903.1 The Department shall pay for all outpatient and emergency room visits at a fixed rate based on each hospital's fiscal 1980 costs, as reflected in that hospital's cost report filed with the Office of Health Care Financing, plus nine percent (9%). The base rate shall be subject to adjustment when the audit of the 1980 cost report is completed.

903.2 The rate established under §903.1 shall be used for all visits occurring after September 17, 1982.

903.3 Outpatient and emergency room services rendered by a hospital prior to September 17, 1982, shall be reimbursed in accordance with the existing reimbursement method.

903.4 The Department shall negotiate a utilization "target" with each hospital for the twelve (12) month period beginning September 17, 1982. Utilization in excess of the target figure shall be paid for at a lower rate.

903.5 For the emergency room patient who is admitted to the hospital as an inpatient, the actual emergency room charges shall be added to the inpatient claim.

903.6 Each eligible hospital shall receive a supplemental hospital access payment calculated as set forth below:

(a) Except as provided in Subsection (c) and (e), for visits and services beginning May 1, 2013 and ending on September 30, 2014, additional quarterly access payments shall be made to each eligible hospital in an amount equal to each hospital's FY 2011 outpatient Medicaid payments divided by the total applicable hospital FY 2011 outpatient Medicaid payments multiplied by one quarter of the total outpatient private hospital access payment pool of $41,025,417 minus $250,000. The private hospital access payment pool shall be equal to the available spending room under the private hospital upper payment limit;

(b) Applicable hospital FY 2011 outpatient Medicaid payments shall include all outpatient Medicaid payments to Medicaid participating hospitals located within the District of Columbia except for the United Medical Center;

(c) In addition to the payment established in Subsection (a), all private children's hospitals with less than 150 beds located in the District of Columbia that participate in the Medicaid program shall receive an additional annual amount of $250,000 as an adjustment to the quarterly access payments;

(d) In no instance shall a Disproportionate Share Hospital (DSH) hospital receive more in quarterly access payments than the hospital-specific DSH limit, as adjusted by the District in accordance with the District's State Plan for Medical Assistance (State Plan). Any private hospital quarterly access payments that would otherwise exceed the adjusted hospital-specific DSH limit shall be distributed to other qualifying private hospitals based on each hospital's FY 2011 outpatient Medicaid payments relative to the total qualifying private hospital FY 2011 outpatient Medicaid payments;

(e) For visits and services beginning May 1, 2013, quarterly access payments shall be made to the United Medical Center. Each payment shall be equal to one quarter of the public hospital access payment pool amount of $1,259,557. The public hospital access payment pool shall be equal to the lesser of the available spending room under the public hospital upper payment limit and the hospital-specific DSH limit as adjusted by the District in accordance with the State Plan; and

(f) Payments shall be made 15 business days after the end of the quarter for the Medicaid visits and services rendered during that quarter.

903.99 Definitions

For purposes of this section, the following terms shall have the meanings ascribed.

Available spending room - The remaining room for outpatient hospital reimbursement that when combined with all other outpatient payments made under the District's Medicaid State plan shall not exceed the allowable federal outpatient hospital upper payment limit specified in 42 C.F.R. § 447.321.

Upper payment limit – The federal requirement limiting outpatient hospital Medicaid reimbursement to a reasonable estimate of the amount that would be paid for the services furnished by the group of facilities under Medicare payment principles consistent with 42 C.F.R. § 447.321.

Disproportionate Share Hospital – A hospital located in the District of Columbia that meets the qualifications established pursuant to Section 1923(b) of the Social Security Act (42 U.S.C. § 1396r–4).

Hospital-specific DSH limit - The federal requirement limiting hospital disproportionate share hospital (DSH) payments to the uncompensated care of providing inpatient and outpatient hospital services to Medicaid

and uninsured individuals, consistent with Section 8 of Attachment 4.19-A of the District’s federally approved Medicaid State plan.

Eligible Hospital – A hospital located in the District of Columbia that participates in the District of Columbia Medicaid program.

SOURCE: Final Rulemaking published at 29 DCR 4132 (September 17, 1982); as amended by Final Rulemaking published at 29 DCR 4551 (October 15, 1982); as amended by Final Rulemaking published at 61 DCR 2119 (March 14, 2014).