5101:3-2-52 Supplemental inpatient hospital payments for private hospitals.

(A) "Private hospital" means an Ohio hospital, other than a public hospital as defined in rule 5101:3-2-50 of the Administrative Code or a state hospital as defined in rule 5101:3-2-51 of the Administrative Code.

(B) All private 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 this rule. The supplemental amounts shall be in addition to any other amounts payable to hospitals with respect to those services.

(C) Data sources utilized in calculating supplemental payments to private 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 SFY 2013, the hospital fiscal year ending in SFY 2010 medicare cost reports retrieved from the hospital cost report information system and the medicaid MMIS discharges and days data and Ohio medicaid cost report payment data from SFY 2010 will be utilized unless otherwise noted.

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

(1) For each private 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 preceeding October 1, 2009 are inflated by five per cent to account for an increase in medicaid payment rates 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 cost per patient day. The average is determined using medicaid cost reports filed in state fiscal years 2005-2009. 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 did 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 determine the inpatient UPL gap for private hospitals. The sum of the differences for these hospitals represents the aggregate UPL gap for all private hospitals.

(E) Private hospitals, excluding children's hospitals defined in rule 5101:3-2-53 of the Administrative Code, that are paid under the inpatient hospital prospective payment system shall receive payments based upon the following hospital-specific calculation:

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

(2) For each private 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 private 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 amount calculated in paragraph (E)(3) of this rule summed across all private hospitals.

(5) From the pool of funds calculated in paragraph (E)(4) of this rule, payments shall be made to all private hospitals based upon the ratio of each private hospital's inpatient medicaid fee-for-service days to the total medicaid fee-for-service inpatient days for all private hospitals. This ratio will be derived from actual patient MMIS fee-for-service date of service claims data in the state fiscal year ending prior to the month of payment.

(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, private hospitals shall receive payments for the provision of inpatient hospital services. These payments will be based on specialty subgroups according to hospital characteristics that are mutually exclusive and are presented in hierarchical order:

(1) Specialty hospitals, which are freestanding rehabilitation hospitals and freestanding long-term hospitals as defined in 5101:3-2- 07.1 of the Administrative Code.

(2) Critical access hospitals (CAHs), which are private hospitals with a critical access designation.

(3) Rural hospitals, which are private hospitals that are classified by the centers for medicare and medicaid services (CMS) as rural hospitals.

(4) Children's hospitals, which are private hospitals as defined in rule 5101:3-2-53 of the Administrative Code.

(5) "Adult disproportionate share (DSH) hospitals," which are private hospitals with adult high DSH designation as of federal fiscal year 2010.

(6) "Magnet education hospitals," which are private hospitals with an education component which have received magnet designation by the American nurses credentialing center as of December 31, 2010.

(7) "Education hospitals," which are private hospitals with a residency program.

(8) General hospitals paid under the inpatient prospective payment system, which are private hospitals which do not qualify for any of the preceding categories defined in paragraphs (F)(1) to (7) of this rule.

(9) From the specialty hospital subgroup, payments shall be made in the form of a percentage increase applied to hospital-specific SFY 2010 medicaid inpatient fee-for-service payments. This percentage increase will be equal to the pool amount of $14,022,012 in SFY 2012 and $13,396,983 in SFY 2013 divided by total private specialty hospital SFY 2010 medicaid inpatient fee-for-service payments.

(10) For the critical access subgroup defined in paragraph (F)(2) of this rule and the rural subgroup defined in paragraph (F)(3) of this rule, payments shall be made to all CAHs and rural hospitals in the form of a per diem payment applied to hospital-specific SFY 2010 medicaid fee-for-service days. This payment will be equal to the pool amount of $11,819,200 in both SFY 2012 and SFY 2013 divided by the total CAH and rural hospital SFY 2010 medicaid fee-for-service days.

(11) For children's hospitals subgroup defined in paragraph (F)(4) of this rule, payments shall be made in accordance with rule 5101:3-2-53 of the Administrative Code.

(12) For the magnet education subgroup defined in paragraph (F)(6) of this rule, payments shall be made to all magnet education hospitals in the form of a percentage increase applied to hospital-specific SFY 2010 medicaid fee-for-service inpatient payments. This percentage increase will be equal to the pool amount of $12,833,490 in SFY 2012 and $12,282,308 in SFY 2013, divided by total magnet education hospital SFY 2010 medicaid inpatient fee-for-service payments.

(13) For the total education subgroup defined in paragraph (F)(7) of this rule, all education hospitals and magnet education hospitals shall receive a percentage increase in medicaid payments applied to their total hospital-specific SFY 2010 medicaid fee-for-service inpatient payments. This percentage increase will be equal to the pool amount of $40,722,805 in SFY 2012 and $39,534,103 in SFY 2013 divided by total education hospitals' and magnet education hospitals' SFY 2010 medicaid inpatient fee-for-service payments. This amount is in addition to the amount paid to magnet education hospitals in paragraph (F)(12) of this rule.

(14) For the pooled amount calculated in paragraph (D) of this rule less payments made in paragraph (E) of this rule and paragraphs (F)(9) to (F)(13) of this rule, all private hospitals, excluding children's hospitals, shall receive a payment. These payments will be in the form of an additional payment per discharge applied to SFY 2010 inpatient medicaid discharges from the SFY 2010 MMIS date of service claims data. This increase will be equal to the pool amount divided by the total private general acute hospital SFY 2010 medicaid charges. These payments are in addition to the payments in paragraph (E) of this rule and paragraphs (F)(9) to (F)(13) of this rule.

(G) Supplemental payments in paragraph (E) of this rule will be paid semianually and supplemental payments in paragraph (F) of this rule shall be paid in four installments within the state fiscal year.

(H) Supplemental payments to cost-based providers, as specified in rule 5101:5-2-07.1 of the Administrative Code, will be excluded from the cost settlement process.

(I) Hospital payments made under this rule, when combined with other payments made in Chapter 5101:3-2 of the Administrative Code, shall not exceed the limit specified in 42 C.F.R. 447.272 .

(J) The total funds that will be paid to each hospital will be included in the calculation of disproportionate share limits as described in rule 5101:3-2-07.5 of the Administrative Code.

Replaces: 5101:3-2-52

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 , 5111.021 , Section 309.30.33 of Am. Sub. H.B. 153 of the 129th G.A.
Prior Effective Dates: 4/8/2010