10 CCR 2505-10
DEPARTMENT OF HEALTH CARE POLICY AND FINANCING Medical Services Board MEDICAL ASSISTANCE – SECTION 8.2000 10 CCR 2505-10 8.2000 [Editor’s Notes follow the text of the rules at the end of this CCR Document.] 8.2000: HOSPITAL PROVIDER FEE COLLECTION AND DISBURSEMENT PURPOSE: Subject to federal approval by the Centers for Medicare and Medicaid Services (CMS), the Colorado Health Care Affordability Act of 2009 (Act), C.R.S. 25.5-4-402.3, authorizes the Department of Health Care Policy and Financing (Department) to assess a hospital provider fee, pursuant to rules adopted by the State Medical Services Board, to generate additional federal Medicaid matching funds to improve reimbursement rates for inpatient and outpatient hospital services provided through Medicaid and the Colorado Indigent Care Program (CICP). In addition, the Act requires the Department to use the hospital provider fee to expand health coverage for parents of Medicaid eligible children, for children and pregnant women under the Child Health Plan Plus (CHP+), and for low-income adults without dependent children; to provide a Medicaid buy-in program for people with disabilities; to implement twelve month continuous eligibility for Medicaid eligible children; and to pay the Department’s administrative costs of implementing and administering the Act.
8.2001: DEFINITIONS “Act” means the Colorado Health Care Affordability Act, C.R.S. 25.5-4-402.3. “Bad Debt” means the unpaid dollar amount for services rendered from a patient or third party payer, for which the hospital expected payment, excluding Medicare bad debt. “Charity Care” means health care services resulting from a hospital’s policy to provide health care services free of charge, or where only partial payments are expected, (not to include contractual allowances for otherwise insured patients) to individuals who meet certain financial criteria. Charity Care does not include any health care services rendered under the CICP or those classified as Bad Debt. “Charity Care Day” means a day for a recipient of the hospital’s Charity Care. “Charity Care Write-Off Charges” means the hospital’s charges for Charity Care less payments from a primary payer, less any copayment due from the client, less any other third party payments “CICP” means the Colorado Indigent Care Program, as described in 10 CCR 2505-10, Section 8.900. “CICP Day” means a day for a recipient enrolled in the CICP. “CICP Write-Off Charges” means those charges reported to the Department by the hospital in accordance with 10 CCR 2505-10, Section 8.903.C.6.
“CMS” means the federal Centers for Medicare and Medicaid Services. “Cost-to-Charge Ratio” means the sum of the hospital’s total ancillary costs and physician costs divided by the sum of the hospital’s total ancillary charges and physician charges. “Critical Access Hospital” means a hospital qualified as a critical access hospital under 42 U.S.C. 1302 Section 1820(c) and certified as a critical access hospital by the Colorado Department of Public Health and Environment.
“DRG” means diagnosis related group, a cluster of similar conditions within a classification system used for hospital reimbursement. It reflects clinically cohesive groupings of inpatient hospitalizations that utilize similar amounts of hospital resources.
“DRG 801” means the DRG for neonates weighing less than 1,000 grams. “Essential Access Hospital” means a Critical Access Hospital or General Hospital located in a Rural Area with 25 or fewer licensed beds.
“Fund” means the hospital provider cash fund described in C.R.S. 25.5-4-402.3(4). “General Hospital” means a hospital licensed as a general hospital by the Colorado Department of Public Health and Environment.
“High Volume Medicaid and CICP Hospital” means a hospital with at least 35,000 Medicaid Days per year that provides over 30% of its total days to Medicaid and CICP clients. “HMO” means a health maintenance organization that provides health care insurance coverage to an individual.
“Hospital-Specific Disproportionate Share Hospital Limit” means a hospital’s maximum allowable Disproportionate Share Hospital payment eligible for Medicaid federal financial participation allowed under 42 U.S.C. 1302 Section 1102.
“Inpatient Services Fee” means an assessment on hospitals based on inpatient Managed Care Days and Non-Managed Care Days.
“Inpatient Upper Payment Limit” means the maximum amount that Medicaid can reimburse a provider for inpatient hospital services and still receive federal financial participation. “Long Term Care Hospital” means a General Hospital that is certified as a long term care hospital by the Colorado Department of Public Health and Environment.
“Managed Care Day” means a day listed as HMO or PPO Days on the hospital’s patient census. “Medicaid Day” means a Managed Care Day or Non-Managed Care Day for which the primary or secondary payer is Medicaid.
“Medicaid Fee-for-Service Day” means a Non-Managed Care Day for which Medicaid is the primary payer. For these days the hospital is reimbursed directly through the Department’s fiscal agent. “Medicaid Managed Care Day” means a Managed Care Day for which the primary payer is Medicaid. “Medicaid NICU Day” means a Medicaid Fee-for-Service Day in a hospital’s neo-natal intensive care unit, reimbursed under DRG 801, up to the average length of stay. “Medicaid Nursery Day” means a Managed Care Day or Non-Managed Care Day provided to Medicaid newborns while the mother is in the hospital.
“Medicaid Psychiatric Day” means a Managed Care Day or Non-Managed Care Day provided to a Medicaid recipient in the hospital’s sub-acute psychiatric unit. “Medicaid Rehabilitation Day” means a Managed Care Day or Non-Managed Care Day provided to a Medicaid recipient in the hospital’s sub-acute rehabilitation unit. “Medicare Fee-for-Service Day” means a Non-Managed Care Day for which Medicare is the primary payer and the hospital is reimbursed on the basis of a DRG. “Medicare HMO Day” means a Managed Care Day for which the primary payer is Medicare. “Medicare-Medicaid Dual Eligible Day” means a day for which the primary payer is Medicare and the secondary payer is Medicaid.
“Non-Managed Care Day” means a day for which the primary payer is an indemnity insurance plan or other insurance plan not serving as an HMO or PPO.
“Non-State-Owned Government Hospital” means a hospital that is either owned or operated by a local government.
“Other Payers Day” means a day where the primary payer is not Medicaid or Medicare, which is not a CICP Day, Charity Care Day, or Uninsured/Self Pay Day, and which is not a Managed Care Day. “Outpatient Services Fee” means an assessment on hospitals based on outpatient hospital charges “Outpatient Upper Payment Limit” means the maximum amount that Medicaid can reimburse a provider for outpatient hospital services and still receive federal financial participation. “Oversight and Advisory Board” means the hospital provider fee oversight and advisory board described in C.R.S. 25.5-4-402.3(6).
“Pediatric Specialty Hospital” means a hospital that provides care exclusively to pediatric populations. “PPO” means a preferred provider organization that is a type of managed care health plan. “Privately-owned Hospital” means a hospital that is privately owned and operated. “Psychiatric Hospitals” means a hospital licensed as a psychiatric hospital by the Colorado Department of Public Health and Environment.
“Rehabilitation Hospital” means an inpatient rehabilitation facility. “Rural Area” means a county outside a Metropolitan Statistical Area designated by the United States Office of Management and Budget.
“State-Owned Government Hospital” means a hospital that is either owned or operated by the State. “State Teaching Hospital” means a High Volume Medicaid and CICP Hospital which provides supervised teaching experiences to graduate medical school interns and residents enrolled in a state institution of higher education, and in which more than fifty percent (50%) of its credentialed physicians are members of the faculty at a state institution of higher education. “Third-Party Medicaid Day” means a day for which third party coverage, other than Medicare, is the primary payer and Medicaid is the secondary payer.
“Uncompensated CICP Costs” means CICP Write-Off Charges multiplied by the most recent provider specific audited Cost-to-Charge Ratio and inflated forward to the payment year. “Uncompensated Charity Care Costs” means Charity Care Write-Off Charges multiplied by the most recent provider specific audited Cost-to-Charge Ratio and inflated forward to the payment year. “Uninsured/Self Pay Day” means a day for self-pay patients and patients without third party health insurance coverage. Uninsured/Self Pay Day does not include Charity Care Days or CICP Days. “Uninsured/Self Pay Write Off Charges” means charges for self-pay patients and those with no third party coverage less adjustments for a hospital’s courtesy or uninsured or self-pay policy discounts. “Urban Center Safety Net Specialty Hospital” means a hospital located in a Metropolitan Statistical Area designated by the United States Office of Management and Budget where its Medicaid Days plus CICP Days relative to total days, rounded to the nearest percent, equals or exceeds 65%. 8.2002: Responsibilities of the Department and Hospitals 8.2002.A. Data Reporting 1. For purposes of calculating the Outpatient Services Fee, Inpatient Services Fee and the distribution of supplemental payments, the Department shall distribute a data survey to all hospitals by March 30 of each year. The Department shall include definitions and descriptions of each data element requested in the survey. Hospitals shall submit the data survey, as requested, to the Department by April 30 of each year. The Department may estimate any survey data element not provided directly by the hospital.
2. Hospitals shall submit the following data elements and any additional elements requested by the Department: (a) Managed Care Days, (b) Non-Managed Care Days, (c) Medicaid Fee-for-Service Days, (c) Medicaid Nursery Days, (e) Medicaid Managed Care Days, (f) Medicaid Psychiatric Days, (g) Medicaid Rehabilitation Days, (h) Medicare Non-Managed Care Days, (i) Medicare HMO Days, (j) CICP Days, (k) Charity Care Days, (l) Uninsured/Self-Pay Days, (m) Other Payers Days, (n) Total days reported on the patient census, (o) Charity Care Write-Off Charges, (p) Bad Debt, (q) Uninsured/Self Pay Write-Off Charges, (r) Medicare-Medicaid Dual Eligible Days, and
3. The Department shall distribute a data confirmation report to all hospitals annually. The data confirmation report shall include a listing of relevant data elements used by the Department in calculating the Outpatient Services Fee, the Inpatient Services Fee and the supplemental payments. The data confirmation report shall clearly state the manner and timeline in which hospitals may request revisions to the data elements recorded by the Department. Revisions to the data will not be permitted by a hospital after the dates outlined in the data confirmation report. 8.2002.B. Fee Assessment and Collection 1. Establishment of Electronic Funds Process. The Department shall utilize an Automated Clearing House (ACH) debit process to collect the Outpatient Services Fee and Inpatient Services Fee from hospitals and an Electronic Funds Transfer (EFT) payment process to deposit supplemental payments in financial accounts authorized by hospitals. The Department shall supply hospitals with all necessary information, authorization forms and instructions to implement this electronic process.
2. Fee Collection and Payment Disbursement. In state fiscal year (SFY) 2009-10 Outpatient Services Fee and Inpatient Services Fee (collectively referred to as “fee” ) will be assessed on an annual basis and collected in four installments on or about, April 16, 2010; April 30, 2010; May 14, 2010 and June 11, 2010.
3. Beginning in SFY 2010-11 the Outpatient Services Fee and Inpatient Services Fee will be assessed on an annual basis and collected in twelve monthly installments. Payments to hospitals will be calculated on an annual basis and disbursed in twelve monthly installments.
4. Payments to hospitals shall be processed by the Department within two business days of receipt of a warrant (paper check) or wire transfer to pay the Outpatient Services Fee and Inpatient Services Fee from hospitals that do not participate in the ACH debit process utilized by the Department. Payments through a warrant (paper check) will be processed by the Department within two business days of receipt of the Outpatient Services Fee or Inpatient Services Fee for those hospitals that do not participate in the EFT payment process utilized by the Department to deposit supplemental payments in financial accounts authorized by hospitals.
5. Electronic Funds Process Waiver. Hospitals not exempt from the Outpatient Services Fee and Inpatient Services Fee must participate in the electronic funds process utilized by the Department for the collection of fees and the disbursement of payments unless the Department has approved an alternative process. A hospital requesting to not participate in the electronic fee collection process and/or payment process must submit a request in writing or by electronic notice to the Department describing an alternative fee collection process and/or payment process. The Department shall approve or deny the alternative process in writing or by electronic notice within 30 calendar days of receipt of the request.
8.2003: Hospital Provider Fee 8.2003.A. Outpatient Services Fee 1. Federal requirements. The Outpatient Services Fee is subject to federal approval by CMS. The Department shall demonstrate to CMS, as necessary for federal financial participation, that the Outpatient Services Fee is in compliance with 42 U.S.C. 1302 Sections 1903(w), 1903(w)(3)(E), and 1903(w)(4).
2. Exempted hospitals. Psychiatric Hospitals, Long Term Care Hospitals and Rehabilitation Hospitals are exempted from the Outpatient Services Fee.
3. Calculation methodology. The Outpatient Services Fee is calculated on an annual basis as 0.535% of total hospital outpatient charges. High Volume Medicaid and CICP Hospitals’ Outpatient Services Fee is discounted by 0.84%.
8.2003.B. Inpatient Services Fee 1. Federal requirements. The Inpatient Services Fee is subject to federal approval by CMS. The Department shall demonstrate to CMS, as necessary for federal financial participation, that the Inpatient Services Fee is in compliance with 42 U.S.C. 1302 Sections 1903(w), 1903(w)(3)(E), and 1903(w)(4).
2. Exempted hospitals. Psychiatric Hospitals, Long Term Care Hospitals and Rehabilitation Hospitals are exempted from the Inpatient Services Fee.
3. Calculation methodology. The Inpatient Services Fee is calculated on an annual per inpatient day basis of $116.07 per day for Managed Care Days and $515.69 per day for all other Days as reported to the Department by each hospital by April 30 with the following exceptions:
1. The Department shall calculate the Inpatient Services Fee and Outpatient Services Fee under this section on an annual basis in accordance with the Act. Upon receiving a favorable recommendation by the Oversight and Advisory Board, the Inpatient Services Fee and Outpatient Services Fee shall be subject to approval by the CMS and the Medical Services Board. Following these approvals, the Department shall notify hospitals, in writing or by electronic notice, of the annual fee to be collected each year, the methodology to calculate such fee, and the fee assessment schedule. Hospitals shall be notified, in writing or by electronic notice, at least thirty calendar days prior to any change in the dollar amount of the Inpatient Services Fee and the Outpatient Services Fee to be assessed.
2. The Inpatient Services Fee and the Outpatient Services Fee will be assessed on the basis of the qualifications of the hospital in the year the fee is assessed as confirmed by the hospital in the data confirmation report. The Department will prorate and adjust the Inpatient Services Fee and Outpatient Services Fee for the expected volume of services for hospitals that open, close, relocate or merge during the payment year.
8.2003.D. Refund of Excess Fees 1. If, at any time, fees have been collected for which the intended expenditure has not received approval for federal Medicaid matching funds by CMS at the time of collection, the Department shall refund to each hospital its proportion of such fees paid within five business days of receipt. The Department shall notify each hospital of its refund amount in writing or by electronic notice. The refunds shall be paid to each hospital according to the process described in Section 8.2002.B.
2. After the close of each State fiscal year and no later than the following August 31, the Department shall present a summary of fees collected, expenditures made or encumbered, and interest earned in the Fund during the State fiscal year to the Oversight and Advisory Board.
8.2004: Supplemental Medicaid and Disproportionate Share Hospital Payments 8.2004.A. Conditions applicable to all supplemental payments 1. All supplemental payments are prospective payments subject to the Inpatient Upper Payment Limit and Outpatient Upper Payment Limit, calculated using historical data, with no reconciliation to actual data for the payment period. In the event that data entry or reporting errors, or other unforeseen payment calculation errors are realized after a supplemental payment has been made, reconciliations and adjustments to impacted hospital payments may be made retroactively, as determined by the Department.
2. No hospital shall receive a payment exceeding its Hospital-Specific Disproportionate Share Hospital Limit. If upon review, the CICP Disproportionate Share Hospital payment or the Uninsured Disproportionate Share Hospital payment exceeds the Hospital-Specific Disproportionate Share Hospital Limit for any qualified hospital, that hospital’s payment shall be reduced to the Hospital- Specific Disproportionate Share Hospital Limit retroactively. The amount of the retroactive reduction for the CICP Disproportionate Share Hospital payment shall be retroactively distributed to the other qualified hospitals in the category based on the qualified hospital’s proportion of Uncompensated CICP Costs, relative to the aggregate of Uncompensated CICP Costs of all qualified providers in the category which do not exceed their Hospital-Specific Disproportionate Share Hospital Limit. The amount of the retroactive reduction for the Uninsured Disproportionate Share Hospital payment shall be retroactively distributed to the other qualified hospitals in the category based on the qualified hospital’s proportion of Uncompensated Charity Care Costs relative to the aggregate of Uncompensated Charity Care Costs of all qualified providers in the category which do not exceed their Hospital-Specific Disproportionate Share Hospital Limit.
3. In order to receive a Supplemental Medicaid Payment or Disproportionate Share Hospital Payment, hospitals must meet the qualifications for the payment in the year the payment is received as confirmed by the hospital during the data confirmation report. Payments will be prorated and adjusted for the expected volume of services for hospitals that open, close, relocate or merge during the payment year.
8.2004.B. Outpatient Hospital Supplemental Medicaid Payment 1. Qualified hospitals. General Hospitals, Rehabilitation Hospitals and Critical Access Hospitals shall 2. Excluded hospitals. Psychiatric Hospitals and Long Term Care Hospitals shall not receive this 3. Calculation methodology for payment. Hospital-specific outpatient billed charges from the Colorado Medicaid Management Information System (MMIS) are multiplied by the hospital’s Medicare cost- to-charge ratio to arrive at hospital-specific outpatient billed costs. For each qualified hospital, the annual Outpatient Hospital Payment Supplemental Medicaid Payment equals hospital-specific outpatient billed costs, adjusted for utilization and inflation, multiplied by 31.50%. If the hospital qualifies as a Pediatric Specialty Hospital this payment equals hospital-specific outpatient billed costs, adjusted for utilization and inflation, multiplied by 27.45%. For State Teaching Hospitals, this payment equals hospital-specific outpatient billed costs, adjusted for utilization and inflation, multiplied by 25%.
8.2004.C. Outpatient High-Volume Small Rural Hospital Supplemental Medicaid Payment 1. Qualified hospitals. General Hospitals and Critical Access Hospitals located in a Rural Area, with 20 or fewer licensed beds, where at least 80% of total Medicaid payments are for outpatient hospital services shall receive this payment.
2. Excluded hospitals. Psychiatric Hospitals and Long Term Care Hospitals shall not receive this 3. Calculation methodology for payment. This payment shall equal 70% of inflated annual hospital- specific Medicaid outpatient billed costs.
8.2004.D. CICP Disproportionate Share Hospital Payment 1. Qualified hospitals. General Hospitals and Critical Access Hospitals that participate in the CICP shall 2. Excluded hospitals. Psychiatric Hospitals, Long Term Care Hospitals and Rehabilitation Hospitals shall not receive this payment.
3. Calculation methodology for payment. There will be three categories for qualified hospitals: State- Owned Government Hospitals, Non-State-Owned Government Hospitals, and Private-Owned Hospitals. State-Owned Government Hospitals shall receive 15.00% of the State’s annual Disproportionate Share Hospital Allotment, Non-State-Owned Government Hospitals shall receive 42.50% and Private-Owned Hospitals shall receive 22.50%. A qualified hospital’s annual payment shall equal its share of the percent of Uncompensated CICP Costs of all qualified hospitals in the category divided by the State’s annual Disproportionate Share Hospital allotment allocated to the category. 8.2004.E. Uninsured Disproportionate Share Hospital Payment 1. Qualified hospitals. General Hospitals and Critical Access Hospitals that report charges for services provided to low-income uninsured persons to the Department in a manner as prescribed by the Department shall receive this payment.
2. Excluded hospitals. Hospitals that participate in the CICP, Psychiatric Hospitals, Long Term Care Hospitals and Rehabilitation Hospitals shall not receive this payment.
3. Calculation methodology for payment. Twenty percent (20.00%) of the State’s annual Disproportionate Share Hospital allotment shall be allocated to the Uninsured Disproportionate Share Hospital Payment. A qualified hospital’s annual payment shall equal its share of the percent of Uncompensated Charity Care Costs of all qualified providers divided by the State’s annual Disproportionate Share Hospital allotment allocated to the Uninsured Disproportionate Share Hospital Payment.
8.2004.F. CICP Supplemental Medicaid Payment 1. Qualified hospitals. General Hospitals and Critical Access Hospitals that participate in the CICP shall 2. Excluded hospitals. Psychiatric Hospitals, Long Term Care Hospitals, Rehabilitation Hospitals and hospitals that do not participate in the CICP shall not receive this payment.
3. Calculation methodology for payment.
1. Qualified hospitals. General Hospitals, Rehabilitation Hospitals, Long Term Care Hospitals and Critical Access Hospitals with an established Medicaid inpatient base rate shall receive this payment.
2. Excluded hospitals. Psychiatric Hospitals shall not receive this payment.
3. Calculation methodology for payment. For each qualified hospital, this annual payment equals the hospital’s expected Medicaid discharges, multiplied by the hospital’s average Medicaid case mix, multiplied by the hospital’s Medicaid base rate with increases as follows:
1. Qualified hospitals. General Hospitals and Critical Access Hospitals certified level IIIb or IIIc neo-natal intensive care unit (NICU) shall receive this payment.
2. Excluded hospitals. Psychiatric Hospitals, Long Term Care Hospitals, Rehabilitation Hospitals, and High Volume Medicaid and CICP Hospitals shall not receive this payment.
3. Calculation methodology for payment. For each qualified hospital, this payment is calculated on an annual basis at $2,500 per Medicaid NICU Day.
8.2004.I. State Teaching Hospital Supplemental Medicaid Payment 1. Qualified hospitals. State Teaching Hospitals shall receive this payment.
2. Calculation methodology for payment. For each qualified hospital, this payment is calculated on an annual basis at $100 per Medicaid Day.
8.2004.J. Acute Care Psychiatric Supplemental Medicaid Payment 1. Qualified hospitals. General Hospitals with licensed distinct-part psychiatric units shall receive this 2. Excluded hospitals. Psychiatric Hospitals, Long Term Care Hospitals, and Rehabilitation Hospitals shall not receive this payment.
3. Calculation methodology for payment. For each qualified hospital, this payment is calculated on an annual basis at $200 per Medicaid Psychiatric Day.
8.2004.K. Large Rural Hospital Supplemental Medicaid Payment 1. Qualified hospitals. General Hospitals located in a Rural Area with 26 or more licensed beds shall 2. Calculation methodology for payment. For each qualified hospital, this payment is calculated on an annual basis at $750 per Medicaid Day.
8.2004.L. Denver Metro Supplemental Medicaid Payment 1. Qualified hospitals. General Hospitals located in Adams County, Arapahoe County, Boulder County, Broomfield County, Denver County, Jefferson County or Douglas County shall receive this 2. Excluded hospitals. Psychiatric Hospitals, Long Term Care Hospitals, Rehabilitation Hospitals, and High Volume Medicaid and CICP Hospitals shall not receive this payment.
3. Calculation methodology for payment.
8.2004.M. Metropolitan Statistical Area Supplemental Medicaid Payment 1. Qualified hospitals. General Hospitals located in El Paso County, Larimer County, Mesa County, Pueblo County or Weld County shall receive this payment.
2. Excluded hospitals. Psychiatric Hospitals, Long Term Care Hospitals, Rehabilitation Hospitals, and High Volume Medicaid and CICP Hospitals shall not receive this payment.
3. Calculation methodology for payment. For each qualified hospital this payment is calculated on an annual basis at $650 per Medicaid Day.
8.2004.N. Pediatric Specialty Hospital Provider Fee Payment 1. Qualified hospitals. Hospitals qualified to receive the Pediatric Major Teaching Hospital Payment in 10 CCR 2505-10 Section 8.903.C.6 shall receive this payment.
2. Calculation methodology for payment. For each qualified hospital, this payment is calculated on an annual basis and shall equal $2 million.
_______________________________________________________________________________ Editor’s Notes 10 CCR 2505-10 has been divided into smaller sections for ease of use. Versions prior to 3/4/07, Statements of Basis and Purpose, and rule history are located in the first section, 10 CCR 2505-10. Prior versions can be accessed from the History link that appears above the text in 10 CCR 2505-10. To view versions effective on or after 3/4/07, select the desired section of the rule, for example 10 CCR 2505-10 8.100, or 10 CCR 2505-10 8.500.
History [For history of this section, see Editor’s Notes in the first section, 10 CCR 2505-10]