5101:3-2-53 Supplemental inpatient hospital payments for children's hospitals.

(A) "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.

(B) Notwithstanding paragraph (C)(5) of rule 5101:3-2-07.9 of the Administrative Code, children's hospitals will be paid for each cost outlier claim made in fiscal years 2012 and 2013, an amount that is the product of the hospital's allowable charges and the hospital's medicaid inpatient cost-to-charge ratio. The cost-to-charge ratio is based on the medicaid charges as reported on the hospital's medicaid cost report (JFS 02930, rev. 4/2010) and the costs attributable to medicaid as calculated based on the proportion of medicaid charges to total charges on the hospital's interim settled cost report as applied to the claim year.

(C) A children's hospital shall cease being paid for a cost outlier claim under the methodology described in paragraph (B) of this rule and revert to being paid for such a claim according to methodology in paragraph (A)(6) or paragraph (C)(5) of rule 5101:3-2-07.9 of the Administrative Code, as applicable, when the difference between the total amount paid according to the methodology described in paragraph (B) of this rule for such claims and the total amount the director would have paid according to the methodology in paragraph (A)(6) or paragraph (C)(5) of rule 5101:3-2-07.9 of the Administrative Code for such claims, as the applicable paragraph existed on June 30, 2007, does not require the expenditure of the total amount available as described in paragraph (E) of this rule for the applicable fiscal year.

(D) Payments shall be made under paragraph (E) of this rule, if the difference between the total amount the director has paid according to the methodology in paragraph (B) of this rule for cost outlier claims and the total amount the director would have paid in according to the methodology in paragraph (A)(6) or (C)(5) of rule 5101:3-2-07.9 of the Administrative Code for such claims, as the applicable paragraph existed on June 30, 2007, does not require the expenditure of the total amount available as described in paragraph (E) of this rule for the applicable fiscal year.

(E) Up to $28,642,247 in SFY 2012 and up to $27,540,622 in SFY 2013 shall be used to pay the amounts described in paragraph (B) of this rule.

(F) The source data for calculations described in paragraphs (B), (C), and (D) of this rule will be based on claims paid for outliers during the prior state fiscal year.

(G) Payments will be made to children's hospitals on an annual basis, based upon chlidren's hospitals' actual inpatient medicaid fee-for-service outliers derived from actual medicaid discharges paid during the prior state fiscal year and upon the difference between what each hospital would be paid according to the methodology described in paragraph (B) of this rule and the amount the hospital had been paid.

(H) If the supplemental payments to children's hospitals for inpatient outliers do not require the expenditure of the amount described in paragraph (E) of this rule for the supplemental outlier payments and available under the upper payment limit as described by paragraph (B) of this rule, the department would make additional supplemental payments to children's hospitals up to the lesser amount descibed in paragraph (E) of this rule or the amount descibed by paragraphs (B), (C), and (D) of this rule as follows: payments will be made to children's hospitals on an annual basis, based upon children's hospitals actual inpatient medicaid fee-for-service days derived from actual medicaid discharges paid during the prior twelve-month period. If the total funds that would be paid to all children's hospitals exceeds the aggregate upper payment limit for all hospitals, then the amount paid to all children's hospitals will be limited to their proportion of the aggregate upper payment limit.

(I) Hospital payments made under this rule shall not exceed the amount available as described in paragraph (E) of this rule for the applicable fiscal year nor, when combined with other payments made to private hospitals under the state plan, the limit specified in 42 C.F.R. 447.272 . If the total funds that would be paid to all children's hospitals exceeds either of those amounts, then the amount paid to each children's hospital would be its proportion of the lesser of: the amount described by paragraphs (B),(C) and (D) of this rule; or the amount described in pagaraph (E) of this rule. Each hospital's proportion would be equal to the difference between the total amount the director would pay according to the methodology described in paragraph (B) of this rule for such claims minus the total amount the director paid for such claims for that hospital divided by the sum of that amount for children's hospitals.

(J) 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. 447.271 .

(K) The total funds that will be paid to each children's 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: 5101:3-2-53

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 , Section 309.30.38 of Am. Sub. H.B. 153 of the 129th G.A.
Prior Effective Dates: 11/24/05, 4/18/08, 4/8/10