KRS § 205.6405 — KY Code / Title XVII / Chapter 205 / Section 205.6405
205.6405 Definitions for KRS 205.6405 to 205.6408
Status: in_force

205.6405 Definitions for KRS 205.6405 to 205.6408.

As used in KRS 205.6405 to 205.6408:

(1) "Assessment" means the hospital assessment authorized by KRS 205.6406;

(2) "Commissioner" means the commissioner of the Department for Medicaid Services;

(3) "Department" means the Department for Medicaid Services;

(4) "Excess disproportionate share taxes" means any excess provider tax revenues

collected under KRS 142.303 that are not needed to fund the state share of hospital

disproportionate share payments under KRS 205.640 due to federal

disproportionate share allotments being reduced and limited to the portion of

provider tax revenues collected under KRS 142.303 necessary to fund the state

share of the difference between the unreduced disproportionate share allotment and

the reduced disproportionate share allotment;

(5) "Intergovernmental transfer" means any transfer of money by or on behalf of a

public agency for purposes of qualifying funds for federal financial participation in

accordance with 42 C.F.R. sec. 433.51;

(6) "Long-term acute hospital" means an in-state hospital that is certified as a long-term

care hospital under 42 U.S.C. sec. 1395ww(d)(1)(B)(iv);

(7) "Managed care" means the provision of Medicaid benefits through managed care

organizations under contract with the department pursuant to 42 C.F.R. sec. 438;

(8) "Managed care gap" means:

(a) For hospital inpatient services, the difference between the maximum

actuarially sound amount that can be included in managed care rates for

hospital inpatient services provided by qualifying hospitals and the amount of

total payments for hospital inpatient services provided by qualifying hospitals

paid by managed care organizations. For purposes of the managed care gap,

total payments shall exclude payments established under KRS 205.6405 to

205.6408; and

(b) For hospital outpatient services, the difference between the maximum

actuarially sound amount that can be included in managed care rates for

hospital outpatient services provided by qualifying hospitals and the amount

of total payments for hospital outpatient services provided by qualifying

hospitals paid by managed care organizations. For purposes of the managed

care gap, total payments shall exclude payments established under KRS

205.6405 to 205.6408;

(9) "Managed care organization" means an entity contracted with the department to

provide Medicaid benefits pursuant to 42 C.F.R. sec. 438;

(10) "Non-state government-owned hospital" means the same as non-state government-

owned or operated facilities in 42 C.F.R. sec. 447.272 and represents one (1) group

of hospitals for purposes of estimating the upper payment limit;

(11) "Pediatric teaching hospital" means the same as in KRS 205.565;

(12) "Private hospitals" means the same as privately owned and operated facilities in 42

C.F.R. sec. 447.272 and represents one (1) group of hospitals for purposes of

estimating the upper payment limit;

(13) "Program year" means the state fiscal year during which an assessment is assessed

and rate improvement payments are made;

(14) "Psychiatric access hospital" means an in-state psychiatric hospital licensed under

KRS Chapter 216B that:

(a) Is not located in a Metropolitan Statistical Area;

(b) Provides at least sixty-five thousand (65,000) days of inpatient care as

reflected in the department's hospital rate data for state fiscal year 1998-1999;

(c) Provides at least twenty percent (20%) of inpatient care to Medicaid-eligible

recipients as reflected in the department's hospital rate data for state fiscal

year 1998-1999; and

(d) Provides at least five thousand (5,000) days of inpatient psychiatric care to

Medicaid recipients in a state fiscal year;

(15) "Qualifying hospital":

(a) Means a Medicaid-participating, in-state hospital licensed under KRS Chapter

216B, including a long-term acute hospital, but excluding a university hospital

and a state mental hospital as defined in KRS 205.639. The department may,

but is not required to, exclude critical access hospitals and rural emergency

hospitals from the definition of "qualifying hospital" for purposes of

calculating the quarterly assessments. Notwithstanding the permission

referenced in this subsection, or any other provision of the law to the contrary,

the department may include critical access hospitals and rural emergency

hospitals for purposes of calculating and paying the quarterly supplemental

payments authorized in KRS 205.6406; and

(b) Notwithstanding paragraph (a) of this subsection, a university hospital that is

not located on the affiliated university's primary campus may be deemed to be

a qualifying hospital if the university hospital does not participate in a

separate directed payment program for university hospitals;

(16) "Qualifying hospital disproportionate share percentage" means a percentage equal

to the amount of hospital provider taxes paid pursuant to KRS 142.303 by

qualifying hospitals in state fiscal year 2016-2017 divided by the amount of hospital

provider taxes paid pursuant to KRS 142.303 by all hospitals in state fiscal year

2016-2017;

(17) "University hospital" means a state university teaching hospital, owned or operated

by either the University of Kentucky College of Medicine or the University of

Louisville School of Medicine, including a hospital owned or operated by a related

organization pursuant to 42 C.F.R. sec. 413.17;

(18) "University hospital disproportionate share percentage" means a percentage equal to

the amount of hospital provider taxes paid pursuant to KRS 142.303 by university

hospitals and state mental hospitals, as defined in KRS 205.639, in state fiscal year

2016-2017 divided by the amount of hospital provider taxes paid pursuant to KRS

142.303 by all hospitals in fiscal year 2016-2017;

(19) "Upper payment limit" or "UPL" means the methodology permitted by federal

regulation to achieve the maximum allowable amount on aggregate hospital

Medicaid payments to non-state government-owned hospitals and private hospitals

under 42 C.F.R. sec. 447.272. A separate UPL shall be estimated for non-state

government-owned hospitals and private hospitals; and

(20) "UPL gap" means the difference between the UPL and amount of total fee-for-

service payments paid by the department for hospital inpatient services provided by

non-state government-owned hospitals and private hospitals to Medicaid

beneficiaries and excluding payments established under KRS 205.6405 to

205.6408. A separate UPL gap shall be estimated for the non-state government-

owned hospitals and private hospitals.