Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.09 - MEDICAID BASIC PLAN BENEFITS › COVERED SERVICES › SUB AREA: HOSPITAL SERVICES › Section 16.03.09.400 - HOSPITAL SERVICES - DEFINITIONS

Current through August 31, 2023
01.
Administratively Necessary Day (AND)
. An Administratively Necessary Day
				  (AND) is intended to allow a hospital time for an orderly transfer or discharge
				  of participant inpatients who are no longer in need of a continued acute level
				  of care. ANDs may be authorized for inpatients who are awaiting placement for
				  nursing facility level of care, or in-home services that are not available, or
				  when catastrophic events prevent the scheduled discharge of an inpatient.
				  (3-17-22)
02.
Allowable
				  Costs
. The current year's Medicaid apportionment of a hospital's
				  allowable costs determined at final or interim settlement if cost settlements
				  are applicable, or determined using the version of the cost report used for
				  prospective payment system (PPS) rate setting, consist of those costs permitted
				  by the principles of reimbursement contained in the Provider Reimbursement
				  Manual (PRM) and do not include costs already having payment limited by
				  Medicaid rate file or any other Medicaid charge limitation. (3-17-22)
03.
Apportioned Costs
.
				  Apportioned costs consist of the share of a hospital's total allowable costs
				  attributed to Medicaid program participants and other patients so that the
				  share borne by the program is based upon actual services received by program
				  participants, as set forth in the applicable Title XVIII principles of cost
				  reimbursement as specified in the PRM and in compliance with Medicaid
				  reimbursement rules. (3-17-22)
04.
Capital Costs
. For the purposes of hospital reimbursement, capital
				  costs are those allowable costs considered in the settlement that represent the
				  cost to each hospital for its reasonable property related and financing
				  expense, and property taxes. (3-17-22)
05.
Case-Mix Index
. The Case-Mix
				  Index for a hospital is the average weight of values assigned to a range of
				  diagnostic related groups and applied to Medicaid discharges. The index will
				  measure the relative resources required to treat Medicaid inpatients. The
				  Case-Mix Index of the current year will be divided by the index of the
				  principal year to assess the percent change between the years.
				  (3-17-22)
06.
Charity
				  Care
. Charity care is care provided to individuals who have no source of
				  payment, third-party or personal resources. (3-17-22)
07.
Children's Hospital
. A
				  Medicare-certified hospital as set forth in
				  42 CFR Section
				  412.23(d).
				  (3-17-22)
08.
Critical Access
				  Hospitals (CAH)
. A rural hospital with twenty-five (25) or less beds as
				  set forth in 42 CFR Section
				  485.620. (3-17-22)
09.
Current Year
. Any hospital
				  cost reporting period for which reasonable cost is being determined will be
				  termed the current year. (3-17-22)
10.
Inpatient Services Customary
				  Hospital Charges
. Customary inpatient hospital charges reflect the
				  regular rates for inpatient services charged to patient(s) liable for payment
				  for their services on a charge basis. Implicit in the use of charges as the
				  basis for comparability (or for apportionment under certain apportionment
				  methods) is the objective that services are related to the cost of services
				  billed to the Department. Effective for service dates beginning July 1, 2021
				  reimbursement will be as follows: (3-17-22)
a.
				  All in-state providers not described in b-d below will be paid a final
				  prospective payment rate using the All Patient Refined Diagnosis Related Group
				  (APR-DRG) classification system as described in Section
				  401 of these rules.
				  (3-17-22)
b. Idaho state-owned
				  hospitals and the Department of Veteran's Affairs Medical Center will be
				  reimbursed at one hundred percent (100%) of allowable cost using a
				  retrospective cost settlement upon receipt of a final Medicare cost report.
				  (3-17-22)
c. In-state, Critical
				  Access Hospitals (CAHs) will be reimbursed at one hundred one percent (101%) of
				  allowable cost using a retrospective cost settlement upon receipt of a final
				  Medicare cost report. (3-17-22)
d.
				  All out-of-state providers not described in a through c above will be paid a
				  final prospective payment rate with no retrospective cost settlement using the
				  All Patient Refined Diagnosis Related Group (APR-DRG) classification system as
				  described in Section 401 of these
				  rules. The out-of-state APR-DRG rates were developed to provide a combined cost
				  coverage of eighty-seven percent (87%) when all out-of-state providers are
				  averaged together in keeping with Section
				  56-265(6)(b),
				  Idaho Code. (3-17-22)