid to all public hospitals electing to participate exceeds the aggregate upper payment limit for all public hospitals calculated each supplemental inpatient upper limit payment program year as described in paragraph (C) of this rule, then the amount paid to each public hospital electing to participate will be limited to its proportion of the aggregate upper payment limit. The department may request adjustments to the amounts transferred from and paid to public hospitals electing to participate for the six-month time period.

(F) The total funds that will be paid to each public hospital electing to receive supplemental inpatient hospital payments from the department as described in paragraph (E)(3) of this rule will be included in the calculation of disproportionate share limits as described in rule 5101:3-2-07.5 of the Administrative Code.

HISTORY: Eff 11-15-01; Replaces: 5101:3-2-50, eff. 7-1-04

Rule promulgated under: RC 119.03

Rule authorized by: RC 5111.02

Rule amplifies: RC 5111.01, 5111.02

R.C. 119.032 review dates: 07/01/2009