4800 MEDICAID REIMBURSEMENT FOR INPATIENT HOSPITAL SERVICES

4800.1 Effective for inpatient hospital discharges occurring on or after April 1, 2010, Medicaid reimbursement for inpatient hospital services shall be on an All Patient- Diagnosis Related Group (APDRG) prospective payment system discharge basis for all hospitals in the District of Columbia except:

1. (a) Washington Specialty-Hadley Memorial Hospital, Washington Specialty-Capitol Hill (MedLink) Hospital, and National Rehabilitation Hospital;
2. (b) Psychiatric hospitals; and
3. (c) Out-of-state hospitals other than hospitals located in Maryland as set forth in subsection 4800.6.

4800.2 Hospital inpatient services subject to the APDRG prospective payment system shall include inpatient hospital stays that last only one (1) day and services provided in Medicare-designated distinct-part psychiatric units and distinct-part rehabilitation units within those hospitals.

4800.3 Payment for each APDRG claim, excluding transfer claims as described in section 4809, shall be based on the following formula:

$$\frac{\begin{array}{c} \text{APDRG Service Intensity Weight for each claim} \ \times \ \text{Final Base Payment Rate} \ + \ \text{Add-on Payments for Capital and Graduate Medical} \ \text{Education Costs} \ + \ \text{Outlier Payment} \end{array}}$$

4800.4 The Department of Health Care Finance (DHCF) has adopted the APDRG classification system as contained in the 2009 APDRGs Definition Manual, Version 26 for purposes of calculating the rates set forth in this Chapter. Subsequent versions may be adopted after publication, if DHCF determines a substantial change has occurred.

4800.5 Effective for inpatient hospital discharges occurring on or after April 1,

2010, Medicaid reimbursement to out-of-state hospitals other than hospitals located in Maryland shall be the weighted average base rate of all hospitals in the Community Hospital and Major Teaching Hospital peer groups. Hospitals located in Maryland shall be reimbursed a percentage of charges.

SOURCE: Final Rulemaking published at 45 DCR 4141, 4142 (June 26, 1998); as amended by Final Rulemaking published at 46 DCR 8271, 8272 (October 15, 1999); as Final Rulemaking published at 49 DCR 8719 (September 20, 2002); as amended by Notice of Emergency and Proposed Rulemaking published at 57 DCR 2691 (March 26, 2010)[EXPIRED]; as amended by Notice of Emergency and Proposed Rulemaking published at 57 DCR 6837 (July 10, 2010)[EXPIRED]; as amended by Notice of Final Rulemaking published at 58 DCR 4323, 4324 (May 20, 2011).