5101:3-2-54 Supplemental outpatient hospital upper limit payments for private, public non state-owned, and public state-owned hospitals.

This rule sets forth the methodology used to determine the supplemental outpatient payments to each class of hospitals required by Section 309.30.17 of Amended Substitute House Bill 1 of the 128th General Assembly.

(A) Definitions

(1) Classification of hospitals: For the purpose of determining upper limit tests for hospitals and making upper limit payments to hospitals, hospitals are grouped into the following three hospital classes, non state-owned public hospitals, state- owned public hospitals and private hospitals.

(2) “Hospital” means an Ohio hospital other than a children’s hospital as defined in rule 5101:3-2-53 of the Administrative Code and is subject to prospective payment as described in rule 5101:3-2- 07.1 of the Administrative Code.

(3) “Available outpatient payment gap” means the difference between what is estimated using the methodology described in paragraphs (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.

(4) “Total medicaid outpatient 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 outpatient visits” means for each hospital the number of outpatient visits to the facility for medicaid patients, as reported on the medicaid cost report, as specified in paragraph (B) of this rule.

(6) “Medicare Outpatient Charges – Critical Access Hospital” – means for each critical access hospital, the amount of outpatient charges, as reported on the medicare cost report, as specified in paragraph (B) of this rule.

(7) “Medicare Outpatient Charges – PPS Hospital” means for each PPS hospital and sub provider, the amount of outpatient charges, as reported on the medicare cost report, as specified in paragraph (B) of this rule.

(8) “Medicare Outpatient Charges – PPS Hospital (Non-PPS Charges)” means for each PPS hospital and sub provider the amount of outpatient non PPS charges, as reported on the medicare cost report, as specified in paragraph (B) of this rule.

(9) “Total medicare outpatient charges” means the sum of paragraphs (A)(6) to (A)(8) of this rule.

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

(11) “Medicare Outpatient Payments – Critical Access Hospital” – the payment for outpatient hospital services for critical access hospitals as reported on the medicare cost report, as specified in paragraph (B) of this rule.

(12) “Medicare Outpatient Payments – PPS Hospital” – the payment for outpatient hospital services for PPS hospitals as reported on the medicare cost report, as specified in paragraph (B) of this rule.

(13) “Medicare Outpatient Direct MedEd Payments” – the payment for outpatient direct medical education for each PPS hospital as reported on the medicare cost report, as specified in paragraph (B) of this rule.

(14) “Medicare Outpatient Payments – PPS Hospital (Sub provider 1)” – means for each sub provider 1, as reported on the medicare cost report, the amount of outpatient payments, as specified in paragraph (B) of this rule.

(15) “Medicare Outpatient Payments – PPS Hospital (Sub provider 2)” – means for each sub provider 2, the amount of outpatient payments, as reported on the medicare cost report, as specified in paragraph (B) of this rule.

(16) “Total medicare outpatient payments” means the sum of paragraphs (A)(11) to (A)(15) of this rule.

(17) “Program year” means the twelve month period beginning on the first day of January and ending on the thirty first day of December.

(B) Source data for calculations.

Unless otherwise specified, the calculations described in this rule will be based on cost reporting data described in rule 5101:3-2-23 of the Administrative Code that reflects the most recent completed interim settled medicaid cost report for the hospitals, and the medicare cost report for the corresponding cost reporting period.

(1) For each hospital, calculate the total medicare outpatient payment by taking the amounts described in paragraph (A)(16) of this rule.

(2) For each hospital, calculate the medicare outpatient payment-to-charge ratio by dividing the amount calculated in paragraph (C)(1) of this rule by the total medicare outpatient charges as described in paragraph (A)(9) of this rule.

(3) For each hospital, calculate the total estimated medicare outpatient payment for medicaid outpatient visits by multiplying the amount calculated in paragraph (C)(2) of this rule by the total medicaid outpatient charges as described in paragraph (A)(10) of this rule.

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

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

(6) For all hospitals in each hospital class, sum the amounts calculated in paragraph (C)(4) of this rule. This is the aggregate outpatient upper limit for all hospitals in each hospital class.

(D) For each supplemental payment made after the effective date of this rule, the resulting upper payment limit 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 payment program year.

(E) Payment of supplemental outpatient hospital upper limit payments to hospitals in each hospital class.

Supplemental outpatient hospital upper limit payments to hospitals shall be made as follows:

(1) In July of each year after the effective date of the medicaid state plan amendment implementing this payment program, the department will calculate for each eligible hospital in each hospital class a supplemental outpatient hospital payment amount by multiplying the aggregate outpatient upper limit gap in each hospital class as calculated in (C)(6) by the ratio of each hospital’s total medicaid fee-for-service outpatient visits to the the total number of medicaid fee-for-service outpatient visits for all hospitals in that class derived from actual outpatient visits paid for through the department’s medicaid management information system (MMIS) in the state fiscal year that ends prior to the month of payment but not earlier than the effective date of the state plan amendment.

(2) If the total of the funds that will be paid to all hospitals in a class exceeds the aggregate upper payment limit for the class calculated each supplemental outpatient upper limit payment program year as described in paragraph (C) of this rule, then the amount paid to each hospital in the class will be limited to each hospital’s proportion of the aggregate upper payment limit for that class.

(3) For each fiscal year the supplemental upper limit payment for private, public non state-owned, and public state-owned hospitals will not exceed the limits specified in 42 C.F.R 447.321.

(F) All medicaid payments including payments made under this rule are subject to the limitations described in rule 5101:3-2-24 of the Administrative Code.

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

Effective: 04/08/2010

R.C. 119.032 review dates: 04/01/2015

Promulgated Under: 119.03

Statutory Authority: 5111.02

Rule Amplifies: 5111.01, 5111.02, 5111.021, Section 309.30.17 of Am. Sub. H.B. 1 of the 128th G.A.