MEDICAID REIMBURSEMENT FOR INPATIENT HOSPITAL SERVICES

4800.1 Effective for inpatient hospital discharges occurring on or after the effective date of these rules, 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 Hospital, Hospital for Sick Children, and National Rehabilitation Hospital as described in Section 4810.1;
2. (b) Psychiatric hospitals as described in Sections 4810.2 and 4810.3;
3. (c) Hospitals located in Maryland as described in Section 4800.5; and
4. (d) Other out-of state hospitals as described in Section 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:

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

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 October 1,

2012, hospitals located within the State of Maryland shall be reimbursed a percentage of charges, except that:

(a) Adventist Behavioral Health (Potomac Ridge), Sheppard Pratt, and any other specialty psychiatric hospital shall be paid the lesser of the hospital's submitted charges or the rates paid to hospitals in Section 4810.3; and

(b) Adventist Rehabilitation Hospital and any other specialty rehabilitation hospital shall be paid the lesser of the hospital's submitted charges or the TEFRA Target Rate for National Rehabilitation Hospital as described in Section 4810.1.

4800.6 With the exception of the State of Maryland, out of state hospitals shall be reimbursed as a Diagnosis Related Group (DRG) payment. The DRG base rate for out of state hospitals shall be the weighted average of the base rates for hospitals in the Community Hospital peer group, as defined in Subsection 4801.1(b).

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); as amended by Final Rulemaking published at 59 DCR 15078 (December 28, 2012).