PURPOSE: This rule provides for the calculation of the Direct Medicaid payments made on or after July 1, 2019.

1. (1) Outpatient Direct Medicaid Payments.

   1. (A) Outpatient direct Medicaid payments will be made to hospitals for the following allowable MO HealthNet cost:

      1. 1. The increased MO HealthNet cost resulting from the

Federal Reimbursement Allowance (FRA) assessment becoming an allowable cost on January 1, 1999.

1. (B) The MO HealthNet Division will calculate the outpatient direct Medicaid payment as follows:

   1. 1. The Medicaid share of the outpatient FRA assessment will

be calculated by dividing the hospital’s outpatient Medicaid charges, fee-for-service (FFS) and managed care (MC), by the total outpatient hospital charges, FFS, and MC, from the base year cost report to arrive at the Medicaid utilization percentage. This percentage is then multiplied by the outpatient FRA assessment for the current state fiscal year (SFY) to arrive at the increased allowable Medicaid cost for the outpatient FRA assessment; and

1. 2. The FFS outpatient ratio will be calculated by dividing

the hospital’s outpatient FFS Medicaid charges by the hospital’s outpatient Medicaid charges, FFS, and MC. This ratio is then multiplied by the increased allowable Medicaid cost for the outpatient FRA assessment to arrive at the FFS direct Medicaid payment.

1. (C) The MO HealthNet Division will calculate the outpatient direct Medicaid payment for new hospitals as follows:

   1. 1. In the absence of adequate cost data, a new hospital’s

Medicaid share of the outpatient FRA assessment shall be one hundred percent (100%) of the weighted average statewide Medicaid utilization percentage, as calculated in paragraph (1) (B)1., for the hospital type (i.e., acute care hospital, psychiatric hospital, long term care hospital, rehabilitation hospital). This percentage is then multiplied by the outpatient FRA assessment for the current SFY to arrive at the increased allowable Medicaid cost for the outpatient FRA assessment; and

1. 2. In the absence of adequate cost data, a new hospital’s

FFS outpatient ratio shall be one hundred percent (100%) of the weighted average statewide FFS outpatient ratio, as calculated in paragraph (1)(B)2., for the hospital type (i.e., acute care hospital, psychiatric hospital, long term care hospital, rehabilitation hospital). This ratio is then multiplied by the increased allowable Medicaid cost for the outpatient FRA assessment to arrive at the FFS direct Medicaid payment.

1. (D) Effective for payments made on or after July 1, 2022, only the FFS component of the Medicaid share of the outpatient FRA assessment will be included in the outpatient direct Medicaid payment.

AUTHORITY: sections 208.153, 208.201, and 660.017, RSMo 2016, and section 208.152, RSMo Supp. 2022.* This rule was previously filed as part of 13 CSR 70-15.010. Emergency rule filed April 30, 2020, effective May 15, 2020, expired Feb. 24, 2021. Original rule filed April 30, 2020, effective Nov. 30, 2020. Emergency amendment filed Aug. 26, 2021, effective Sept. 10, 2021, expired March 8, 2022. Amended: Filed Aug. 26, 2021, effective March 30, 2022. Emergency amendment filed June 14, 2022, effective July 1, 2022, expired Feb. 23, 2023. Amended: Filed June 14, 2022, effective Jan. 30, 2023. *Original authority: 208.152, RSMo 1967, amended 1969, 1971, 1972, 1973, 1975, 1977, 1978, 1981, 1986, 1988, 1990, 1992, 1993, 2004, 2005, 2007, 2011, 2013, 2014, 2015, 2016, 2018, 2021; 208.153, RSMo 1967, amended 1967, 1973, 1989, 1990, 1991, 2007, 2012; 208.201, RSMo 1987, amended 2007; and 660.017, RSMo 1993, amended 1995.