Hawaii Administrative Rules › Title 17 - DEPARTMENT OF HUMAN SERVICES › Department of Human Services › Chapter 1739 - AUTHORIZATION, PAYMENT, AND CLAIMS IN THE FEE-FOR-SERVICE MEDICAL ASSISTANCE PROGRAM › Subchapter 3 - PROSPECTIVE PAYMENT FOR ACUTE CARE SERVICES › Section 17-1739-55 - Payment for acute care services -general provisions

Current through June, 2024
(a)
				  The Hawaii medicaid program shall reimburse qualified providers for inpatient
				  institutional services based solely on the prospective payment rates developed
				  for each facility as determined in accordance with this subchapter. The
				  estimated average proposed payment rate under this subchapter is reasonably
				  expected to pay no more in the aggregate for inpatient hospital services than
				  the amount that the department reasonably estimates would be paid for those
				  services under Medicare principles of reimbursement.
(b) A hospital-specific retrospective
				  settlement adjustment shall be made for those providers whose medicaid charges
				  are less than medicaid payments on the cost report and do not qualify as
				  nominal charge providers under Medicare principles of reimbursement.
(c) Prospective rates shall be derived from
				  historical facility costs, and facilities shall be classified based on
				  discharge volume and participation in an approved intern and resident teaching
				  program.
(d) Providers which
				  average fewer than 250 medicaid discharges per year shall be classified as
				  classification I facilities and shall receive payment based on either an
				  all-inclusive psychiatric services per diem rate or an all-inclusive
				  nonpsychiatric services per diem rate, which includes an adjustment for
				  capital, disproportionate share, and medical education and, for proprietary
				  facilities, return on equity and gross excise tax.
(e) Providers which average two hundred fifty
				  medicaid discharges or more per year shall be separated into two facility
				  classifications (classifications II and III) and shall receive payment based
				  upon the type of services required by the patient. Psychiatric services will be
				  paid on the basis of an all-inclusive per diem rate. Nonpsychiatric claims will
				  be designated as requiring either surgical, medical, or maternity care and will
				  be paid on the basis of a routine per diem rate for the service type plus an
				  ancillary per discharge rate for the service type. The per diem and per
				  discharge rates shall include adjustments for capital, medical education,
				  disproportionate share, and for proprietary facilities, return on equity and
				  gross excise tax.
(f) The
				  freestanding rehabilitation hospital shall be excluded from classifications I,
				  II, and III and shall receive payment based on either an all-inclusive
				  psychiatric services per diem rate or an all-inclusive nonpsychiatric services
				  per diem rate, with the same adjustments noted above.
(g) Claims for payment shall be submitted
				  following discharge of a patient, except as follows:
(1) Claims for nonpsychiatric inpatient stays
				  which exceed $35,000 shall be submitted in accordance with section
				  17-1739-72;
(2) If a patient is
				  hospitalized in the freestanding rehabilitation hospital for more than thirty
				  days, the facility may submit an interim claim for payment every thirty days
				  until discharge. The final claim for payment shall cover services rendered on
				  all those days not previously included in an interim claim.