Wyo. Code R. 048-0037-32
Medicaid
Chapter 32: Reimbursement of Disproportionate Share Hospitals
Effective Date: 02/18/1997 to 11/18/1997
Rule Type: Superceded Rules & Regulations
Reference Number: 048.0037.32.02181997
This Chapter is promulgated by the Department of Health pursuant to the Medical Assistance and Services Act at W.S. § 42-4-101 et seq and the Wyoming Administrative Procedures Act at W. S. § 16-3-101 et seq.
(a) This Chapter shall apply to and govern disproportionate share payments made on or after its effective date. This Chapter is intended to implement the Department's responsibility to make disproportionate share payments under Section 1923 of the Social Security Act, codified at 42 U.S.C. § 1396r-4. Hospital services are also subject to the provisions of Chapters 3, 8, 9, 24, 30, 31 and 33 of these rules, except as otherwise specified in this Chapter.
(b) The Department may issue Provider Manuals, Provider Bulletins, or both, to providers and/or other affected parties to interpret the provisions of this Chapter. Such Provider Manuals and Provider Bulletins shall be consistent with and reflect the policies contained in this Chapter. The provisions contained in Provider Manuals or Provider Bulletins shall be subordinate to the provisions of this Chapter.
(a) Terminology. Except as otherwise specified, the terminology used in this Chapter is the standard terminology and has the standard meaning used in accounting, health care, Medicaid and Medicare.
(b) General methodology. Disproportionate share hospitals receive an annual payment after the year end settlement of the hospital's cost report. The hospital's eligibility for and the amount of any disproportionate share payment shall be determined pursuant to this Chapter.
(c) Disproportionate share payments shall not be redetermined because of changes that result from a reopening, redetermination, administrative hearing, settlement agreement, or other change in a hospital's allowable costs.
(a) 'Admitted.' The act by which an individual is admitted to a hospital as an inpatient or an outpatient. 'Admitted' does not include an individual that is transferred from one unit of a hospital to another unit in the hospital or to a distinct part hospital unit.
(b) 'Chapter 1.' Chapter 1, Rules for Medicaid Administrative Hearings, of the Wyoming Medicaid rules.
(c) 'Chapter 3.' Chapter 3, Provider Participation, of the Wyoming Medicaid Rules.
(d) 'Chapter 8.' Chapter 8, Inpatient Admission Certification, of the Wyoming Medicaid Rules.
(e) 'Chapter 9.' Chapter 9, Hospital Services, of the Wyoming Medicaid Rules.
(f) 'Chapter 24.' Chapter 24, Wyoming Hospital Reimbursement System, of the Wyoming Medicaid Rules.
(g) 'Chapter 30.' Chapter 30, Level of Care Inpatient Hospital Reimbursement, of the Wyoming Medicaid Rules.
(h) 'Chapter 31.' Chapter 31, Selective Contracting of Hospital Services, of the Wyoming Medicaid Rules.
(i) 'Chapter 33.' Chapter 33, Reimbursement of Outpatient Hospital Services, of the Wyoming Medicaid Rules.
(j) 'Cost report.' A cost report prepared and submitted in conformance with Medicare requirements. 'Cost report' includes any supplemental request by the Department for additional information relating to the hospital's costs.
(k) 'Department.' The Wyoming Department of Health, its agent, designee or successor.
(l) 'Director.' The Director of the Department or the Director's designee.
(m) 'Disproportionate share hospital.' A hospital located in Wyoming that is entitled to a DSH payment pursuant to Section 5.
(n) 'Disproportionate share ('DSH') payments.' Medicaid payments made to a disproportionate share hospital in accordance with this Chapter.
(o) 'Division.' The Division of Health Care Financing of the Department, its agent, designee or successor.
(p) 'Enrolled.' Enrolled as defined in Chapter 3, Section 3(l), which is incorporated by this reference.
(q) 'Excess payments.' Medicaid funds received by a provider which exceed the Medicaid allowable payment established by the Department.
(r) 'Financial records.' All records, in whatever form, used or maintained by a hospital in the conduct of its business affairs and which are necessary to substantiate or understand the information contained in the hospital's cost reports or a claim.
(s) 'HCFA.' The Health Care Financing Administration of the United States Department of Health and Human Services, its agent, designee or successor.
(t) 'HHS.' The United States Department of Health and Human Services, its agent, designee or successor.
(u) 'Hospital.' An institution that: (i) is approved to participate as a hospital under Medicare; (ii) is maintained primarily for the treatment and care of patients with disorders other than mental diseases or tuberculosis; (iii) has a provider agreement; (iv) is enrolled in the Medicaid program; and (v) is licensed to operate as a hospital by the State of Wyoming.
(v) 'Inpatient.' An 'inpatient' as defined by 42 C.F.R. § 440.2(a), which is incorporated by this reference.
(w) 'Inpatient hospital services.' Inpatient hospital services as defined by 42 C.F.R. § 440.10, which is incorporated by this reference.
(x) 'Low income utilization rate.' The sum of:
(i) A fraction (expressed as a percentage), the numerator of which is the sum of the total Medicaid payments made to the hospital by the State for patient services (other than payments for specialty services) and the amount of cash subsidies received by the hospital from State and local governments for patient services, and the denominator of which is the total amount of revenues (including cash subsidies) received for patient services; and
(ii) A fraction (expressed as a percentage), the numerator of which is the amount of inpatient hospital charges attributable to charity care (not including contractual allowances and discounts) less the amount of cash subsidies attributable to inpatient services, and the denominator of which is the total amount of inpatient hospital charges.
(y) 'Medicaid.' Medical assistance and services provided pursuant to Title XIX of the Social Security Act and the Wyoming Medical Assistance and Services Act.
(z) 'Medicaid inpatient utilization rate.' A fraction (expressed as a percentage) the numerator of which is the number of Wyoming Medicaid paid days in a period, and the denominator of which is the total number of inpatient days for that period.
(aa) 'Medical record.' All documents, in whatever form, in the possession of or subject to the control of the hospital which describe the recipient's diagnosis, condition or treatment, including, but not limited to, the plan of care for the recipient.
(bb) 'Medicare.' The health insurance program for the aged and disabled established pursuant to Title XVIII of the Social Security Act.
(cc) 'Most recently settled cost report.' A facility's most recent Medicare cost report which has been: (i) submitted to Medicare in accordance with Medicare standards and procedures; and (ii) cost settled by the Medicare intermediary using Medicare principles of cost reimbursement.
(dd) 'Notice of disproportionate share payment.' Written notice from the Department to a hospital, sent by certified mail, of the amount of disproportionate share payment, if any, to which the hospital is entitled pursuant to this Chapter.
(ee) 'Outpatient hospital services.' Outpatient hospital services as defined by 42 C.F.R. § 449.20(a), which is incorporated by this reference.
(ff) 'Patient.' An individual admitted to a hospital or other provider of inpatient or outpatient hospital services.
(gg) 'Provider.' A provider as defined by Chapter 3, which definition is incorporated by this reference.
(hh) 'Recipient.' A person who has been determined eligible for Medicaid.
(ii) 'Reopen.' A request by a hospital, pursuant to the procedures and standards established by Medicare, to re-examine or review the correctness of a cost settlement determination or decision made by or on behalf of Medicare.
(jj) 'Request for consideration of disproportionate share payments based on low income utilization rate.' A request by a hospital that the Department determine whether the hospital is entitled to disproportionate share payment based on the hospital's low income utilization rate. Such a request must be in writing, sent by certified mail, include the information necessary for the Department to compute the hospital's low income utilization rate, and be prepared in the form specified by the Department. 'Request for consideration of disproportionate share payment based on low income utilization rate" includes any supplemental request by the Department for additional information. The failure to provide any requested supplemental information within forty-five days after the date of the request shall result in the denial of the request with prejudice.
(kk) "Settled cost report." A hospital's cost report which has been:
(i) Submitted to Medicare in accordance with Medicare standards and procedures;
(ii) Cost settled by the Medicare intermediary using Medicare principles of cost reimbursement (a cost report is considered settled notwithstanding a request to reopen);
(iii) For which a notice of program reimbursement has been issued; and
(iv) For which a notice of Medicaid program reimbursement has been issued (for fiscal years ending on or before December 31, 1994).
(ll) "Specialty services." "Specialty services" as defined in Chapter 31, which definition is incorporated by this reference.
(mm) "Survey agency." The Health Facilities Survey, Certification and Licensure Office of the Department, its agent, designee or successor.
Section 5. Disproportionate share payment.
(a) In addition to the payment rates established pursuant to Chapters 30 and 31, a disproportionate share hospital shall be entitled to a disproportionate share payment computed pursuant to this section.
(b) Determination of disproportionate share hospital. A disproportionate share hospital is one which has either a:
(i) Medicaid utilization rate at least one standard deviation above the mean Medicaid utilization rate for Wyoming hospitals; or
(ii) Low income utilization rate which exceeds twenty-five percent.
(c) Determination of disproportionate share payment.
(i) Disproportionate share payments based on Medicaid utilization rate. A hospital which meets the criterion of paragraph (b)(i) shall receive a DSH payment determined as follows: The sum, not to exceed ten percent, of the mean disproportionate share calculation for hospitals, as determined pursuant to subparagraph (B), plus one standard deviation shall be subtracted from the hospital's Wyoming Medicaid utilization rate. The difference shall be multiplied by the hospital's Wyoming inpatient Medicaid payment during the hospital's fiscal year. The sum shall be the amount of the disproportionate share payment for that fiscal year.
(A) Hospitals shall be automatically considered for a disproportionate share payment pursuant to this paragraph.
(B) Determination of mean disproportionate share calculation. The Department shall determine the mean disproportionate share calculation of Medicaid utilization for hospitals for each Wyoming State fiscal year using the most recently settled cost reports, adjusted to reflect Wyoming Medicaid claims history.
(ii) Disproportionate share payments based on low income utilization rate.
(A) Request for consideration. A hospital which wishes to be considered for disproportionate share payments pursuant to paragraph (b)(ii) shall submit a request for consideration of disproportionate share payment based on low income utilization rate.
(B) Time and content of request. The Department shall notify hospitals that it is determining eligibility for low income utilization DSH payments. Such notices shall:
(I) Be in writing;
(II) Be sent by certified mail, return receipt requested;
(III) Specify the fiscal period for which low income utilization DSH payments are being calculated;
(IV) Specify the information which must be contained in a request for consideration of disproportionate share payments based on low income utilization rate; and
(V) Specify the date by which a request for low income DSH payments must be made.
(C) The failure to timely submit a request for consideration of disproportionate share payments based on low income utilization rate, including the correct cost report, if available, shall preclude the hospital from requesting or receiving a disproportionate share payment pursuant to paragraph (b)(ii). If the hospital cannot submit the correct cost report because of delay caused by the intermediary, the hospital must submit verification of the delay from the intermediary on or before the date the request is due. In such a case, the Department shall not compute the hospital's disproportionate share payment until after the hospital submits the correct cost report.
(D) Calculation of payments. The disproportionate share payment shall be based on the settled cost report for the year specified in the notice, adjusted to reflect Wyoming Medicaid claims history. A hospital which meets the criterion of paragraph (b)(ii) shall receive a payment determined as follows. If the low income utilization rate exceeds twenty-five percent, the hospital shall be entitled to a disproportionate share payment. The disproportionate share payment shall be equal to the low income utilization rate in excess of twenty-five percent multiplied by the hospital's Wyoming inpatient Medicaid payment during the hospital's fiscal year..
(iii) A hospital which qualifies under paragraphs (b)(i) and (b)(ii) shall receive the amount determined pursuant to (c)(i) or the amount determined pursuant to (c)(ii), whichever is greater.
(d) Notice of disproportionate share payment. The Department shall provide notice to:
(i) All hospitals of whether they are entitled to disproportionate share payments pursuant to (b)(i); and
(ii) Those hospitals which request consideration for payment based on low income utilization rate (pursuant to (b)(ii)).
(iii) Such notice shall:
(A) Be in writing;
(B) Be mailed by certified mail, return receipt requested; and
(C) Include the hospital's right to request reconsideration of the determination of disproportionate share payments or the denial of DSH payments.
(e) Method of payment. The Department shall request the issuance of a payment warrant for the lump sum payment of disproportionate share payments within fifteen days after the date of the notice provided pursuant to subsection (d).
(f) A change in a provider's allowable costs or reimbursement rate as the result of a reopening, reconsideration, administrative hearing or judicial proceeding shall not result in the recomputation of the provider's disproportionate share payment pursuant to this Chapter.
(a) A hospital must comply with Chapter 3, Section 7, which is incorporated by this reference.
(b) Out-of-state records. If a provider maintains financial records or medical records in a state other than Wyoming, the provider shall either transfer the records to an in-state location that is suitable for the Department or reimburse the Department for reasonable costs, including travel, lodging and meals, incurred in performing the audit in an out-of-state location, unless otherwise agreed by the Department.
(a) The Department may perform audits pursuant to Chapter 30, which is incorporated by this reference.
(b) Reporting audit results. If at anytime during a financial audit or a medical audit, HCF discovers evidence suggesting fraud or abuse by a provider, that evidence, in addition to HCF's final audit report regarding that provider, shall be referred to the Medicaid Fraud Control Unit of the Wyoming Attorney General's Office.
Section 8. Recovery of excess payments. The Department shall recover excess payments pursuant to Chapter 3, Section 12, which is incorporated by this reference.
(a) Request for reconsideration. A provider may request reconsideration of a request to recover excess payments, or the denial or calculation of disproportionate share payments. Such a request must be mailed to the Department, by certified mail, return receipt requested, within twenty days after the date the provider receives notice pursuant to Section 5. The request must state with specificity the reasons for the request. Failure to provide such a statement shall result in the dismissal of the request with prejudice.
(b) Reconsideration. The Department shall review the matter and send written notice by certified mail, return receipt requested, to the provider of its final decision within forty-five days after receipt of the request for reconsideration or the receipt of any additional information requested pursuant to (c), whichever is later.
(c) Request for additional information. The Department may request additional information from the provider as apart of the reconsideration process. Such a request shall be made in writing by certified mail, return receipt requested. The provider must provide the requested information within the time specified in the request. Failure to provide the requested information shall result in the dismissal of the request with prejudice.
(d) Matters subject to reconsideration. A provider may request reconsideration of the following:
(ii) The denial or calculation of disproportionate share payments.
(e) Reconsideration shall be limited to whether the Department has complied with the provisions of this Chapter.
(f) Informal resolution. The provider or the Department may request an informal meeting before the final decision on reconsideration to determine whether the matter may be resolved. The substance of the discussions and/or settlement offers made pursuant to an attempt at informal resolution shall not be admissible as part of a subsequent administrative hearing or judicial proceeding.
(g) Administrative hearing. A provider may request an administrative hearing regarding the final agency decision pursuant to Chapter 1 of these rules by mailing by certified mail, return receipt requested or personally delivering a request for hearing to the Department within twenty days after the date the provider receives notice of the final agency decision. At the hearing, the burden shall be on the provider to show that the agency's final decision does not comply with this Chapter.
(h) Failure to request reconsideration. A provider which fails to request reconsideration pursuant to this Section may not subsequently request an administrative hearing pursuant to Chapter 1.
(i) Matters not subject to reconsideration.
(i) The use or reasonableness of the disproportionate share methodology set forth in this Chapter;
(ii) A change in payment caused by a change in the disproportionate share methodology as the result of a change in state or federal law, including an amendment to this Chapter or other rules of the Department; or
(iii) The denial of low income utilization DSH payments based on a hospital's failure to timely submit a request for consideration of disproportionate share payments based on low income utilization rate.
(j) Confidentiality of settlement agreements. If the Division and a provider enter into a settlement agreement as part of a reconsideration or an administrative hearing, such agreement shall be confidential, except as otherwise required by law. A breach of confidentiality by the provider shall, at the Division's option, result in the settlement agreement becoming null and void.
(k) Effect of change in payment. A change to any disproportionate share payment as a result of a reconsideration, reopening, administrative hearing, or court review, shall not result in the redetermination of any arrays, medians, averages or other system wide computations.
(a) The order in which the provisions of this Chapter appear is not to be construed to mean that any one provision is more or less important than any other provision.
(b) The text of this Chapter shall control the titles of various provisions.
Section 11. Automatic expiration of rule. This Chapter shall automatically expire upon the elimination of Section 1923 of the Social Security Act and/or any other relevant provisions of Federal statutes or regulations.
Section 12. Superseding effect. This Chapter supersedes all prior rules or policy statements issued by the Department, including provider manuals and provider bulletins, which are inconsistent with this Chapter, except as otherwise specified in this Chapter.
Section 13. Severability. If any portion of these rules is found to be invalid or unenforceable, the remainder shall continue in effect.
The Wyoming Department of Health (the Department) is the single state agency appointed pursuant to the Social Security Act (the Act) to administer the Medicaid program in Wyoming. The Wyoming Medical Assistance and Services Act of 1967 (the Wyoming Act) requires the Department to administer the Medicaid program in conformance with federal standards.
The Wyoming Act authorizes the Department to promulgate necessary rules. The Wyoming Administrative Procedure Act requires all agency statements of general applicability that implement, interpret or prescribe law or policy be promulgated as rules.
The Act requires the Department to provide for additional Medicaid payments to hospitals that provide a disproportionate share of inpatient hospital services to Medicaid recipients and/or low income patients. The Act establishes the methods and standards the Department must follow in making such disproportionate share payments.
The Department promulgated Chapter 32 to provide for disproportionate share hospital payments in conformance with Federal law. (Hospital services are generally reimbursed pursuant to Chapters 30, 31 and 33 of the Department's Medicaid rules.)
Chapter 32 is being amended to clarify the procedures and standards used to make disproportionate share hospital payments. It will replace the existing Chapter 32.