PURPOSE: This rule establishes the legal basis for the administration of the state agency’s plan for reimbursement of covered inpatient hospital services in accordance with the principles and provisions described in this rule and also establishes the legal basis for the state agency’s methodology employed for reimbursement of covered outpatient hospital services.

PUBLISHER’S NOTE: The secretary of state has determined that the publication of the entire text of the material which is incorporated by reference as a portion of this rule would be unduly cumbersome or expensive. Therefore, the material which is so incorporated is on file with the agency who filed this rule, and with the Office of the Secretary of State. Any interested person may view this material at either agency’s headquarters or the same will be made available at the Office of the Secretary of State at a cost not to exceed actual cost of copy reproduction. The entire text of the rule is printed here. This note refers only to the incorporated by reference material.

1. (1) General Reimbursement Principles.

   1. (A) For inpatient hospital services provided for an individual entitled to Medicare Part A inpatient hospital benefits and eligible for Medicaid, reimbursement from the Missouri Medicaid Program will be available only when Medicaid’s applicable payment schedule amount exceeds the amount paid by Medicare. Medicaid’s payment will be limited to the lower of the deductible and coinsurance amounts or the amount the Medicaid applicable payment schedule amount exceeds the Medicare payments. For all other Medicaid recipients, unless otherwise limited by rule, reimbursement will be based solely on the individual recipient’s days of care (within benefit limitations) multiplied by the individual hospital’s Title XIX per-diem rate. As described in paragraph (5)(D)2. of this rule, as part of each hospital’s fiscal year-end cost settlement determination, a comparison of total Medicaid-covered aggregate charges and total Medicaid payments will be made and any hospital whose aggregate Medicaid per-diem payments exceed aggregate Medicaid charges will be subject to a retroactive adjustment.
   2. (B) The Title XIX reimbursement for hospitals located outside Missouri and for federally-operated hospitals in Missouri will be determined as stated in section (14) of this plan.

   3. (C) The Title XIX reimbursement for hospitals, excluding those located outside Missouri and in-state federal hospitals, shall include per-diem payments, outpatient payments, disproportionate share payments; various Medicaid Add-On payments, as described in this rule; or a safety net adjustment, paid in lieu of Direct Medicaid Payments described in section (15) and Uninsured Add-Ons described in subsections (18)(B). Reimbursement shall be subject to availability of federal financial participation (FFP).

      1. 1. Per-diem reimbursement—The per-

diem rate is established in accordance with section (3).

1. 2. Outpatient reimbursement is de-

scribed in section (13).

1. 3. Disproportionate share reimburse-

ment—The disproportionate share payments described in section (16), and subsection (18)(B) include both the federally mandated reimbursement for hospitals which meet the federal requirements listed in section (6) and the discretionary disproportionate share payments which are allowable but not mandated under federal regulation. A Safety Net Adjustment, section (16), and Uninsured Add-Ons, subsection (18)(B), are subject to federal limitation described in Omnibus Reconciliation Act of 1993 (OBRA 93) and section (17) of this regulation.

1. 4. Medicaid Add-Ons—Medicaid Add-

Ons are described in sections (15), (19) and (21) and are in addition to Medicaid per-diem payments. These payments are subject to the federal Medicare Upper Limit test.

1. 5. Safety Net Adjustment—The pay-

ments described in subsection (16)(A) are paid in lieu of Direct Medicaid Payments described in section (15) and Uninsured Add- Ons described in subsection (18)(B).

1. (2) Definitions.

   1. (A) Allowable costs. Allowable costs are those related to covered Medicaid services defined as allowable in 42 CFR chapter IV, part 413, except as specifically excluded or restricted in 13 CSR 70-15.010 or the Missouri Medicaid hospital provider manual and detailed on the desk-reviewed Medicaid cost report. Penalties or incentive payments as a result of Medicare target rate calculations shall not be considered allowable costs. Implicit in any definition of allowable cost is 13 CSR 70-15

that this cost is allowable only to the extent that it relates to patient care; is reasonable, ordinary and necessary; and is not in excess of what a prudent and cost-conscious buyer pays for the given service or item.

1. (B) Bad debt. Bad debts should include the costs of caring for patients who have insurance but are not covered for the particular services, procedures or treatment rendered. Bad debts should not include the cost of caring for patients whose insurance covers the given procedures but limits coverage. In addition, bad debts should not include the cost of caring for patients whose insurance covers the procedure although the total payments to the hospital are less than the actual cost of providing care.
2. (C) Base cost report. Desk-reviewed Medicare/Medicaid cost report. When a facility has more than one (1) cost report with periods ending in the fourth prior calendar year, the cost report covering a full twelve (12)- month period will be used. If none of the cost reports covers a full twelve (12) months, the cost report with the latest period will be used. If a hospital’s base cost report is less than or greater than a twelve (12)-month period, the data shall be adjusted, based on the number of months reflected in the base cost report to a twelve (12)-month period.
3. (D) Charity care. Results from a provider’s policy to provide health care services free of charge or a reduction in charges because of the indigence or medical indigence of the patient.
4. (E) Contractual allowances. Difference between established rates for covered services and the amount paid by third-party payers under contractual agreements.
5. (F) Cost report. A cost report details, for purposes of both Medicare and Medicaid reimbursement, the cost of rendering covered services for the fiscal reporting period. The Medicare/Medicaid Uniform Cost Report contains the forms utilized in filing the cost report.
6. (G) Critical access. Hospitals which meet the federal definition found in section 1820(c)(2)(B) of the Social Security Act. A Missouri expanded definition of critical access shall also include hospitals which meet the federal definitions of both a rural referral center and sole community provider and is adjacent to at least one county that has a Medicaid eligible population of at least thirty percent (30%) of the total population of the county or hospitals which are the sole community hospital located in a county that has a Medicaid population of at least thirty percent (30%) of the total population of the county.
7. (H) Disproportionate share reimbursement. The disproportionate share payments described in section (16), and subsection (18)(B) include both the federally mandated reimbursement for hospitals which meet the federal requirements listed in section (6) and the discretionary disproportionate share payments which are allowed but not mandated under federal regulation. A Safety Net Adjustment, section (16), and Uninsured Add-Ons, subsection (18)(B), are subject to federal limitation as described in Omnibus Reconciliation Act of 1993 (OBRA 93) and section (17) of this regulation.

8. (I) Effective date.

   1. 1. The plan effective date shall be Octo-

ber 1, 1981.

1. 2. The adjustment effective date shall be

thirty (30) days after notification to the hospital that its reimbursement rate has been changed unless modified by other sections of the plan.

1. (J) Medicare rate. The Medicare rate is the rate established on the basis of allowable cost as defined by applicable Medicare standards and principles of reimbursement (42 CFR part 405) as determined by the servicing fiscal intermediary based on yearly hospital cost reports.

2. (K) Nonreimbursable items. For purposes of reimbursement of reasonable cost, the following are not subject to reimbursement:

   1. 1. Allowances for return on equity capi-

tal;

1. 2. Amounts representing growth allow-

ances in excess of the intensity allowance, profits, efficiency bonuses, or a combination of these;

1. 3. Cost in excess of the principal of

reimbursement specified in 42 CFR chapter IV, part 413; and

1. 4. Costs or services or costs and ser-

vices specifically excluded or restricted in this plan or the Medicaid hospital provider manual.

1. (L) Per-diem rates. The per-diem rates shall be determined from the individual hospital cost report in accordance with section

1. (3) of the regulation.

   1. (M) Reasonable cost. The reasonable cost of inpatient hospital services is an individual hospital’s Medicaid per-diem cost per day as determined in accordance with the general plan rate calculation from section (3) of this regulation using the base year cost report.
   2. (N) Trend factor. The trend factor is a measure of the change in costs of goods and services purchased by a hospital during the course of one (1) year.
   3. (O) Children’s hospital. An acute care hospital operated primarily for the care and treatment of children under the age of eighteen

2. (18) and which has designed in its licensure application at least sixty-five percent (65%) of its total licensed beds as a pediatric unit as defined in 19 CSR 30-20.021(4)(F).

   1. (P) FRA. The Federal Reimbursement Allowance (FRA) is identified in 13 CSR 70- 15.110. Effective January 1, 1999, the assessment shall be an allowable cost.

   2. (Q) Incorporates by Reference. This rule incorporates by reference the following:

      1. 1. Institutional Provider Manual; and
      2. 2. Worksheet E-3 Part IV from the

Medicare cost report (HCFA 2552-96).

1. (3) Per-Diem Reimbursement Rate Computation. Each hospital shall receive a Medicaid per-diem rate based on the following computation.

   1. (A) The per-diem rate shall be determined from the 1995 base year cost report in accordance with the following formula:

      (OC * TI) CMC

   Per Diem= + MPD MPDC

   1. 1. OC—The operating component is the

hospital’s total allowable cost (TAC) less CMC;

1. 2. CMC—The capital and medical edu-

cation component of the hospital’s TAC;

1. 3. MPD—Medicaid inpatient days;
2. 4. MPDC-MPD—Medicaid patient days

for capital costs as defined in paragraph (3)(A)3. with a minimum utilization of sixty percent (60%) as described in paragraph (5)(C)4.;

1. 5. TI—Trend indices. The trend indices

are applied to the OC of the per-diem rate. The trend indices for SFY 1995 is used to adjust the OC to a common fiscal year end of June 30;

1. 6. TAC—Allowable inpatient routine and

special care unit expenses, ancillary expenses and graduate medical education costs will be added to determine the hospital’s total allowable cost (TAC);

1. 7. The per diem shall not exceed the

average Medicaid inpatient charge per diem as determined from the base year cost report and adjusted by the TI; and

1. 8. The per diem shall be adjusted for

rate increases granted in accordance with subsection (5)(F) for allowable costs not included in the base year cost report.

1. (B) Trend Indices (TI). Trend indices are determined based on the four (4)-quarter average DRI Index for DRI-Type Hospital Market Basket as published in Health Care Costs by DRI/McGraw-Hill for each State Fiscal Year (SFY) 1995 to 1998. Trend indices starting in SFY 1999 will be determined based on CPI Hospital indexed as published in Health Care Costs by DRI/McGraw-Hill for each State Fiscal Year (SFY).

   1. 1. The TI are—

      1. A. SFY 1994—4.6%
      2. B. SFY 1995—4.45%
      3. C. SFY 1996—4.575%
      4. D. SFY 1997—4.05%
      5. E. SFY 1998—3.1%
      6. F. SFY 1999—3.8%
      7. G. SFY 2000—4.0%
      8. H. SFY 2001—4.6%
      9. I. SFY 2002—4.8%.
   2. 2. The TI for SFY 1996 through SFY

1998 are applied as a full percentage to the OC of the per-diem rate and for SFY 1999 the OC of the June 30, 1998 rate shall be tended by 1.2% and for SFY 2000 the OC of the June 30, 1999 rate shall be tended by 2.4%. The OC of the June 30, 2000 rate shall be tended by 1.95% for SFY 2001.

1. 3. The per-diem rate shall be reduced as

necessary to avoid any negative Direct Medicaid Payments computed in accordance with subsection (15)(B).

1. (4) Per-Diem Rate—New Hospitals.

   1. (A) Facilities Reimbursed by Medicare on a Per-Diem Basis. In the absence of adequate cost data, a new facility’s Medicaid rate may be its most current Medicare rate on file for two (2) fiscal years following the facility’s initial fiscal year as a new facility. The Medicaid rate for this third fiscal year will be the lower of the most current Medicare rate on file by review date or the facility’s Medicaid rate for its second fiscal year indexed forward by the inflation index for the current fiscal year. The Medicaid rate for the facility’s fourth fiscal year will be determined in accordance with sections (1)–(3) of this plan.
   2. (B) Facilities Reimbursed by Medicare on a Diagnosis Related Grouping (DRG) Basis. In the absence of adequate cost data, a new facility’s Medicaid rate may be one hundred twenty percent (120%) of the average-weighted, statewide per-diem rate for two (2) fiscal years following the facility’s initial fiscal year as a new facility. The Medicaid rate for the third fiscal year will be the facility’s Medicaid rate for its second fiscal year indexed forward by the inflation index for the current fiscal year. The Medicaid rate for the facility’s fourth fiscal year will be determined in accordance with sections (1)–(3) of this plan.

2. (5) Administrative Actions.

   1. (A) Cost Reports.

      1. 1. Each hospital participating in the

Missouri Medical Assistance Program shall submit a cost report in the manner prescribed by the state Medicaid agency. The cost report shall be submitted within five (5) calendar months after the close of the reporting period. The period of a cost report is defined in 42 CFR 413.24(f). A single extension, not to exceed thirty (30) days, may be granted upon the request of the hospital and the approval of the Missouri Division of Medical Services when the provider’s operation is significantly affected due to extraordinary circumstances over which the provider had no control such as fire or flood. The request must be in writing and postmarked prior to the first day of the sixth month following the hospital’s fiscal year end.

1. 2. The termination of or by a hospital of

participation in the program requires that the hospital submit a cost report for the period ending with the date of termination within five (5) calendar months after the close of the reporting period. No extensions in the submitting of cost reports shall be allowed when a termination of participation has occurred. The payments due the hospital shall be withheld until the cost report for the final reporting period is filed with the Division of Medical Services.

1. 3. All cost reports shall be submitted

and certified by an officer or administrator of the provider. Failure to file a cost report, within the period prescribed in this subsection, may result in the impositions of sanctions as described in 13 CSR 70-3.030.

1. 4. Amended cost reports or other sup-

plemental. The division will notify hospital by letter when the desk review of its cost report is completed. Since, this data may be used in the calculation of per-diem rates, direct payments, tended costs or uninsured add-on payments, the hospital shall review the desk review data and the schedule of key data elements and submit amended or corrected data to the division within fifteen (15) days. Data received after the fifteen (15)-day deadline will not be considered by the division for per-diem rates, direct payments, tended costs or uninsured payments unless the hospital requests in writing and receives an extension to file additional information prior to the end of the fifteen (15)-day deadline.

1. (B) Records.

   1. 1. All hospitals are required to maintain

financial and statistical records in accordance with 42 CFR 413.20. For purposes of this plan, statistical and financial records shall include beneficiaries’ medical records and patient claim logs separated for inpatient and outpatient services billed to and paid for by Missouri Medicaid (excluding cross-over claims) respectively. Separate logs for inpatient and outpatient services should be maintained for Medicaid recipients covered by managed care (MC+). All records must be available upon request to representatives, employees or contractors of the Missouri Medical Assistance Program, Missouri Department of Social Services, General Accounting Office (GAO) or the United States Department of Health and Human Services (HHS). The content and organization of the inpatient and outpatient logs shall include the following:

1. A. A separate Medicaid log for each

fiscal year must be maintained by either date of service or date of payment by Medicaid for claims and all adjustments of those claims for services provided in the fiscal period. Lengths of stay covering two (2) fiscal periods should be recorded by date of admission. The information from the Medicaid log should be used to complete the Medicaid worksheet in the hospital’s cost report;

1. B. Data required to be recorded in

logs for each claim include:

1. (I) Recipient name and Medicaid

number;

1. (II) Dates of service;
2. (III) If inpatient claim, number of

days paid for by Medicaid, classified by adults and peds, each subproviders, newborn or specific type of intensive care;

1. (IV) Charges for paid inpatient days

and inpatient ancillary charges for paid days classified by cost center as reported in the cost report or allowed outpatient services, classified by cost center as reported on cost report;

1. (V) Noncovered charges combined

under a separate heading;

1. (VI) Total charges;
2. (VII) Any partial payment made by

third-party payers (claims paid equal to or in excess of Medicaid payment rates by thirdparty payers shall not be included in the log); (VIII) Medicaid payment received or the adjustment taken; and

1. (IX) Date of remittance advice

upon which paid claim or adjustment appeared;

1. C. A year-to-date total must appear at

the bottom of each log page or after each applicable group total or a summation page of all subtotals for the fiscal year activity must be included with the log; and

1. D. Not to be included in the outpa-

tient log are claims or line item outpatient charges denied by Medicaid or claims or charges paid from an established Medicaid fee schedule. This would include payments for General Relief (GR) recipients, payments for hospital-based physicians and certified registered nurse anesthetists billed by the hospital on a professional services claim, 13 CSR 70-15

payments for certain specified clinical diagnostic laboratory services, or payments for services provided by the hospital through enrollment as a Medicaid provider-type other than hospital outpatient.

1. 2. Records of related organizations, as

defined by 42 CFR 413.17, must be available upon demand to those individuals or organizations as listed in paragraph (5)(B)1. of this rule.

1. 3. The Missouri Division of Medical

Services shall retain all uniform cost reports submitted for a period of at least three (3) years following the date of submission of the reports and will maintain those reports pursuant to the record keeping requirements of 42 CFR 413.20. If an audit by, or on behalf of, the state or federal government has begun but is not completed at the end of the three (3)-year period, or if audit findings have not been resolved at the end of the three (3)-year period, the reports shall be retained until resolution of the audit findings.

1. 4. The Missouri Division of Medical

Services shall maintain any responses received on this plan, subsequent changes to this plan and rates for a period of three (3) years from the date of receipt.

1. (C) New, Expanded or Terminated Services.

   1. 1. A hospital, at times, may offer to the

public new or expanded services for the provision of allowable inpatient services which require Certificate of Need (CON) approval or permanently terminate a service. For a state hospital, i.e., one owned or operated by the board of curators as provided for in Chapter 172, RSMo, or one owned or operated by the Department of Mental Health, the state hospital may offer new or expanded inpatient services to the public provided it receives legislative appropriations for the project and the project meets the CON costs threshold. Within six (6) months after this event, the hospital must submit a request for rate reconsideration with a budget which shall take into consideration new, expanded or terminated services. Since a state hospital is not subject to the CON approval process, a state hospital will have six (6) months after the effective date of this amendment to file a budget for CON type projects completed after its base year cost report and will then have six (6) months after the completion of the new or expanded service is offered to the public. The budgets will be subject to desk review and audit. Upon completion of the desk review, reimbursement rates may be adjusted, if indicated. Failure to submit a request for rate reconsideration and budget within the six (6)-month period shall disqualify the hospital from receiving a rate increase. Failure to submit a request shall not prohibit the division from reducing the rate in the case of a terminated service.

1. 2. Failure to submit a budget concerning

terminated services may result in the imposition of sanctions as described in 13 CSR 70- 3.030.

1. 3. Rate adjustments due to new or

expanded services will be determined as total allowable project cost (i.e., the sum of annual depreciation, annualized interest expense and annual additional operating costs) multiplied by the ratio of total inpatient costs (less swing bed cost) to total hospital cost as submitted on the most recent cost report filed with the agency as of the review date divided by total acute care patient days including all special care units and nursery, but excluding swing bed days.

1. 4. Total acute care patient days (exclud-

ing nursery and swing bed days) must be at least sixty percent (60%) of total possible bed days. Total possible bed days will be determined using the number of licensed beds times three hundred sixty-five (365) days. If the days, including neonatal units, are less than sixty percent (60%), the sixty percent (60%) number plus newborn days will be used to determine the rate increase. This computation will apply to capital costs only.

1. (D) Audits.

   1. 1. A comprehensive hospital audit pro-

gram shall be established in cooperation with the Missouri Medicare fiscal intermediary. Under the terms of the Common Audit Agreement, the Medicare intermediary shall perform the following:

1. A. Desk review all hospital cost

reports;

1. B. Determine the scope and format

for on-site audits;

1. C. Perform field audits when indicat-

ed in accordance with Title XIX principles; and

1. D. Submit to the state agency the final

Title XVIII cost report with respect to each provider.

1. 2. The state agency shall review audited

Medicaid-Medicare cost reports for each hospital’s fiscal year in accordance with 13 CSR 70-15.040.

1. (E) Adjustments to Rates. The prospectively determined individual hospital’s reimbursement rate may be adjusted only under the following circumstances:

   1. 1. When information contained in the

cost report is found to be intentionally misrepresented. The adjustment shall be made retroactive to the date of the original rate. This adjustment shall not preclude the Medicaid agency from imposing any sanctions authorized by any statute or rule;

1. 2. When rate reconsideration is granted

in accordance with subsection (5)(F);

1. 3. When the Medicare per-diem rate is

changed by the servicing fiscal intermediary based on a new audit finding for the base year. This adjustment may be applied and effective no earlier than the first day of the month following notification by the Division of Medical Services; or

1. 4. When a hospital documents to the

Division of Medical Services a change in its status from nonprofit to proprietary, or from proprietary to nonprofit, its direct Medicaid payments for the state fiscal year will be adjusted to take into account any change in its Medicaid inpatient allowable costs due to the change in its property taxes. The Medicaid share of the change in property taxes will be calculated for the state fiscal year in which the change is reported by multiplying the increase or decrease in property taxes applicable to the current state fiscal year by the ratio of allowable Medicaid inpatient hospital costs to total costs of the facility. (For example, if the property taxes are assessed starting January 1 for the calendar year, then one-half (1/2) of the calendar year property taxes will be used to calculate the additional inpatient direct Medicaid payments for the period of January 1 to June 30.)

1. (F) Rate Reconsideration.

   1. 1. Rate reconsideration may be request-

ed under this subsection for changes in allowable cost which occur subsequent to the base period described in subsection (3)(A). The effective date for any increase granted under this subsection shall be no earlier than the first day of the month following the Division of Medical Services’ final determination on rate reconsideration.

1. 2. The following may be subject to

review under procedures established by the Medicaid agency:

1. A. Substantial changes in or costs due

to case mix;

1. B. New, expanded or terminated ser-

vices as detailed in subsection (5)(C);

1. C. When the hospital experiences

extraordinary circumstances which may include, but are not limited to, an act of God, war or civil disturbance; and

1. D. Per-diem rate adjustments for crit-

ical access and trauma center hospitals.

1. (I) Critical access hospitals meeting

either the federal definition or the Missouri expanded definition may request per-diem rate adjustments in accordance with this subsection. The per-diem rate increase will result in a corresponding reduction in the Medicaid direct payment.

1. (a) Hospitals which meet the

federal definition as a critical access hospital may request a per-diem rate equal to one hundred percent (100%) of their estimated Medicaid cost per day as determined in section (15).

1. (b) Hospitals which meet the

Missouri expanded definition as a critical access hospital may request a per-diem rate equal to seventy-five percent (75%) of their estimated Medicaid cost per day as determined in section (15).

1. 3. The following will not be subject to

review under these procedures:

1. A. The use of Medicare standards and

reimbursement principles;

1. B. The method for determining the

trend factor;

1. C. The use of all-inclusive prospec-

tive reimbursement rates; and

1. D. Increased costs for the successor

owner, management or leaseholder that result from changes in ownership, management, control, operation or leasehold interests by whatever form for any hospital previously certified at any time for participation in the Medicaid program, except a review may be conducted when a hospital changes from nonprofit to proprietary or vice versa to recognize the change in its property taxes, see paragraph (5)(E)4.

1. 4. As a condition of review, the Missouri

Division of Medical Services may require the hospital to submit to a comprehensive operational review. The review will be made at the discretion of the state Medicaid agency and may be performed by it or its designee. The findings from any such review may be used to recalculate allowable costs for the hospital.

1. 5. The request for an adjustment must

be submitted in writing to the Missouri Division of Medical Services and must specifically and clearly identify the issue and the total dollar amount involved. The total dollar amount must be supported by generally acceptable accounting principles. The hospital shall demonstrate the adjustment is necessary, proper and consistent with efficient and economical delivery of covered patient care services. The hospital will be notified in writing of the agency’s decision within sixty (60) days of receipt of the hospital’s written request or within sixty (60) days of receipt of any additional documentation or clarification which may be required, whichever is later. Failure to submit requested information within the sixty (60)-day period shall be grounds for denial of the request. If the state does not respond within the sixty (60)-day period, the request shall be deemed denied.

1. (G) Sanctions. Sanctions may be imposed against a provider in accordance with 13 CSR 70-3.030 and other applicable state and federal regulations.

1. (6) Disproportionate Share.

   1. (A) Inpatient hospital providers may qualify as a Disproportionate Share Hospital

2. (DSH) based on the following criteria. Hospitals shall qualify as Disproportionate Share Hospitals for a period of only one (1) state fiscal year and must requalify at the beginning of each state fiscal year to continue their disproportionate share classification—

   1. 1. If the facility offered nonemergency

obstetric services as of December 21, 1987, there must be at least two (2) obstetricians with staff privileges at the hospital who have agreed to provide obstetric services to individuals entitled to these services under the Missouri Medicaid plan. In the case of a hospital located in a rural area (area outside of a metropolitan statistical area, as defined by the federal Executive Office of Management and Budget), the term obstetrician includes any physician with staff privileges at the hospital to perform nonemergency obstetric procedures. This section does not apply to hospitals either with inpatients predominantly under eighteen (18) years of age or which did not offer nonemergency obstetric services as of December 21, 1987;

1. 2. As determined from the fourth prior

year desk-reviewed cost report, the facility must have either—

1. A. A Medicaid inpatient utilization

rate (MIUR) at least one (1) standard deviation above the state’s mean MIUR for all Missouri hospitals. The MIUR will be expressed as the ratio of total Medicaid days (TMD) provided under a state plan divided by the provider’s total number of inpatient days (TNID). The state’s mean MIUR will be expressed as the ratio of the sum of the total number of the Medicaid days for all Missouri hospitals divided by the sum of the total patient days for the same Missouri hospitals. Data for hospitals no longer participating in the program will be excluded;

TMD

MIUR = TNID

or

1. B. A low-income utilization rate

(LIUR) in excess of twenty-five percent (25%). The LIUR shall be the sum (expressed as a percentage) of the fractions, calculated as follows:

1. (I) Total Medicaid patient revenues

(TMPR) paid to the hospital for patient services under a state plan plus the amount of the cash subsidies (CS) directly received from state and local governments, divided by the total net revenues (TNR) (charges, minus contractual allowances, discounts and the like) for patient services plus the CS; and

1. (II) The total amount of the hospi-

tal’s charges for patient services attributable to charity care (CC) (care provided to individuals who have no source of payment, third-party or personal resources) less CS directly received from state and local governments in the same period, divided by the total amount of the hospital’s charges (THC) for patient services. The total patient charges attributed to CC shall not include any contractual allowances and discounts other than for indigent patients not eligible for medical assistance under a state plan;

TMPR + CS CC - CS

LIUR = + TNR + CS THC

1. 3. As determined from the fourth prior

year desk-reviewed cost report, the hospital—

1. A. Has an unsponsored care ratio of

at least ten percent (10%). The unsponsored care ratio is determined as the sum of bad debts and CC divided by TNR and also meets either of the criteria in paragraph (6)(A)2.; or

1. B. Ranks in the top fifteen (15) in the

number of Medicaid inpatient days provided by that hospital compared to Medicaid patient days provided by all hospitals, and the hospitals also have a Medicaid nursery utilization ratio greater than thirty-five percent (35%) as computed by dividing Title XIX nursery and neonatal days by total nursery and neonatal days; or

1. C. Operated a neonatal intensive care

unit with a ratio of Missouri Medicaid neonatal patient days to Missouri Medicaid total patient days in excess of nine percent (9%) reported or verified by the division from the fourth prior year cost report;

1. 4. As determined from the fourth prior

year desk-reviewed cost report—

1. A. The acute care hospital has an

unsponsored care ratio of at least sixty-five percent and is licensed for less than fifty inpatient beds; or

1. B. The acute care hospital has an

unsponsored care ratio of at least sixty-five percent (65%) and is licensed for fifty inpatient beds or more and has an occupancy rate of more than forty percent (40%); or

1. C. The hospital is owned or operated

by the Board of Curators as defined in Chapter 172, RSMo and the Missouri Rehabilitation Center created by Chapter 199, RSMo or their successors; or

1. D. The hospital is a public hospital

operated by the Department of Mental Health primarily for the care and treatment of mental disorders; and 13 CSR 70-15

1. 5. As determined from the fourth prior

year desk-reviewed cost report, hospitals which annually provide more than five thousand (5,000) Title XIX days of care and whose Title XIX nursery days represent more than fifty percent (50%) of the hospital’s total nursery days.

1. (B) Those hospitals which meet the criteria established in paragraphs (6)(A)1., (6)(A)2. and (6)(A)4. shall be deemed safety net hospitals. Those hospitals which meet the criteria established in (6)(A)1. and (6)(A)3. shall be deemed first tier Disproportionate Share Hospitals (DSH). Those hospitals which meet only the criteria established in paragraphs (6)(A)1. and (6)(A)2. or (6)(A)1. and (6)(A)5. shall be deemed second tier DSH.
2. (C) A hospital not meeting the requirements in subsection (6)(A), but has a Medicaid inpatient utilization percentage of at least one percent (1%) for Medicaid-eligible recipients may at the option of the state be deemed a Disproportionate Share Hospital (DSH). These facilities may receive only the DSH payments identified in section (18).
3. (D) Hospitals shall not send amended cost reports or other data necessary for qualification for disproportionate share classification for purposes of rate reconsideration unless the reports or other necessary data are received within sixty (60) days of the date of the division’s notification of the final determination of the rate.

1. (7) Outlier Adjustment.

   1. (A) Effective for admissions beginning on or after July 1, 1991, outlier adjustments for medically necessary inpatient services involving exceptionally high cost or exceptionally long lengths of stay for Missouri Medicaid-eligible children under the age of six (6) will be made to hospitals meeting the disproportionate share requirements in subsection (6)(A) and, for Missouri Medicaideligible infants under the age of one (1), will be made to any other Missouri Medicaid hospital.

      1. 1. The following criteria must be met for

the services to be eligible for outlier review:

1. A. The patient must be a Missouri

Medicaid-eligible infant under the age of one (1) year, or for disproportionate share hospitals a Missouri Medicaid-eligible child under the age of six (6) years, for all dates of service presented for review;

1. B. Hospitals requesting outlier review

for children one (1) year of age to children under six (6) years of age, must have qualified for disproportionate share status under section (6) of this plan for the state fiscal year corresponding with the fiscal year end of the cost report referred to in paragraph (7)(A)5.; and

1. C. One (1) of the following conditions

must be satisfied:

1. (I) The total reimbursable charges

for dates of service as described in paragraph (7)(A)3. must be at least one hundred fifty percent (150%) of the sum of total third-party liabilities and Medicaid inpatient claim payments for that claim; or

1. (II) The dates of service must

exceed sixty (60) days and less than seventyfive percent (75%) of the total service days was reimbursed by Medicaid.

1. 2. Claims for all dates of service eligible

for outlier review must—

1. A. Have been submitted to the

Division of Medical Services fiscal agent or the MC+ health plan in their entirety for routine claims processing, and claim payment must have been made before the claims are submitted to the division for outlier review; and

1. B. Be submitted for outlier review

with all documentation as required by the Division of Medical Services no later than ninety (90) days from the last payment made by the fiscal agent or the MC+ health plan through the normal claims processing system for those dates of service.

1. 3. Claim charges and Medicaid payment

data will be determined from claims data, submitted to the Division of Medical Services fiscal agent or MC+ health plan, by the hospital through normal claims processing.

1. 4. The claims may be reviewed for—

   1. A. Medical necessity at an inpatient

hospital level-of-care;

1. B. Appropriateness of services pro-

vided in connection with the diagnosis; and

1. C. Charges that are not permissible

per the Division of Medical Services; policies established in the institutional manual and hospital bulletins.

1. 5. After the review, reimbursable costs

for each claim will be determined using the following data from the most recent Medicaid hospital cost report filed by June 1 of each year:

1. A. Average routine (room and board)

costs for the general and special care units for all days of the stay eligible per the outlier review;

1. B. Ancillary cost-to-charge ratios

applied to claim ancillary charges determined eligible for reimbursement per the outlier review; and

1. C. No cost will be calculated for

items such as malpractice insurance premiums, interns and residents, professional services or return on equity.

1. 6. Each state fiscal year, outlier adjust-

ment payments for each hospital will be made for all claims submitted before March 1 of the preceding state fiscal year which satisfy all conditions in paragraphs (7)(A)1.–4. The payments will be determined for each hospital as follows:

1. A. Sum all reimbursable costs per

paragraph (7)(A)5. for all applicable outlier claims to equal total reimbursable costs;

1. B. Subtract third-party payments and

Medicaid payments for those claims from total reimbursable costs to equal excess cost; and

1. C. Multiply excess costs by fifty per-

cent (50%).

1. (B) Effective for admissions beginning on or after July 1, 1997, outlier adjustments shall also be made for Missouri Medicaid recipients enrolled in MC+. All criteria listed under subsection (7)(A) applies to MC+ outlier submissions.

1. (8) Payment Assurance.

   1. (A) The state will pay each hospital, which furnishes the services in accordance with the requirements of the state plan, the amount determined for services furnished by the hospital according to the standards and methods set forth in the rules implementing the Hospital Reimbursement Program.
   2. (B) Where third-party payment is involved, Medicaid will be the payor of last resort with the exception of state programs, such as Vocational Rehabilitation and the Missouri Crippled Children’s Service. Procedures for remitting third-party payments are provided in the Missouri Medical Assistance Program provider manuals.
   3. (C) Regardless of changes of ownership, management, control, operation, leasehold interests by whatever form for any hospital previously certified for participation in the Medicaid program, the department will continue to make all the Title XIX payments directly to the entity with the hospital’s current provider number and hold the entity with the current provider number responsible for all Medicaid liabilities.
2. (9) Provider Participation. Payments made in accordance with the standards and methods described in this rule are designed to enlist participation of a sufficient number of hospitals in the program, so that eligible persons can receive the medical care and services included in the state plan at least to the extent these services are available to the general public.
3. (10) Payment in Full. Participation in the program shall be limited to hospitals who accept as payment in full for covered services rendered to Medicaid recipients the amount paid in accordance with the rules implementing the Hospital Reimbursement Program.
4. (11) Plan Evaluation. Documentation will be maintained to effectively monitor and evaluate experience during administration of this plan.

5. (12) Inappropriate Placements.

   1. (A) The hospital per-diem rate as determined under this plan and in effect on October 1, 1981, shall not apply to any recipient who is receiving inpatient hospital care when s/he is only in need of nursing home care.

      1. 1. If a hospital has an established inter-

mediate care facility/skilled nursing facility (ICF/SNF) or SNF-only Medicaid rate for providing nursing home services in a distinct part setting, reimbursement for nursing home services provided in the inpatient hospital setting shall be made at the hospital’s ICF/SNF or SNF-only rate.

1. 2. If a hospital does not have an estab-

lished Medicaid rate for providing nursing home services in a distinct part setting, reimbursement for nursing home services provided in the inpatient hospital setting shall be made at the state swing bed rate.

1. 3. No Medicaid payments will be made

on behalf of any recipient who is receiving inpatient hospital care and is not in need of either inpatient or nursing home care.

1. (13) Outpatient Hospital Services Reimbursement for Hospitals Located Within Missouri.

   1. (A) Outpatient hospital services, unless otherwise limited by rule, shall be reimbursed on an interim basis by Medicaid at the lesser of seventy-five percent (75%) of usual and customary charges as billed by the provider for covered services or one hundred percent (100%) of the facility’s Medicaidallowable cost-to-charge ratio as determined from the most recent desk-reviewed cost report. Reimbursement at the applicable percentage shall be effective July 1 of each SFY for all providers and shall be subject to adjustment whenever the inpatient rate is changed.

      1. 1. All services provided to GR recipi-

ents will be reimbursed from the Medicaid fee schedule in accordance with provisions of 13 CSR 70-2.020.

1. 2. Effective for dates of service

September 1, 1985, and annually updated, certain clinical diagnostic laboratory procedures will be reimbursed from a Medicaid fee schedule which shall not exceed a national fee limitation.

1. 3. Services of hospital-based physicians

and certified registered nurse anesthetists shall be billed on an HCFA-1500 professional claim form and reimbursed from a Medicaid fee schedule or the billed charge, if less.

1. (B) The final outpatient settlements for hospitals will be calculated for each fiscal year in accordance with 13 CSR 70- 15.040(4).
2. (C) For reporting purposes in the outpatient Medicaid data, facilities shall not include services reimbursed from a fee schedule, which include services to GR recipients, the clinical diagnostic laboratory services and services of hospital-based physicians and certified registered nurse anesthetists.
3. (D) Outpatient hospital services provided for those recipients having available Medicare benefits shall be reimbursed by Medicaid to the extent of the deductible and coinsurance as imposed under Title XVIII.

1. (14) Out-of-State Hospital and Instate Federally-Operated Hospital Reimbursement.

   1. (A) Inpatient Reimbursement.

      1. 1. Effective for admissions beginning

after April 1, 1994, inpatient services for Missouri Medicaid recipients age twenty-one (21) or older in hospitals located outside Missouri and federally-operated hospitals located within Missouri will be reimbursed at the lower of—

1. A. The charges for those services; or
2. B. The individual recipient’s days of

care (within benefit limitations) multiplied by the Title XIX per-diem rate of three hundred forty-five dollars and thirteen cents ($345.13).

1. 2. Effective for admission beginning

after April 1, 1994, inpatient services for children under the age of twenty-one (21) in hospitals located outside Missouri will be reimbursed at the lower of—

1. A. The charges billed for those ser-

vices; or

1. B. The individual recipient’s days of

care (within benefit limitations) multiplied by the Title XIX per-diem rate established by the host state’s Medicaid agency. If the host state does not reimburse inpatient hospital services on a per-diem basis, the per-diem rate shall be six hundred sixty dollars and eighty-nine cents ($660.89). The inpatient psychiatric limitation (section (15)) shall apply.

1. 3. There will be no adjustments or

exemptions to this per-diem rate and no individual rate reconsideration will be performed.

1. 4. Payments on claims submitted, unless

otherwise specified, constitute final payment to hospitals located outside Missouri and to federally-operated hospitals within Missouri on those claims and no year-end cost settlements will be done. Therefore, these hospitals are not required to file Medicaid cost reports with Missouri.

1. (B) Outpatient Reimbursement.

   1. 1. Out-of-state outpatient hospital ser-

vices and services of federally-operated hospitals located within Missouri will be reimbursed by Missouri Medicaid at sixty percent (60%) of usual and customary charges as billed by the provider for covered services with the exceptions specified in paragraphs (11)(A)1.–4.

1. 2. Payments on claims submitted, unless

otherwise specified, constitute final payment on those claims to hospitals located outside Missouri and to federally-operated hospitals located within Missouri and no year-end cost settlements will be done.

1. (15) Direct Medicaid Payments.

   1. (A) Direct Medicaid Payments. Direct Medicaid payments will be made to hospitals for the following allowable Medicaid costs not included in the per-diem rate as calculated in section (3):

      1. 1. The increased Medicaid costs result-

ing from the FRA assessment not included in the cost report ending prior to January 1, 2001;

1. 2. The unreimbursed Medicaid costs

applicable to the trend factor which is not included in the per-diem rate;

1. 3. The unreimbursed Medicaid costs for

capital and medical education not included in the tended per-diem cost as a result of the application of the sixty percent (60%) minimum utilization adjustment in paragraph (3)(A)4.;

1. 4. The increased cost per day resulting

from the utilization adjustment. The increase cost per day results from lower utilization of inpatient hospital services by Medicaid recipients now covered by an MC+ health plan;

1. 5. The poison control adjustment shall

be determined for hospitals which operated a poison control center during the base year and which continues to operate a poison control center in a Medicaid managed care region; and

1. 6. The increased cost resulting from

including out-of-state Medicaid days in total projected Medicaid days.

1. (B) Direct Medicaid payment will be computed as follows:

   1. 1. The Medicaid share of the FRA

assessment will be calculated by dividing the hospital’s Medicaid patient days by total hos- 13 CSR 70-15

pital’s patient days to arrive at the Medicaid utilization percentage. This percentage is then multiplied by the FRA assessment for the current SFY to arrive at the increased allowable Medicaid costs;

1. 2. The unreimbursed Medicaid costs are

determined by subtracting the hospital’s perdiem rate from its trended per-diem costs. The difference is multiplied by the estimated Medicaid patient days for the current SFY.

1. A. The trended cost per day is calcu-

lated by trending the base year costs per day by the trend indices listed in paragraph (3)(B)1., using the rate calculation in subsection (3)(A). In addition to the trend indices applied to inflate base period costs to the current fiscal year, base year costs will be further adjusted by a Missouri Specific Trend. The Missouri Specific Trend will be used to address the fact that costs for Missouri inpatient care of Medicaid residents have historically exceeded the compounded inflation rates estimated using national hospital indices for a significant number of hospitals. The Missouri Specific Trend will be applied at one and one-half percent (1.5%) per year to the hospital’s base year. For example, hospitals with a 1998 base year will receive an additional six percent (6%) trend and hospitals with a 1999 base year will receive an additional four and one-half percent (4.5%) trend.

1. B. For hospitals that meet the require-

ments in paragraphs (6)(A)1., (6)(A)2. and (6)(A)4. of this rule (safety net hospitals), the base year cost report may be from the third prior year, the fourth prior year, or the fifth prior year. For hospitals that meet the requirements in paragraphs (6)(A)1. and (6)(A)3. of this rule (first tier Disproportionate Share Hospitals), the base year operating costs may be the third or fourth prior year cost report. The Division of Medical Services shall exercise its sole discretion as to which report is most representative of costs. For all other hospitals, the base year operating costs are based on the fourth prior year cost report. For any hospital that has both a twelve (12)- month cost report and a partial year cost report, its base period cost report for that year will be the twelve (12)-month cost report.

1. C. The tended cost per day does not

include the costs associated with the FRA assessment, the application of minimum utilization, the utilization adjustment and the poison control costs computed in paragraphs (15)(B)1., 3., 4., and 5.;

1. 3. The minimum utilization costs for

capital and medical education is calculated by determining the difference in the hospital’s cost per day when applying the minimum utilization as identified in paragraph (5)(C)4., and without applying the minimum utilization. The difference in the cost per day is multiplied by the estimated Medicaid patient days for the SFY;

1. 4. The utilization adjustment cost is

determined by estimating the number of Medicaid inpatient days the hospital will not provide as a result of the MC+ Health Plans limiting inpatient hospital services. These days are multiplied by the hospital’s cost per day to determine the total cost associated with these days. This cost is divided by the remaining total patient days from its base period cost report to arrive at the increased cost per day. This increased cost per day is multiplied by the estimated Medicaid days for the current SFY to arrive at the Medicaid utilization adjustment;

1. 5. The poison control cost shall reim-

burse the hospital for the prorated Medicaid managed care cost. It will be calculated by multiplying the estimated Medicaid share of the poison control costs by the percentage of MC+ recipients to total Medicaid recipients; and

1. 6. The costs for including out-of-state

Medicaid days is calculated by subtracting the hospital’s per-diem rate from its tended perdiem cost and multiplying this difference by the out-of-state Medicaid days from the base year cost report.

1. (16) Safety Net Adjustment. A safety net adjustment, in lieu of the Direct Medicaid Payments and Uninsured Add-Ons, shall be provided for each hospital which qualified as disproportionate share under the provision of paragraph (6)(A)4. The safety net adjustment payment shall be made prior to the end of each federal fiscal year.

   1. (A) The safety net adjustment for facilities which qualify under subparagraph (6)(A)4.A. of this regulation shall be computed in accordance with the Direct Medicaid Payment calculation described in section (15) and the Uninsured Add-Ons calculation in subsection (18)(B) of this regulation. The safety net adjustment will include the last three (3) quarters of the SFY ending June 30 and the first quarter of the next SFY beginning July 1 to correspond with the FFY of October 1 to September 30.
   2. (B) The safety net adjustment for facilities which qualify under subparagraph (6)(A)4.B., (6)(A)4.C. or (6)(A)4.D. of this regulation shall be computed in accordance with the Direct Medicaid Payment calculation described in section (15) and one hundred percent (100%) of the Uninsured costs calculation described in subsection (18)(B) of this regulation. The safety net adjustment will include the last three (3) quarters of the SFY ending June 30 and the first quarter of the next SFY beginning July 1 to correspond with the FFY of October 1 to September 30.
   3. (C) The state share of the safety net adjustment for hospitals described in subparagraphs (6)(A)4.A. and (6)(A)4.D. shall come from cash subsidy (CS) certified by the hospitals. If the aggregate CS are less than the state match required, the total aggregate safety net adjustment will be adjusted downward accordingly, and distributed to the hospitals in the same proportions as the original safety net adjustments.
2. (17) OBRA 93 Limitation. In accordance with OBRA 93, disproportionate share payments shall not exceed one hundred percent (100%) of the unreimbursed cost for Medicaid and the cost of the uninsured. The OBRA 93 Limitation shall be computed using the fourth prior year desk-reviewed cost report tended through the current state fiscal year. If the sum of disproportionate share payments exceeds the estimated OBRA 93 Limitation, the difference shall be deducted in order as necessary from the Safety Net payment, other disproportionate share lump sum payments, direct Medicaid payments and if necessary as a reduced per diem.

3. (18) In accordance with state and federal laws regarding reimbursement of unreimbursed costs and the costs of services provided to uninsured patients, reimbursement for each State Fiscal Year (SFY) (July 1–June 30) shall be determined as follows:

   1. (A) Medicaid Add-Ons for Shortfall. The Medicaid Add-On for the period of July 1, 1998 to December 31, 1998 will be based on fifty percent (50%) of the unreimbursed Medicaid costs as calculated for SFY 98 (Medicaid Shortfall); and

   2. (B) Uninsured Add-Ons. The hospital shall receive eighty-nine percent (89%) of the Uninsured costs prorated over the SFY. Hospitals which contribute through a plan approved by the director of health to support the state’s poison control center and the Primary Care Resource Initiative for Missouri (PRIMO) shall receive ninety percent (90%) of its uninsured costs prorated over the SFY. The uninsured Add-On will include:

      1. 1. The Add-On payment for the cost of

the Uninsured will be based on a three (3) year average of the fourth, fifth, and sixth prior base year cost reports. For any hospital that has both a twelve (12) month cost report and a partial year cost report, its base period cost report for that year will be the twelve (12) month cost report. Cost of the uninsured is determined by multiplying the charges for charity care and allowable bad debts by the hospital’s total cost-to-charge ratio for allowable hospital services from the base year cost report’s desk review. The cost of the Uninsured is then tended to the current year using the trend indices reported in subsection (3)(B). Allowable bad debts do not include the costs of caring for patients whose insurance covers the particular service, procedure or treatment;

1. 2. An adjustment to recognize the

Uninsured patients’ share of the FRA assessment not included in the desk-reviewed cost. The FRA assessment for Uninsured patients is determined by multiplying the current FRA assessment by the ratio of uninsured days to total inpatient days from the base year cost report;

1. 3. The difference in the projected

General Relief per-diem payments and tended costs for General Relief patient days; and

1. 4. The increased costs per day resulting

from the utilization adjustment in subsection (15)(B) is multiplied by the estimated uninsured days.

1. (19) Medicaid GME Add-On—A Medicaid Add-On determined for Graduate Medical Education (GME) costs shall be allocated based on the estimated effect of implementation of a Medicaid managed care system such as MC+ in accordance with this section.

   1. (A) The Medicaid GME Add-On for Medicaid clients covered under a Managed Care Plan shall be determined using the base year cost report and paid in quarterly installments. The base year cost report shall be the fourth prior fiscal year (i.e., the base year for SFY 1999 is the FY 1995 cost report). The hospital per diem shall continue to include a component for GME related to Medicaid clients not included in a managed care system.

      1. 1. Total GME cost shall be multiplied by

a managed care allocation factor which incorporates the estimated percentage of the hospital’s Medicaid population included in a managed care system and the estimated implementation date for a managed care system. For example: If a hospital has 1) an annual GME cost of one hundred thousand dollars ($100,000), 2) forty percent (40%) of their Medicaid days are related to Medicaid recipients eligible for Medicaid managed care, and 3) the projected implementation date for managed care is October 1, 1995; the prorated GME Add-On is thirty thousand dollars ($30,000).

1. 2. The annual GME Add-On shall be

paid in quarterly installments. (20) Hospital Mergers. Hospitals that merge their operations under one (1) Medicare and Medicaid provider number shall have their Medicaid reimbursement combined under the surviving hospital’s (the hospital whose Medicare and Medicaid provider number remains active) Medicaid provider number.

1. (A) The disproportionate share status of the merged hospital provider shall be—

   1. 1. The same as the surviving hospital’s

status was prior to the merger for the remainder of the state fiscal year in which the merger occurred; and

1. 2. Determined based on the combined

desk-reviewed data from the appropriate cost reports for the merged hospitals in subsequent fiscal years.

1. (B) The per-diem rate for merged hospitals shall be calculated—

   1. 1. For the remainder of the state fiscal

year in which the merger occurred by multiplying each hospital’s estimated Medicaid paid days by its per-diem rate, summing the estimated per-diem payments and estimated Medicaid paid days, and then dividing the total estimated per-diem payments by the total estimated paid days to determine the weighted per-diem rate. The effective date of the weighted per-diem rate will be the date of the merger; and

1. 2. For subsequent state fiscal years

based on the combined desk-reviewed data after taking into account the different fiscal year ends of the cost reports.

1. (C) The Medicaid Direct Payments and Uninsured Add-On shall be—

   1. 1. Combined under the surviving hospi-

tal’s Medicaid provider number for the remainder of the state fiscal year in which the merger occurred; and

1. 2. Calculated for subsequent state fiscal

years based on the combined data from the appropriate cost report for each facility.

1. (D) Merger of Children’s Acute Care Hospital. When an acute care children’s hospital merges with another acute care hospital, all the provisions in subsection (20)(A) shall apply, except the Medicaid provider number for the children’s hospital will remain active. The only payments made under the children’s provider number will be the per-diem and outpatient payments. The Direct Medicaid payments and Uninsured Add-On payments will be made under the Medicaid number associated with the surviving Medicare provider number.

1. (21) Enhanced Graduate Medical Education

2. (GME) Payment—An enhanced GME payment shall be made to any acute care hospital that provides graduate medical education (teaching hospital).

   1. (A) The enhanced GME payment shall be computed in accordance with subsection (21)(B). The payment shall be made at the end of the state fiscal year. The enhanced GME payment for each state fiscal year shall be computed using the most recent cost data available when the enhanced GME payment is computed. If the cost report is less than or more than a twelve (12)-month period, the cost report data will be adjusted to reflect a twelve (12)-month period. The state share of the enhanced GME payment to a hospital that has cash subsidies shall come from funds certified by the hospital.
   2. (B) The enhanced GME payment will be computed by first determining the percentage difference between the McGraw-Hill CPI index for hospital services and Medicare update factors applied to the per resident amounts from 1986 to the most recent SFY. For example, the percentage difference has been computed to be eighty-five and sixtytwo-one-hundredth percent (85.62%) for SFY 2000. The percentage difference is then multiplied by the Medicaid share of the aggregate approved amount reported on worksheet E-3 part IV of the Medicare cost report (HCFA 2552-96) for the fourth prior fiscal year and tended to the current state fiscal year. The resulting product is the enhanced GME payment.

AUTHORITY: sections 208.152, 208.153 and 208.201, RSMo 2000 and 208.471, RSMo Supp. 2001.* This rule was previously filed as 13 CSR 40-81.050. Original rule filed Feb. 13, 1969, effective Feb. 23, 1969. Emergency rescission and rule filed Sept. 21, 1981, effective Oct. 1, 1981, expired Jan. 13, 1982. Rescinded and readopted: Filed Sept. 21, 1981, effective Jan. 14, 1982. Emergency amendment filed June 21, 1982, effective July 1, 1982, expired Oct. 10, 1982. Amended: Filed June 21, 1982, effective Oct. 11, 1982. Emergency amendment filed July 21, 1982, effective July 30, 1982, expired Nov. 27, 1982. Emergency amendment filed June 21, 1983, effective July 1, 1983, expired Oct. 12, 1983. Amended: Filed June 21, 1983, effective Oct. 13, 1983. Amended: Filed Sept. 13, 1983, effective Dec. 11, 1983. Emergency amendment filed Dec. 21, 1983, effective Jan. 1, 1984, expired April 11, 1984. Emergency amendment filed March 14, 1984, effective March 28, 1984, expired June 10, 1984. Amended: Filed March 14, 1984, effective June 11, 1984. Emergency amendment filed June 21, 1984, effective July 1, 1984, expired Oct. 10, 1984. Amended: Filed July 12, 1984, effective Oct. 11, 1984. Amended: Filed Sept. 12, 1984, effective Jan. 12, 1985. Amended: Filed Jan. 15, 1985, 13 CSR 70-15 effective May 27, 1985. Amended: Filed May 16, 1985, effective Sept. 1, 1985. Emergency amendment filed June 20, 1985, effective July 1, 1985, expired Oct. 28, 1985. Amended: Filed June 20, 1985, effective Oct. 1, 1985. Amended: Filed Sept. 4, 1985, effective Dec. 1, 1985. Emergency amendment filed Oct. 17, 1985, effective Oct. 27, 1985, expired Jan. 11, 1986. Amended: Filed Oct. 17, 1985, effective Feb. 13, 1986. Amended: Filed Dec. 16, 1985, effective April 1, 1986. Amended: Filed Feb. 14, 1986, effective May 11, 1986. Amended: Filed March 17, 1986, effective June 28, 1986. Amended: Filed April 2, 1986, effective July 1, 1986. Amended: Filed Aug. 1, 1986, effective Oct. 11, 1986. Emergency amendment filed Sept. 19, 1986, effective Oct. 1, 1986, expired Jan. 15, 1987. Emergency amendment filed Sept. 24, 1986, effective Oct. 4, 1986, expired Jan. 29, 1987. Emergency amendment filed Oct. 22, 1986, effective Nov. 1, 1986, expired Feb. 1, 1987. Amended: Filed Nov. 4, 1986, effective Jan. 30, 1987. Amended: Filed Nov. 12, 1986, effective Feb. 2, 1987. Amended: Filed Nov. 14, 1986, effective Jan. 30, 1987. Emergency amendment filed June 19, 1987, effective July 1, 1987, expired Oct. 29, 1987. Amended: Filed Aug. 18, 1987, effective Oct. 25, 1987. Amended: Filed Jan. 5, 1988, effective March 25, 1988. Amended: Filed March 2, 1988, effective May 12, 1988. Emergency amendment filed April 15, 1988, effective April 25, 1988, expired Aug. 22, 1988. Emergency amendment filed May 17, 1988, effective May 27, 1988, expired Sept. 23, 1988. Amended: Filed May 17, 1988, effective Aug. 11, 1988. Amended: Filed June 2, 1988, effective Aug. 25, 1988. Emergency amendment filed June 21, 1988, effective July 1, 1988, expired Oct. 28, 1988. Emergency amendment filed June 21, 1988, effective July 1, 1988, expired Oct. 28, 1988. Amended: Filed June 28, 1988, effective Sept. 29, 1988. Emergency amendment filed July 15, 1988, effective July 25, 1988, expired Nov. 21, 1988. Amended: Filed July 15, 1988, effective Oct. 29, 1988. Emergency amendment filed Aug. 5, 1988, effective Aug. 15, 1988, expired Dec. 13, 1988. Amended: Filed Oct. 18, 1988, effective Jan. 13, 1989. Emergency amendment filed Dec. 16, 1988, effective Jan. 1, 1989, expired May 1, 1989. Amended: Filed Aug. 16, 1989, effective Nov. 11, 1989. Amended: Filed Sept. 26, 1989, effective Dec. 28, 1989. Emergency amendment filed Dec. 1, 1989, effective Jan. 1, 1990, expired April 29, 1990. Amended: Filed Dec. 1, 1989, effective Feb. 25, 1990. Amended: Filed Dec. 1, 1989, effective May 11, 1990. Amended: Filed Jan. 10, 1989, effective April 12, 1990. Amended: Filed Feb. 5, 1990, effective May 11, 1990. Amended: Filed Feb. 16, 1990, effective April 26, 1990. Emergency amendment filed May 30, 1990, effective July 1, 1990, expired Oct. 28, 1990. Amended: Filed May 30, 1990, effective Sept. 28, 1990. Emergency amendment filed May 30, 1990, effective July 1, 1990, expired Oct. 28, 1990. Amended: Filed May 30, 1990, effective Sept. 28, 1990. Amended: Filed Oct. 2, 1990, effective Feb. 14, 1991. Emergency amendment filed Oct. 15, 1990, effective Nov. 1, 1990, expired Feb. 28, 1991. Amended: Filed Oct. 15, 1990, effective Feb. 14, 1991. Amended: Filed Oct. 15, 1990, effective Feb. 14, 1991. Emergency amendment filed Dec. 21, 1990, effective Jan. 1, 1991, expired March 31, 1991. Emergency amendment filed Jan. 3, 1991, effective Jan. 15, 1991, expired May 13, 1991. Amended: Filed Feb. 14, 1991, effective July 8, 1991. Emergency amendment filed March 4, 1991, effective March 14, 1991, expired May 13, 1991. Emergency amendment filed March 7, 1991, effective March 17, 1991, expired July 14, 1991. Amended: Filed March 7, 1991, effective Aug. 30, 1991. Emergency amendment filed June 20, 1991, effective July 1, 1991, expired Oct. 28, 1991. Emergency amendment filed June 20, 1991, effective July 1, 1991, expired Oct. 28, 1991. Amended: Filed June 18, 1991, effective Oct. 31, 1991. Emergency amendment filed July 5, 1991, effective July 15, 1991, expired Aug. 15, 1991. Amended: Filed July 2, 1991, effective Dec. 9, 1991. Amended: Filed July 2, 1991, effective Dec. 9, 1991. Emergency amendment filed Aug. 8, 1991, effective Aug. 18, 1991, expired Dec. 15, 1991. Amended: Filed Aug. 5, 1991, effective Jan. 13, 1992. Emergency amendment filed Oct. 11, 1991, effective Oct. 21, 1991, expired Feb. 17, 1992. Emergency amendment filed Oct. 18, 1991, effective Oct. 28, 1991, expired Feb. 24, 1992. Emergency amendment filed Oct. 18, 1991, effective Oct. 28, 1991, expired Feb. 24, 1992. Amended: Filed Oct. 18, 1991, effective April 9, 1992. Emergency amendment filed Nov. 15, 1991, effective Dec. 3, 1991, expired April 1, 1992. Emergency amendment filed March 13, 1992, effective April 2, 1992, expired July 30, 1992. Amended: Filed Nov. 15, 1991, effective April 9, 1992. Emergency amendment filed Feb. 3, 1992, effective Feb. 18, 1992, expired June 16, 1992. Emergency amendment filed Feb. 7, 1992, effective Feb. 19, 1992, expired June 17, 1992. Emergency amendment filed March 13, 1992, effective April 2, 1992, expired July 30, 1992. Emergency amendment filed April 2, 1992, effective April 18, 1992, expired Aug. 15, 1992. Emergency amendment filed Aug. 6, 1992, effective Aug. 16, 1992, expired Dec. 13, 1992. Amended: Filed April 2, 1992, effective Feb. 26, 1993. Emergency amendment filed Sept. 21, 1992, effective Oct. 1, 1992, expired Jan. 28, 1993. Emergency amendment filed Sept. 21, 1992, effective Oct. 1, 1992, expired Jan. 28, 1993. Emergency amendment filed Sept. 21, 1992, effective Oct. 1, 1992, expired Jan. 28, 1993. Emergency amendment filed Nov. 3, 1992, effective Nov. 20, 1992, expired March 19, 1993. Emergency amendment filed Nov. 3, 1992, effective Nov. 20, 1992, expired March 19, 1993. Emergency amendment filed Nov. 16, 1992, effective Dec. 2, 1992, expired March 31, 1993. Emergency amendment filed Jan. 15, 1993, effective Jan. 25, 1993, expired May 24, 1993. Emergency amendment filed Jan. 15, 1993, effective Jan. 25, 1993, expired May 24, 1993. Emergency amendment filed Jan. 15, 1993, effective Jan. 25, 1993, expired May 24, 1993. Emergency amendment filed March 2, 1993, effective March 22, 1993, expired July 19, 1993. Amended: Filed Sept. 21, 1992, effective June 7, 1993. Amended: Filed Sept. 21, 1992, effective June 7, 1993. Amended: Filed Nov. 3, 1992, effective June 7, 1993. Amended: Filed Nov. 3, 1992, effective June 7, 1993. Amended: Filed Nov. 16, 1992, effective June 7, 1993. Emergency amendment filed May 14, 1993, effective May 25, 1993, expired Sept. 21, 1993. Emergency amendment filed May 14, 1993, effective May 25, 1993, expired Sept. 21, 1993. Emergency amendment filed May 14, 1993, effective May 25, 1993, expired Sept. 21, 1993. Emergency amendment filed June 17, 1993, effective June 27, 1993, expired Oct. 24, 1993. Emergency amendment filed June 18, 1993, effective July 1, 1993, expired Oct. 28, 1993. Amended: Filed March 16, 1993, effective Oct. 10, 1993. Amended: Filed April 6, 1993, effective Oct. 10, 1993. Emergency amendment filed Sept 2, 1993, effective Sept. 18, 1993, expired Jan. 15, 1994. Emergency amendment filed Sept. 2, 1993, effective Sept. 18, 1993, expired Jan. 15, 1994. Amended: Filed Sept. 2, 1993, effective Jan. 31, 1994. Emergency amendment filed Oct. 15, 1993, effective Oct. 25, 1993, expired Feb. 21, 1994. Amended: Filed Oct. 15, 1993, effective June 6, 1994. Amended: Filed Oct. 15, 1993, effective June 6, 1994. Emergency amendment filed Dec. 2, 1993, effective Dec. 18, 1993, expired April 16, 1994. Amended: Filed Dec. 2, 1993, effective July 30, 1994. Emergency amendment filed Dec. 13, 1993, effective Jan. 5, 1994, expired May 4, 1994. Amended: Filed Dec. 13, 1993, effective July 30, 1994. Emergency amendment filed Dec. 20, 1993, effective Jan. 1, 1994, expired April 30, 1994. Amended: Filed Dec. 20, 1993, effective July 30, 1994. Emergency amendment filed Jan. 14, 1994, effective Feb. 2, 1994, expired June 1, 1994. Amended: Filed Jan. 14, 1994, effective July 30, 1994. Emergency amendment Jan. 14, 1994, effective Feb. 2, 1994, expired June 1, 1994. Emergency amendment filed Jan. 26, 1994, effective Feb. 5, 1994, expired June 4, 1994. Amended: Filed Jan. 14, 1994, effective July 30, 1994. Emergency amendment filed Feb. 16, 1994, effective Feb. 26, 1994, expired June 25, 1994. Emergency amendment filed March 14, 1994, effective April 2, 1994, expired July 30, 1994. Emergency amendment filed April 4, 1994, effective April 16, 1994, expired July 29, 1994. Emergency amendment filed April 6, 1994, effective April 17, 1994, expired Aug. 14, 1994. Emergency amendment filed April 25, 1994, effective May 5, 1994, expired Sept. 1, 1994. Emergency amendment filed May 20, 1994, effective June 2, 1994, expired Sept. 29, 1994. Emergency amendment filed May 20, 1994, effective June 2, 1994, expired Sept. 29, 1994. Emergency amendment filed May 20, 1994, effective June 5, 1994, expired Oct. 2, 1994. Emergency amendment filed June 2, 1994, effective June 12, 1994, expired Oct. 9, 1994. Emergency amendment filed June 2, 1994, effective June 12, 1994, expired Oct. 9, 1994. Amended: Filed Feb. 28, 1994, effective Sept. 30, 1994. Emergency amendment filed June 15, 1994, effective June 25, 1994, expired Oct. 22, 1994. Emergency amendment filed June 16, 1994, effective June 26, 1994, expired Oct. 23, 1994. Emergency amendment filed June 20, 1994, effective July 1, 1994, expired Oct. 28, 1994. Emergency amendment filed June 23, 1994, effective July 12, 1994, expired Nov. 8, 1994. Amended: Filed April 4, 1994, effective Oct. 30, 1994. Amended: Filed April 4, 1994, effective Oct. 30, 1994. Amended: Filed June 15, 1994, effective Jan. 29, 1995. Emergency amendment filed Aug. 30, 1994, effective Sept. 9, 1994, expired Jan. 6, 1995. Emergency amendment filed Sept. 23, 1994, effective Oct. 3, 1994, expired Jan. 30, 1995. Emergency amendment filed Oct. 7, 1994, effective Oct. 23, 1994, expired Feb. 19, 1995. Emergency amendment filed Oct. 12, 1994, effective Oct. 22, 1994, expired Feb. 18, 1995. Emergency amendment filed Dec. 15, 1994, effective Jan. 1, 1995, expired April 30, 1995. Emergency amendment filed Jan. 20, 1995, effective Jan. 31, 1995, expired May 30, 1995. Emergency amendment filed Feb. 9, 1995, effective Feb. 20, 1995, expired June 19, 1995. Emergency amendment filed June 20, 1995, effective June 30, 1995, expired Oct. 27, 1995. Emergency amendment filed June 20, 1995, effective July 1, 1995, expired Oct. 28, 1995. Amended: Filed Dec. 15, 1994, effective July 30, 1995. Amended: Filed Feb. 9, 1995, effective Aug. 30, 1995. Emergency amendment filed July 31, 1995, effective Aug. 10, 1995, expired Dec. 7, 1995. Amended: Filed May 15, 1995, effective Dec. 30, 1995. Amended: Filed May 19, 1995, effective Dec. 30, 1995. Emergency amendment filed Nov. 27, 1995, effective Dec. 8, 1995, expired June 4, 1996. Emergency amendment filed Dec. 1, 1995, effective Dec. 11, 1995, expired June 7, 1996. Emergency amendment filed Feb. 5, 1996, effective Feb. 15, 1996, expired Aug. 12, 1996. Amended: Filed Nov. 15, 1995, effective May 30, 1996. Amended: Filed Nov. 27, 1995, effective July 30, 1996. Amended: Filed Feb. 15, 1996, effective Aug. 30, 1996. Emergency amendment filed June 21, 1996, effectively July 1, 1996, expired Dec. 27, 1996. Amended: Filed June 17, 1996, effective Jan. 30, 1997. Amended: Filed June 17, 1996, effective Jan. 30, 1997. Emergency amendment filed Sept. 13, 1996, effective Oct. 1, 1996, expired March 29, 1997. Amended: Filed Sept. 13, 1996, effective April 30, 1997. Amended: Filed June 3, 1997, effective Dec. 30, 1997. Emergency amendment filed June 3, 1997, effective June 13, 1997, expired Dec. 9, 1997. Amended: Filed June 3, 1997, effective Dec. 30, 1997. Emergency amendment filed June 3, 1997, effective July 1, 1997, expired Dec. 27, 1997. Amended: Filed June 3, 1997, effective Dec. 30, 1997. Emergency amendment filed June 3, 1997, effective June 13, 1997, expired Dec. 9, 1997. Amended: Filed June 3, 1997, effective Dec. 30, 1997. Emergency amendment filed March 2, 1998, effective April 1, 1998, expired Sept. 27, 1998. Amended: Filed March 2, 1998, effective Sept. 30, 1998. Emergency amendment filed Aug. 31, 1998, effective Sept. 10, 1998, expired March 8, 1999. Amended: Filed Jan. 14, 1999, effective July 30, 1999. Amended: Filed May 14, 1999, effective Nov. 30, 1999. Amended: Filed May 14, 1999, effective Nov. 30, 1999. Emergency amendment filed June 18, 1999, effective June 28, 1999, expired Dec. 24, 1999. Amended: Filed July 1, 1999, effective Jan. 30, 2000. Emergency amendment filed Nov. 22, 1999, effective Dec. 2, 1999, terminated May 4, 2000. Amended: Filed Aug. 16, 1999, effective April 30, 2000. Amended: Filed Dec. 15, 1999, effective June 30, 2000. Emergency amendment filed May 1, 2000, effective May 11, 2000, terminated Sept. 4, 2000. Emergency amendment filed Aug. 25, 2000, effective Sept. 4, 2000, expired March 2, 2001. Amended: Filed May 1, 2000, effective Dec. 30, 2000. Emergency amendment filed April 9, 2001, effective April 19, 2001, expired Oct. 15, 2001. Amended: Filed April 9, 2001, effective Sept. 30, 2001. Amended: Filed Aug. 24, 2001, effective March 30, 2002. Emergency amendment filed May 28, 2002, effective June 6, 2002, expired Dec. 2, 2002. Amended: Filed April 29, 2002, effective Nov. 30, 2002.

*Original authority: 208.152, RSMo 1967, amended 1969, 1971, 1972, 1973, 1975, 1977, 1978, 1981, 1986, 1988, 1990, 1992, 1993; 208.153, RSMo 1967, amended 1967, 1973, 1989, 1990, 1991; 208.201, RSMo 1987; and 208.471, RSMo 1992, amended 2001.