5101:3-2-51 Supplemental inpatient hospital upper payment limit payments for state hospitals.

(A) "State hospital" means an Ohio hospital owned and operated by the state.

(B) Non-psychiatric state hospitals, as of October first of the year preceding payments, shall be paid supplemental amounts for the provision of hospital inpatient services set forth in paragraphs (C) through (F) of this rule. The supplemental amounts shall be in addition to any other amounts payable to hospitals with respect to those services.

(C) Data sources used in calculating supplemental payments to state-owned hospitals include the medicare cost report (CMS 2552-96), the Ohio medicaid hospital cost report (JFS 02930, rev. 4/2010), and medicaid management information system (MMIS) inpatient fee-for-service date of service claims data. For state fiscal year (SFY) 2012 and 2013, the hospital fiscal year ending in state fiscal year 2010 medicare cost reports retrieved from the hospital cost report information system and the medicaid MMIS data and Ohio medicaid cost reports (JFS 02930, rev. 4/2010) payment data from the state fiscal year prior to the month of payment will be utilized unless otherwise noted.

(D) The total supplemental payments shall not exceed the amount calculated using the following methodology:

(1) For each non-psychiatric state hospital, total medicare costs are divided by total medicare charges to establish the cost-to-charge ratio.

(2) Ohio medicaid payments for the portion of the hospital fiscal year preceding October 1, 2009 are inflated by five per cent to account for an increase in medicaid payment rates effective October 1, 2009.

(3) Ohio medicaid charges are multiplied by the cost-to-charge- ratio in paragraph (D)(1) of this rule to establish estimated Ohio medicaid costs.

(4) Ohio medicaid costs from paragraph (D)(3) of this rule are inflated using a hospital-specific five year average of medicaid costs per patient day. This hospital-specific inflation factor is applied to individual hospital costs at a discounted rate for the partial year for all hospitals with fiscal year end before the 2010 state fiscal year end of June 30, 2010, plus two years to determine the upper payment limit (UPL) for SFY 2012 and for a third year to determine the UPL for SFY 2013. In the event in which hospital data does not exist for any hospital in years 2005-2009, the state average of 4.43 per cent is utilized. Ohio medicaid costs are multiplied by a factor of 1.01 for the critical access hospitals.

(5) Ohio medicaid payments from paragraph (D)(2) of this rule are then subtracted from the total in paragraph (D)(4) of this rule to find the inpatient UPL gap for state hospitals. The sum of the differences for these state hospitals represents the total state-owned inpatient upper payment limit gap.

(E) Each non-psychiatric state hospital paid under the prospective payment system shall receive payments based on the following hospital-specific calculation:

(1) For each non-psychatric state hospital, calculate a medicare payment-to-charge ratio by dividing total medicare inpatient payments by total medicare inpatient charges.

(2) For each non-psychiatric state hospital, calculate the total estimated medicare inpatient payment for medicaid inpatient discharges by multiplying the amount calculated in paragraph (E)(1) of this rule by the total medicaid inpatient charges.

(3) For each non-psychiatric state hospital, subtract total inpatient medicaid payments from the amount calculated in paragraph (E)(2) of this rule.

(4) The pooled amount will then be equal to the summation of the amounts calculated for all non-psychiatric state hospitals in accordance with paragraph (E)(3) of this rule.

(5) Each non-psychiatric state hospital for which the amount calculated in paragraph (E)(3) of this rule is greater than zero shall receive an allotment of the pooled amount calculated in paragraph (E)(4)) of this rule. This allotment is based on the ratio of hospital-specific medicaid discharges to the total state hospital medicaid discharges.

(F) From a pool of funds calculated in paragraph (D)(5) of this rule, less the payments made in paragraph (E)(5)) of this rule, resulting in a remaining pool amount, state hospitals shall receive a percentage increase in inpatient medicaid payments. The percentage increase on state fiscal year 2010 total inpatient hospital medicaid payments will be equal to the remaining pool amount divided by state hospital medicaid inpatient hospital fee-for-service payments.

(G) Using the source data described in paragraph (C) of this rule), for each freestanding psychiatric state hospital owned or operated by the state, calculate the estimated amount that medicare would have paid for an inpatient discharge if medicare were paying the care for medicaid consumers by subtracting medicaid inpatient payments from medicaid inpatient costs.

(H) For each state psychiatric hospital that has an inpatient payment gap greater than zero resulting from the calculations in paragraph (G) of this rule, calculate the per discharge supplemental inpatient hospital payment amount by dividing the amount in paragraph (G) of this rule by the state hospital's medicaid discharges. Payments will be made on a semiannual basis, based upon the product of each psychiatric hospital per discharge gap amount and medicaid discharges paid during the prior six-month period.

(I) Payments in paragraph (E) of this rule will be paid semiannually and payments in paragraph (F) of this rule will be paid in four installments within the state fiscal year. If the total funds that will be paid to all state hospitals exceeds the aggregate upper payment limit for state hospitals, then the amount paid to all state hospitals will be limited to their proportion of the aggregate upper payment limit.

(J) Supplemental payments to cost-based providers, as specified in rule 5101:3-2-07.1 of the Administrative Code, will be excluded from the cost settlement process.

(K) Hospital payments made under this section, when combined with other payments, shall not exceed te limit specified in 42 C.F.R. 447.271 and 42 C.F.R. 447.272 .

(L) The total funds that will be paid to each hospital will be included in the calculation of disproportionate share limits as decribed in rules 5101:3-2-07.5 and 5101:3-2-10 of the Administrative Code.

Replaces: 5101:3-2-51

Effective: 08/24/2012
R.C. 119.032 review dates: 08/01/2017
Promulgated Under: 119.03
Statutory Authority: 5111.02
Rule Amplifies: 5111.01 , 5111.02 , 511.021, Section 309.30.33 of Am. Sub. H.B. 153 of the 129th G.A.
Prior Effective Dates: 7/22/02, 9/1/03, 4/1/09, 4/8/10