Missouri Code of State Regulations › Title 13 - DEPARTMENT OF SOCIAL SERVICES › Division 70 - MO HealthNet Division › Chapter 15 - Hospital Program › Section 13 CSR 70-15.015 - Direct Medicaid Payments

Current through Register Vol. 49, No. 14, July 15, 2024
PURPOSE: This rule is being amended to remove
				  outdated language and update the criteria used to determine safety net
				  hospitals.
(1) Direct
				Medicaid Qualifying Criteria.
(A) An inpatient
				hospital provider may qualify as a Disproportionate Share Hospital (DSH) based
				on the following criteria. Hospitals shall qualify as a DSH for a period of
				only one (1) state fiscal year (SFY) and must requalify at the beginning of
				each SFY to continue their DSH classification.
1. If the facility offered nonemergency
				obstetric services as of December 21, 1987, there must be at least two (2)
				obstetricians with staff privileges at the hospital who have agreed to provide
				obstetric services to individuals entitled to these services under the Missouri
				Medicaid plan. In the case of a hospital located in a rural area (area outside
				of a metropolitan statistical area, as defined by the federal Executive Office
				of Management and Budget), the term obstetrician includes any physician with
				staff privileges at the hospital to perform nonemergency obstetric procedures.
				This section does not apply to hospitals either with inpatients predominantly
				under eighteen (18) years of age or which did not offer nonemergency obstetric
				services as of December 21, 1987.
2. As determined from the fourth prior year
				audited cost report, the facility must have either-
A. A Medicaid inpatient utilization rate
				(MIUR) at least one (1) standard deviation above the state's mean MIUR for all
				Missouri hospitals. The MIUR will be expressed as the ratio of total Medicaid
				days (TMD) provided under a state plan divided by the provider's total number
				of inpatient days (TNID). The state's mean MIUR will be expressed as the ratio
				of the sum of the total number of the Medicaid days for all Missouri hospitals
				divided by the sum of the total patient days for the same Missouri hospitals.
				Data for hospitals no longer participating in the program will be excluded;
MIUR = TMD / TNID
or
B. A
				low-income utilization rate (LIUR) in excess of twenty-five percent (25%). The
				LIUR shall be the sum (expressed as a percentage) of the fractions, calculated
				as follows:
(I) Total MO HealthNet patient
				revenues (TMPR) paid to the hospital for patient services under a state plan
				plus the amount of the cash subsidies (CS) directly received from state and
				local governments, divided by the total net revenues (TNR) (charges, minus
				contractual allowances, discounts, and the like) for patient services plus the
				CS; and
(II) The total amount of
				the hospital's charges for patient services attributable to charity care (CC)
				(care provided to individuals who have no source of payment, third-party, or
				personal resources) less CS directly received from state and local governments
				in the same period, divided by the total amount of the hospital's charges (THC)
				for patient services. The total patient charges attributed to CC shall not
				include any contractual allowances and discounts other than for indigent
				patients not eligible for MO HealthNet under a state plan.
LIUR = ((TMPR + CS) / (TNR + CS)) + ((CC - CS) /
				  (THC))
3. As determined from the fourth prior year
				audited cost report, the hospital-
A. Has an
				unsponsored care ratio of at least ten percent (10%). The unsponsored care
				ratio is determined as the sum of bad debts and CC divided by TNR and also
				meets either of the criteria in paragraph (1)(A)2.; or
B. Ranks in the top fifteen (15) in the
				number of Medicaid inpatient days provided by that hospital compared to
				Medicaid patient days provided by all hospitals, and the hospitals also have a
				Medicaid nursery utilization ratio greater than thirty-five percent (35%) as
				computed by dividing Title XIX nursery and neonatal days by total nursery and
				neonatal days; or
C. Operated a
				neonatal intensive care unit with a ratio of Missouri Medicaid neonatal patient
				days to Missouri Medicaid total patient days in excess of nine percent (9%)
				reported or verified by the division from the fourth prior year cost
				report.
4. As determined
				from the fourth prior year audited cost report-
A. The acute care hospital has an unsponsored
				care ratio of at least sixty-five percent (65%) and is licensed for less than
				fifty (50) inpatient beds; or
B.
				The acute care hospital has an unsponsored care ratio of at least sixty-five
				percent (65%) and is licensed for fifty (50) inpatient beds or more and has an
				occupancy rate of more than forty percent (40%); or
C. A public non-state governmental acute care
				hospital with an LIUR of at least fifty percent (50%) and an MIUR greater than
				one (1) standard deviation from the mean, and is licensed for fifty (50)
				inpatient beds or more and has an occupancy rate of at least forty percent
				(40%); or
D. The hospital is owned
				or operated by the Board of Curators as defined in Chapter 172, RSMo, or their
				successors; or
E. The hospital is
				a public hospital operated by the Department of Mental Health primarily for the
				care and treatment of mental disorders.
5. As determined from the fourth prior year
				audited cost report, hospitals which annually provide more than five thousand
				(5,000) Title XIX days of care and whose Title XIX nursery days represent more
				than fifty percent (50%) of the hospital's total nursery days.