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

(A) Definitions.

(1) "Children's hospital" means an Ohio hospital as defined in section 3702.51 of the Revised Code that is owned and operated by a private entity and is subject to prospective payment as described in rule 5101:3-2-07.1 of the Administrative Code.

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

(3) "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.

(4) "Public hospital" means an Ohio hospital owned and operated by a governmental entity other than the state.

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

(B) Supplemental outpatient payments for state hospitals.

(1) State hospitals, as of October first of the year preceding payments, shall be paid supplemental amounts for the provision of hospital outpatient services set forth in paragraph (B) of this rule. The supplemental amounts shall be in addition to any other amounts payable to hospitals with respect to those services.

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

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

(a) For each state hospital, total medicare outpatient costs are divided by the total outpatient medicare charges to establish the hospital-specific outpatient cost to charge ratio.

(b) For each state hospital, total Ohio medicaid outpatient charges are multipled by the cost to charge ratio calculated in paragraph (B)(3)(a) of this rule to calculate Ohio medicaid outpatient costs.

(c) The outpatient hospital market basket update value of two point six per cent is applied to each state hospital's Ohio medicaid costs from paragraph (B)(3)(b) of this rule at a discounted rate for hospitals with fiscal year ends prior to 2010 state fiscal year end of June 30, 2010 plus for two years to determine the upper payment limit (UPL) for SFY 2012 and for a third year for SFY 2013. Ohio medicaid outpatient costs are additionally multiplied by a factor of one point zero one for critical access hospitals.

(d) Ohio medicaid outpatient payments for SFY 2010 are then subtracted from the amounts determined in paragraph (B)(3)(c) of this rule to find the outpatient upper payment limit gap. The sum of the differences for these public hospitals represents the total state owned outpatient UPL gap.

(4) From a pool of funds calculated in paragraph (B)(3) of this rule, state hospitals shall receive a percentage increase in outpatient hospital medicaid payments applied to SFY 2010 outpatient hospital medicaid fee-for-service payments. This percentage increase will be equal to the pool amount divided by total state hospital SFY 2010 medicaid outpatient fee-for-service payments. Supplemental payments shall be paid in four installments within the state fiscal year.

(5) Supplemental payments made to cost-based providers will be excluded from the cost settlement process.

(6) Hospital payments made under this section, when combined with other payments made under the state plan shall not exceed the limit specified in 42 C.F.R. 447.321 .

(7) 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.

(C) Supplemental outpatient payments for public hospitals.

(1) Public hospitals as of October first of the year preceding payments shall be paid supplemental amounts for the provision of hospital outpatient services set forth in paragraph (C) of this rule. The supplemental amounts shall be in addition to any other amounts payable to hospitals with respect to those services.

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

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

(a) For each public hospital, total medicare outpatient costs are divided by the total outpatient medicare charges to establish the hospital-specific outpatient cost to charge ratio.

(b) For each public hospital, total Ohio medicaid outpatient charges are multiplied by the cost to charge ratio calculated in paragraph (C)(3)(a) of this rule to calculate Ohio medicaid outpatient costs.

(c) The outpatient hospital market basket update value of two point six per cent is applied to Ohio medicaid outpatient costs from paragraph (C)(2)(b) of this rule at a discounted rate for hospitals with fiscal year end prior to 2010 state fiscal year end June 30, 2010 plus for two years to determine the UPL for SFY 2012 and for a third year for SFY 2013. Ohio medicaid outpatient costs are additionally multiplied by one point zero one for the critical access hospitals.

(d) Ohio medicaid outpatient payments for SFY 2010 are then subtracted from the amounts determined in paragraph (C)(3)(c) of this rule to find the outpatient UPL gap. The sum of the differences for these public hospitals represents the total public hospital UPL gap.

(4) From the pool amount determined in paragraph (C)(3)(d) of this rule, up to $3,673,852 in both SFY 2012 and SFY 2013 shall be used to make supplemental payment to all public hospitals paid under the outpatient prospective payment system. Each hospital payment will be equal to the pool amount calculated in paragraph (C)(3)(d) of this rule multiplied by the hospital-specific ratio of each hospital's outpatient medicaid fee-for-service visits to the total medicaid outpatient fee-for-service visits for all public hospitals. Supplemental payments under this paragraph shall be paid semianually.

(5) From the pool amount calculated in paragraph (C)(3)(d) of this rule less payments made in paragraph (C)(4) of this rule, public hospitals with fewer than two hundred hospital beds shall receive a percentage increase applied to SFY 2010 outpatient medicaid fee-for-service payments. This percentage increase will be equal to the pool amount divided by the total small public non-state hospital SFY 2010 medicaid outpatient fee-for-service payments. Supplemental payments under this section shall be paid in four installments within the state fiscal year.

(6) Supplemental payments made to cost-based providers will be excluded from the cost settlement process.

(7) Hospital payments made under the state plan, when combined with other payments made under Chapter 5101:3-2 of the Administrative Code, shall not exceed the limit specified in 42 C.F.R. 447.321 .

(8) 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.

(D) Supplemental payments for private hospitals.

(1) All private hospitals as of October first of the year preceding payments shall be paid supplemental amounts for the provision of outpatient hospital services set forth in paragraph (D) of this rule. The supplemental amounts shall be in addition to any other amounts payable to hospitals with respect to those services.

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

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

(a) For each private hospital, total medicare outpatient costs are divided by the total outpatient medicare charges to establish the hospital-specific cost to charge ratio.

(b) For each private hospital, total Ohio medicaid outpatient charges are multiplied by the cost to charge ratio calculated in paragraph (D)(3)(a) of this rule to calculate Ohio medicaid outpatient costs.

(c) The outpatient hospital market basket update value of two point six per cent is applied to Ohio medicaid outpatient costs from paragraph (D)(3)(b) of this rule at a discounted rate for hospitals with fiscal year end prior to 2010 state fiscal year end June 30,2010 plus two years to determine the UPL for SFY 2012 and for a third year for SFY 2013. Ohio medicaid costs are additionally multiplied by a factor of one point zero one for the critical access hospitals.

(d) Ohio medicaid outpatient hospital payments for state fiscal year 2010 are then subtracted from the amounts determined in paragraph (D)(3)(d) of this rule to find the outpatient UPL gap. The sum of the differences for these private hospitals represents the total privately-owned outpatient UPL gap.

(4) From the pool amount determined in paragraph (D)(3)(d) of this rule, up to $11,806,618 in both SFY 2012 and SFY 2013, shall be made to all private hospitals paid under the outpatient prospective payment system, except children's hospitals as defined in paragraph (A)(1) of this rule. The payment will be equal to the pool amount multipled by the ratio of each private Ohio hospital paid under the outpatient prospective payment system outpatient medicaid fee-for-service visits to the total outpatient medicaid fee-for-service encounters for all Ohio private hospitals paid under the outpatient prospective payment system.

(5) From the pool amount calculated in paragraph (D)(3)(d) of this rule, less payments made in paragraph (D)(4) of this rule, private hospitals will be paid the following supplemental payments for the provision of hospital outpatient services. All private hospitals shall receive a percentage increase applied to total SFY 2010 medicaid outpatient fee-for-service payments. This percentage increase will be equal to the pool amount divided by total private hospital SFY 2010 medicaid outpatient fee-for-service payments.

(6) Supplemental payments in paragraph (D)(4) of this rule shall be paid semiannually and supplemental payments in paragraph (D)(5) of this rule shall be paid in four installments within the state fiscal year.

(7) Supplemental payments made to cost-based providers will be excluded from the settlement process.

(8) Hospital payments made under this paragraph, when combined with other payments made under the state plan shall not exceed the limit specified in 42 C.F.R. 447.321 .

(9) 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: 5101:3-2-54

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: 4/8/10