Arkansas Administrative Code › Agency 016 - DEPARTMENT OF HUMAN SERVICES › Division 06 - Medical Services › Rule 016.06.15-011 - SPA #2014-011 and Hospital #4-15

Current through Register Vol. 49, No. 6, June, 2024
Section
			 IIHospital/Critical Access Hospital (CAH)/End Stage Renal Disease
			 (ESRD)
250.230
Daily Upper Limit
A daily upper limit to inpatient hospital reimbursement is
				established in the Title XIX State Plan.
A. A daily upper limit amount of $675.00 is
			 effective for dates of service April 1, 1996 through June 30, 2006. The $675.00
			 daily upper limit for this period represents the 90th percentile of the
			 cost-based per diems (per the cost settlements of their fiscal year-end 1994
			 cost reports) of all hospitals subject to the Arkansas Medicaid daily upper
			 limit at the time of the computation.
B. For dates of service July 1, 2006 and
			 after, DMS will review the hospital cost report data at least biennially and
			 adjust the daily upper limit reimbursement amount if necessary.
C. A daily upper limit amount of $850.00 is
			 effective for dates of service on and after January 1, 2007; effective October
			 1, 2014 inpatient days beyond 24 will be reimbursed at $400.00 per day. This is
			 a prospective per diem rate and will not be included in the cost
			 settlement.
D. The daily upper
			 limit does not apply to the following.
1.
			 Pediatric hospitals
2. Arkansas
			 State Operated Teaching Hospitals, effective for cost reporting periods ending
			 on or after June 30, 2000
3. Border
			 City, University-affiliated, Pediatric Teaching hospitals
4. Inpatient services for children under the
			 age of 1
5. Inpatient services for
			 children, from their first birthday until their discharge date, who were
			 admitted on or before their first birthday and were discharged after their
			 first birthday
E. The
			 daily upper limit is determined as follows.
1.
			 The aggregate daily upper limit amount for a hospital is calculated by
			 multiplying the hospital's cost-reporting period's covered days (excluding days
			 subject to the $400 per diem prospective reimbursement amount) by the $850
			 upper cost per diem limit.
2. The
			 aggregate daily upper limit amount is compared to the amount carried forward
			 from the comparison of TEFRA-limited costs or charges.
3. The lesser of those two amounts becomes
			 the new aggregate daily upper limit amount, subject to any additional payments
			 or adjustments that may apply, such as direct graduate medical education (GME)
			 costs or disproportionate share hospital (DSH) payments.
4. Effective for dates of service on or after
			 July 1, 2006, Medicaid will review hospital cost report data at least
			 biennially, in accordance with the methodology described above in subparts 1,
			 2, and 3 and adjust the daily upper limit amount if necessary.
AMOUNT, DURATION AND SCOPE OF SERVICES
				PROVIDED
ATTACHMENT 3.1-A
1. Inpatient Hospital Services
All inpatient admissions to an acute care/general hospital or
				rehabilitative hospital will be allowed up to four (4) days of service per
				admission when determined inpatient care is medically necessary. On the fifth
				day of hospitalization, if the physician determines the patient should not be
				discharged on the fifth day of hospitalization, the hospital may contact the
				Quality Improvement Organization
(QIO)
and request an extension of
				inpatient days. The Quality Improvement Organization will then determine
				medically necessary days. Calls for extension of days may be made at any point
				from the fourth day of stay through discharge. However the provider must accept
				the financial liability should the stay not meet the necessary medical criteria
				for inpatient services. Medically necessary inpatient days are available to
				individuals under age 1 without regard to the four day limit and extension
				procedures required under the plan. Additionally, effective for dates of
				service on or after November 1,2001, a benefit limit of 24 days per State
				Fiscal Year (July 1 through June 30) is imposed for recipients age 21 and
				older. No extensions will be authorized. The benefit limit does not apply to
				recipients under age 21 in the Child Health Services (EPSDT) Program or
				beneficiaries, regardless of age, who meet the following criteria:
I. Diagnosis (one of the following)
a. the presence of two or more diagnoses on
			 Axis I and/or II is indicative of a serious emotional disorder
b.the presence of a diagnosis on Axis I or II
			 and a diagnosis on Axis III
II. Poor prognostic factors are as evidenced
			 by
a.early age at time of onset
b.positive family history for major mental
			 illness
c.prior treatment has been
			 ineffective; treatment failure, poor response to treatment
d.co-occurring presentation (medical illness,
			 developmental disability, substance abuse/disorder & mental
			 illness)
e. non-compliance with
			 treatment
f.compromised social
			 support system
g.other
			 evidence-based poor prognostic factors (varies by condition or
			 disorder)
III. Patient
			 was referred by another behavioral health professional for an expert opinion
Effective for dates of service on or after October
				1,2014, days over 24 days per State Fiscal Year will be reimbursed for age 21
				and older.
Inpatient hospital services required for pancreas/kidney
				transplants, liver/bowel transplants and skin transplants for burns are covered
				for eligible Medicaid recipients in the Child Health Services (EPSDT) Program.
				Refer to Attachment 3.1-E, Pages 2, 4 and 6
ATTACHMENT 3.1-B
All inpatient admissions to an acute care/general hospital or
				rehabilitative hospital will be allowed up to four (4) days of service per
				admission when determined inpatient care is medically necessary. On the fifth
				day of hospitalization, if the physician determines the patient should not be
				discharged on the fifth day of hospitalization, the hospital may contact the
				Quality Improvement Organization
(QIO)
and request an extension of
				inpatient days. The Quality Improvement Organization will then determine
				medically necessary days. Calls for extension of days may be made at any point
				from the fourth day of stay through discharge. However the provider must accept
				the financial liability should the stay not meet the necessary medical criteria
				for inpatient services. Medically necessary inpatient days are available to
				individuals under age 1 without regard to the four day limit and extension
				procedures required under the plan. Additionally, effective for dates of
				service on or after November 1,2001, a benefit limit of 24 days per State
				Fiscal Year (July 1 through June 30) is imposed for recipients age 21 and
				older. No extensions will be authorized. The benefit limit does not apply to
				recipients under age 21 in the Child Health Services (EPSDT) Program.
Effective for dates of service on or after October 1,2014, days over 24
				days per State Fiscal Year will be reimbursed for age 21 and
				older.
Inpatient hospital services required for pancreas/kidney
				transplants, liver/bowel transplants and skin transplants for burns are covered
				for eligible Medicaid recipients in the Child Health Services (EPSDT) Program.
				Refer to Attachment 3.1-E, Pages 2, 4, and 6.
METHODS AND STANDARDS FOR ESTABLISHING PAYMENT RATES
				-INPATIENT HOSPITAL SERVICES
ATTACHMENT 4.19-A
The State has in place a public process, which complies with
				the requirements of Section 1902(a)(13)(A) of the Social Security Act.
In accordance with Section 1902(s) of the Social Security Act,
				we do not impose dollar limits on any inpatient hospital services for children
				under age one (or children that are hospitalized on their first birthday). This
				includes the $850.00 per diem cost limit, the TEFRA rate of increase limit, the
				customary charge upper limit or the $150,000 bone marrow transplant limit. This
				applies to all inpatient hospitals.
Effective for claims with dates of service on or after January
				1,2007, all acute care hospitals with the exception of Pediatric Hospitals,
				Border City University-Affiliated Pediatric Teaching Hospitals, Arkansas State
				Operated Teaching Hospitals, Rehabilitative Hospitals, Inpatient Psychiatric
				Hospitals, Out-Of-State Hospitals and Critical Access Hospitals will be
				reimbursed based on reasonable cost with interim per diem rates and year-end
				cost settlements, with a cost limit of $850 per day.
Effective for dates of services October 1,2014 and after
				for recipients age 21 and older, all acute care, Pediatric, Border-City
				University-affiliated Pediatric Teaching Hospitals, Arkansas State Operated
				Teaching Hospitals will be reimbursed a $400 prospective per diem rate with no
				cost settlement for hospital days beyond 24 during the State Fiscal Year. The
				$400 prospective per diem rate does not apply to beneficiaries age 21 and older
				who receive inpatient services in accordance with special diagnosis criteria
				identified in Attachment 3.1-A Page la, Sectionl.
Arkansas Medicaid will use the lesser of cost or charges or the
				$850 per diem cost limit multiplied by total hospital Medicaid days
24
				and under
to establish cost settlements. Except for malpractice
				insurance, graduate medical education costs and the base period for determining
				the TEFRA target limits, the interim per diem rates and the cost settlements
				are calculated in a manner consistent with the method used by the Medicare
				Program. The definition of allowable costs to be used is as follows:
(a) The State will use the Medicare allowable
			 costs as stated in the HIM-15/PRM-15.
The State will use the criteria referenced in
				42 CFR, Section
				413.89(e) - Criteria for
				allowable bad debt, to determine allowable bad debt.
(b) Physicians/Administrative/Teachers will
			 be included in costs as recognized by Medicare reimbursement principles.
At cost settlement, Arkansas Medicaid will limit reimbursement
				to the lowest of the following:
(a)
			 Allowable costs after application of the TEFRA rate of increase limit. The
			 TEFRA rate of increase limit is the hospital's TEFRA target rate multiplied by
			 its total number of Medicaid discharges.
Effective for cost reporting periods ending on or after June
				30,2000, the TEFRA rate of increase limit will no longer be applied to Arkansas
				State Operated Teaching Hospitals.
(b) The hospital's customary charges to the
			 general public for the services. (This will be applied on an annual basis at
			 cost settlement.)
(c) A maximum
			 limit per Medicaid days. The maximum limit is the total number of Medicaid
			 inpatient days during the cost reporting period multiplied by the $850.00 per
			 diem cost limit.
Rehabilitative Hospitals
Effective for dates of service on or after August 1,1991,
				rehabilitative hospitals are reimbursed hospital-specific prospective per diem
				rates, subject to an upper limit, with no cost settlement. Rates will be
				effective July 1 of each year. The rate year is the State fiscal year, July 1
				through June 30.
Effective October 1, 2014 for recipients age 21 and
				older, all in-state and out-of-state rehabilitative hospitals will be
				reimbursed a $400 prospective per diem rate for hospital days beyond 24 during
				the State Fiscal Year.
The prospective per diem rates are established using total
				reimbursable costs under Medicare principles of reasonable cost reimbursement,
				except that the gross receipts tax is not an allowable cost. The initial per
				diem rate is calculated from the hospital's most recent unaudited cost report
				submitted to Medicare prior to July 1, 1991, trended forward for inflation.
				Arkansas Medicaid will calculate a new per diem rate annually, based on the
				provider's most recent unaudited cost report, and adjust the per diem rate for
				inflation.
The inflation factor used will be the Consumer Price Index for
				all urban consumers (CPI-U), U.S. city average for all items. We will use the
				change in the CPI-U during the calendar year before the start of the rate year.
				For example, we will use the 12-month change in the CPI-U as of December 31,
				1991, to set the rates that will be effective July 1, 1992. The inflation
				adjustment will be made at the beginning of each rate year.
The upper limit is set annually at the 70th percentile of all
				rehabilitative hospitals' inflation-adjusted Medicaid per diem rate. Arkansas
				Medicaid will negotiate with the Arkansas Hospital Association annually (State
				fiscal year July 1 through June 30) regarding adjustment of the 70th percentile
				upper limit.