4800 MEDICAID REIMBURSEMENT FOR INPATIENT HOSPITAL SERVICES

4800.1 Effective September 21, 2002, Medicaid reimbursement for hospital inpatient services shall be on an All Patient Diagnosis-Related Group (APDRG) Prospective Payment System discharge basis for Children's Hospital National Medical Center, Columbia Hospital for Women, Howard University Hospital, George Washington University Hospital, Georgetown University Hospital, Greater Southeast Community Hospital, Providence Hospital, Washington Hospital Center and Sibley Hospital.

4800.2 Hospital inpatient services shall include inpatient hospital stays that last only one day, and services provided in Medicare-designated distinct-part psychiatric units.

4800.3 Services provided in Medicare-designated distinct-part rehabilitation units as described in 42 C.F.R. §412.23 shall be reimbursed on a per diem basis.

4800.4 Payment for each APDRG claim, excluding transfer claims as described in §4808.1, shall be based on the following formula:

APDRG Relative Weight for each Claim

Final Base Payment Rate

Add-On Payments for Capital and Graduate Medical Education

and Indirect Medical Education

Outlier Payment

4800.5 The APDRG Prospective Payment System shall be based on a base year payment rate for each hospital. The base year payment rate for each hospital shall be based on costs from each hospital's submitted Medicaid cost reports as follows:

(a) Adjusted, reported costs for hospital discharges on or after April 15, 1995, but before January 1, 1996, for each hospital with a fiscal year ending December 31, 1995; or

(b) Adjusted, reported costs for hospital discharges on or after July 1, 1995, but before July 1, 1996, for each hospital with a fiscal year ending June 30, 1996, that filed a Medicaid cost report for Fiscal Year 1996 by September 1, 1997.

4800.6 The Fiscal Year 1995 Medicaid cost report for each hospital with a fiscal year that ended June 30, 1996, that failed to file a cost report for Fiscal Year 1996 by September 1, 1997, shall be

used solely for the purpose of calculating add-ons to the base year payment rate.

4800.7 The Medicaid cost report for Sibley Hospital for the base year shall be used solely for the purpose of calculating add-one to the base year payment rate.

4800.8 The base year payment rate for each hospital that is reimbursed pursuant to APDRG methodology as of July 1, 1997, and that has filed its Fiscal Year 1996 Medicaid cost report by September 1, 1997, shall equal the Blended Average Cost Per Discharge (“Blended ACD”).

4800.9 The Blended ACD shall be equal to the average of the Hospital Specific Average Cost Per Discharge (“Hospital Specific ACD”), determined in accordance with §4801, and the District-wide Average Cost Per Discharge (“District-wide ACD”), determined in accordance with §4802.

4800.10 The base year payment rate for each hospital that failed to file their Fiscal year 1996 cost report by September 1, 1997, shall equal 100% of the District-wide ACD.

4800.11 The base year payment rate for Sibley Hospital shall equal 100% of the District-wide ACD.

4800.12 Beginning October 1, 2000, the base year payment rate for all hospitals subject to APDRG reimbursement methodology shall equal 100% of the District-wide ACD.

AUTHORITY: Unless otherwise noted, the authority for this chapter is D.C. Code, 2001 Ed. 1-307.02; Reorganization Plan No. 4 of 1996, 3 D.C. Code, 2001 Ed. at 413; and Mayor’s Order 97-42 (February 18, 1997).

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).