Wyo. Code R. 048-0037-32
Medicaid
Chapter 32: Reimbursement of Disproportionate Share Hospitals
Effective Date: 06/28/1994 to 02/18/1997
Rule Type: Superceded Rules & Regulations
Reference Number: 048.0037.32.06281994
Date Filed 06/28/94
Expr Date
Supr Date
Repeal Date
Document Type RULES
This rule 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 rule shall apply to and govern Medicaid payments to disproportionate share hospitals for inpatient hospital services provided on or after July 1, 1994. This rule is intended to implement and be read in conjunction with 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 rule 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.
(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 July 1, 1994 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 disproportionate share hospital as defined by 42 U.S.C. 1396r-4(b)(1), which is incorporated by this reference.
(n) 'Division.' The Division of Health Care Financing of the Department, its agent, designee or successor.
(o) 'Enrolled.' Enrolled as defined in Chapter 3, Section 3(l), which is incorporated by this reference.
(p) 'Excess payments.' Medicaid funds received by a provider which exceed the Medicaid allowable payment established by the Department.
(q) '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.
(r) 'HCFA.' The Health Care Financing Administration of the United States Department of Health and Human Services, its agent, designee or successor.
(s) 'HHS.' The United States Department of Health and Human Services, its agent, designee or successor.
(t) '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; (v) is licensed to operate as a hospital by the State of Wyoming or, if the institution is out-of-state, licensed by the state in which the institution is located; and (vi) meets the requirements of 42 U.S.C. 1396r-4.
(u) 'Inpatient.' An 'inpatient' as defined by 42 C.F.R. 440.2(a), which is incorporated by this reference.
(v) 'Inpatient hospital services.' Inpatient hospital services as defined by 42 C.F.R. 440.10, which is incorporated by this reference.
(w) 'Low income utilization rate.' The low income utilization rate as defined by 42 U.S.C. 1396r-4(b)(3), which is incorporated by this reference.
(x) 'Medicaid.' Medical assistance and services provided pursuant to Title XIX of the Social Security Act and the Wyoming Medical Assistance and Services Act.
(y) 'Medicaid inpatient utilization rate.' The Medicaid inpatient utilization rate as defined by 42 U.S.C. 1396r-4(b)(2), which is incorporated by this reference.
(z) '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.
(aa) 'Medicare.' The health insurance program for the aged and disabled established pursuant to Title XVIII of the Social Security Act.
(bb) '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.
(cc) '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.
(dd) 'Outpatient hospital services.' Outpatient hospital services as defined by 42 C.F.R. 449.20(a), which is incorporated by this reference.
(ee) 'Patient.' An individual admitted to a hospital or other provider of inpatient or outpatient hospital services.
(ff) 'Provider.' A provider as defined by Chapter 3, which definition is incorporated by this reference.
(ff) 'Recipient.' A person who has been determined eligible for Medicaid.
(hh) 'Request for consideration of disproportionate share payment.' A request by a hospital located outside the State of Wyoming that the department determine whether the hospital is entitled to disproportionate share payment. Such a request must be in writing, sent by certified mail, include the information necessary for the Department to compute the hospital's Medicaid utilization rate or the hospital's low income utilization rate, depending on whether the hospital is requesting payments pursuant to Section 5(b)(i) or (ii), and must be prepared in the form specified by the Department. 'Request for consideration of disproportionate share payment' 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.
(ii) 'Request for consideration of disproportionate share payments based on low income utilization rate.' A request by a hospital located in the State of Wyoming 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.
(jj) '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 reports 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.
(kk) 'Survey agency.' The Health Facilities Survey, Certification and Licensure Office of the Department, its agent, designee or successor, or a comparable agency in another state.
(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. Payments made pursuant to this section shall not exceed the limits established by 42 U.S.C. 1396r-4, which is incorporated by this reference.
(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 twentyfive 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 payment determined as follows: The sum of the mean disproportionate share calculation for hospitals in Wyoming, as determined pursuant to subparagraph (C), 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 located in Wyoming shall be automatically considered for a disproportionate share payment pursuant to this paragraph.
(B) Hospitals located outside Wyoming that wish to be considered for disproportionate share payments pursuant to this paragraph must comply with subparagraph (C).
(C) Determination of mean disproportionate share calculation for hospitals in Wyoming. The Department shall determine the mean disproportionate share calculation of Medicaid utilization for hospitals in Wyoming for each Wyoming State fiscal year using the most recently settled cost reports, adjusted to reflect Wyoming Medicaid claims history, submitted for hospitals located in Wyoming.
(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. A request for disproportionate share payment pursuant to paragraph (b)(ii) must be sent to the Department, by certified mail, on or before October 31st of each year. The hospital must contact the Department before that date to determine which fiscal year's cost report to submit with the request. The failure to timely submit a request, 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.
(C) Calculation of payments. The disproportionate share payment shall be based on the most recently settled cost report, adjusted to reflect Wyoming Medicaid claims history. A hospital which meets the criterion of paragraph (b)(ii) shall receive a payment determined in accordance with Section 1923 of the Social Security Act. 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 total allowable Wyoming Medicaid costs for inpatient hospital services.
(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) Disproportionate share payments for hospitals located outside Wyoming.
(i) Request. An out-of-state hospital which wishes to be considered for disproportionate share payments must submit a request for consideration of disproportionate share payment.
(ii) Time and contents of request. A request for consideration for disproportionate share payment must be sent to the Department as set forth in subparagraph (c)(ii)(B).
(iii) Determination of amount of payment. The amount of the disproportionate share payment shall be that proportion of the amount determined pursuant to (c)(i) or (c)(ii) which is attributable to the hospital's Wyoming Medicaid utilization rate. The payment amount shall be determined based on the array of Wyoming hospitals.
(e) Notice of disproportionate share payment. The Department shall provide notice to all in-state hospitals which are entitled to disproportionate share payment pursuant to (b)(i) or which request consideration for payment pursuant to (b)(ii), and to all out-of-state hospitals which request disproportionate share payments. Notice of disproportionate share payment must include the hospital's right to request reconsideration of the disproportionate share determination pursuant to Section 9. The reconsideration shall be limited to whether the Department has complied with the provisions of this Chapter.
(f) 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 (g).
(g) 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 the state where the provider is located, 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.
Section 7. Audits. The Department may perform audits pursuant to Chapter 30, which is incorporated by this reference.
Section 8. Recovery of excess payments. The Department may 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. 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 8. 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) 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.
(g) 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.
(h) Matters not subject to reconsideration.
(i) The use or reasonableness of the disproportionate share methodology set forth in this Chapter; or
(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.
(i) 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.
Section 10. 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 11. 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.
This Chapter is being promulgated to authorize the Department, in conformance with Federal law, to make disproportionate share payments to qualified providers of inpatient hospital services. (Hospital services are generally reimbursed pursuant to Chapters 30, 31 and 33 of the Department's Medicaid rules.)
Chapter 32 will apply to disproportionate share payments based on services furnished on or after July 1, 1994. Disproportionate share payments for services furnished before that date will be reimbursed pursuant to Chapter 24.