Kentucky Administrative Regulations › Title 907 - CABINET FOR HEALTH AND FAMILY SERVICES - DEPARTMENT FOR MEDICAID SERVICES › Chapter 10 - Hospital Service Coverage and Reimbursement › Section 907 KAR 10:815 - Per diem inpatient hospital reimbursement

Current through Register Vol. 51, No. 1, July 1, 2024
RELATES TO:
				KRS
				13B.140,
				205.510(16),
				205.637,
				205.638,
				205.639,
				205.640,
				205.6405,
				205.6406,
				205.6407,
				205.6408,
				216.380,
				42 C.F.R. Parts 412, 413,
				440.10,
				440.140,
				447.250447.280,
				42 U.S.C.
				1395f(l),
				1395x(mm),
				1395tt,
				1395ww(d)(5)(F),
				1396a,
				1396b,
				1396d,
				1396r-4
NECESSITY, FUNCTION, AND CONFORMITY: The Cabinet for Health and
				Family Services, Department for Medicaid Services has responsibility to
				administer the Medicaid program.
				KRS
				205.520(3) authorizes the
				cabinet, by administrative regulation, to comply with a requirement that may be
				imposed, or opportunity presented by federal law for the provision of medical
				assistance to Kentucky's indigent citizenry. This administrative regulation
				establishes provisions related to per diem inpatient hospital reimbursement
				including provisions necessary to enhance reimbursement pursuant to
				KRS
				205.638.
Section
			 1. Definitions.
(1) "Base year"
			 means the state fiscal year cost reporting period used to establish a per diem
			 rate.
(2) "Capital costs" means
			 capital related expenses including insurance, taxes, interest, and depreciation
			 related to plant and equipment.
(3)
			 "CMS" means Centers for Medicare and Medicaid Services.
(4) "Critical access hospital" or "CAH" means
			 a hospital meeting the licensure requirements established in
			 906 KAR
			 1:110.
(5)
			 "Department" means the Department for Medicaid Services or its
			 designee.
(6) "Diagnosis related
			 group" or "DRG" means a clinically-similar grouping of services that can be
			 expected to consume similar amounts of hospital resources.
(7) "Distinct part unit" means a separate
			 unit within an acute care hospital that meets the qualifications established in
			 42 C.F.R.
			 412.25.
(8) "DRG service" means a discharge,
			 excluding crossover claims or no pay claims, assigned a discharge
			 classification by the diagnosis related group grouper used by the department
			 pursuant to
			 907
			 KAR 10:830, whether the discharge is reimbursed by
			 discharge or via a per diem basis.
(9) "GII" means Global Insight,
			 Incorporated.
(10) "Indexing
			 factor" means the percentage that the cost of providing a service is expected
			 to increase during the universal rate year.
(11) "Inflation factor" means the percentage
			 that the cost of providing a service has increased, or is expected to increase,
			 for a specific period of time.
(12)
			 "Long-term acute care hospital" or "LTAC hospital" means a hospital that meets
			 the requirements established in
			 42 C.F.R.
			 412.23(e).
(13) "Medical education cost" means a direct
			 cost that is:
(a) Associated with an approved
			 intern and resident program; and
(b) Subject to limits established by
			 Medicare.
(14)
			 "Operating cost" means allowable routine, ancillary service, or special care
			 unit cost related to inpatient hospital care.
(15) "Parity factor" means a factor applied
			 to a per diem rate to establish cost coverage parity with diagnosis related
			 group hospital reimbursement.
(16)
			 "Per diem rate" means a hospital's all-inclusive daily rate as calculated by
			 the department.
(17) "Psychiatric
			 hospital" means a hospital meeting the licensure requirements established in
			 902 KAR
			 20:180.
(18) "Rebase" means to redetermine per diem
			 rates using more recent data.
(19)
			 "Rehabilitation hospital" means a hospital meeting the licensure requirements
			 established in
			 902
			 KAR 20:240.
(20) "State-designated free-standing
			 rehabilitation teaching hospital that is not state-owned or operated" means a
			 hospital not state-owned or operated that:
(a) Provides at least 3,000 days of
			 rehabilitation care to Medicaid-eligible recipients in a fiscal year;
(b) Provides at least fifty-one (51) percent
			 of the statewide total of inpatient acute rehabilitation care to
			 Medicaid-eligible recipients;
(c)
			 Provides physical and occupational therapy services to Medicaid recipients
			 needing inpatient rehabilitation services in order to function independently
			 outside of an institution postdischarge;
(d) Is licensed as an acute hospital limited
			 to rehabilitation; and
(e) Is a
			 teaching hospital.
(21)
			 "Swing bed" means a bed approved pursuant to
			 42 U.S.C.
			 1395tt to be used to provide either acute
			 care or extended skilled nursing care to a recipient.
(22) "Third party" means a payor of a third
			 party pursuant to
			 KRS
			 205.510(18).
(23) "Trending factor" means the inflation
			 factor as applied to that period of time between a facility's base fiscal year
			 end and the beginning of the universal rate year.
(24) "Universal rate year" means the twelve
			 (12) month period under the prospective payment system, beginning July of each
			 year, for which a payment rate is established for a hospital regardless of the
			 hospital's fiscal year end.
(25)
			 "Weighted average" means an average that reflects an individual element's
			 proportionality to all elements.