Ohio Administrative Code › Title 5160 - Ohio Department of Medicaid › Chapter 5160-2 - Hospital Services › Section 5160-2-09 - Payment policies for disproportionate share and indigent care adjustments for hospital services

Current through all regulations passed and filed through July 1, 2024
This rule is applicable for each program year for all
				medicaid-participating providers of hospital services included in the
				definition of "hospital" as described under section
				5168.01 of the Revised
				Code.
(A) Definitions.
(1) "Total fee for service (FFS) medicaid
			 costs" for each hospital means the sum of inpatient program costs reported on
			 ODM 02930, schedule H, section I, columns 1 and 3, line 1 and outpatient
			 medicaid program costs as reported on ODM 02930, "Ohio Medicaid Hospital Cost
			 Report," section II, column 1, line 10 for the applicable state fiscal
			 year.
(2) "Total medicaid managed
			 care plan (MCP) inpatient costs" for each hospital means the amount on ODM
			 02930 schedule I, column 3, line 202.
(3)
			 "Total medicaid MCP outpatient costs" for each hospital means the amount on ODM
			 02930 schedule I, column 5, line 202.
(4)
			 "Total Title V costs" for each hospital means the sum of the inpatient and
			 outpatient program costs as reported on ODM 02930, schedule H, section I,
			 column 2, line 1 and section II, column 2, line 10.
(5)
			 "Total inpatient uncompensated care costs for people without insurance" for
			 each hospital means the sum of the  inpatient uncompensated care
			 costs below the poverty level and
			 inpatient uncompensated care costs above the poverty level amounts as totaled
			 on ODM 02930, schedule F, column 5.
(6) "Total inpatient
			 uncompensated care costs under one hundred per cent" for each hospital means
			 the sum of the inpatient uncompensated care costs under one hundred per cent
			 for patients with and without insurance as reported on the ODM 02930, schedule
			 F, columns 4 and 5.
(7) "Total inpatient
			 uncompensated care costs above one hundred per cent without insurance" for each
			 hospital means the sum of the inpatient uncompensated care costs over one
			 hundred per cent for patients without insurance as reported on the ODM 02930,
			 schedule F, column 5.
(8)
			 "Total outpatient uncompensated care costs under one hundred per cent" for each
			 hospital means the sum of the outpatient care costs under one hundred per cent
			 for patients with and without insurance as on the ODM 02930, schedule F,
			 columns 4 and 5.
(9) "Total outpatient
			 uncompensated care costs above one hundred per cent without insurance" for each
			 hospital means the sum of the outpatient uncompensated care costs above one
			 hundred per cent for patients without insurance as reported on the ODM 02930,
			 schedule F, column 5.
(10) "Total
			 uncompensated care costs under one hundred per cent" for each hospital means
			 the sum of total inpatient uncompensated care costs under one hundred per cent
			 as described in paragraph (A)(6) of this rule, and total outpatient uncompensated
			 care costs under one hundred per cent as described in paragraph (A)(8) of this
			 rule.
(11) "Total
			 uncompensated care costs above one hundred per cent without insurance" for each
			 hospital means the sum of total inpatient uncompensated care costs above one
			 hundred per cent without insurance as described in paragraph (A)(7) of this rule,
			 and total outpatient uncompensated care costs above one hundred per cent
			 without insurance as described in paragraph (A)(9) of this
			 rule.
(12) "Total outpatient
			 uncompensated care costs for people without insurance" for each hospital means
			 the sum of the  outpatient uncompensated care costs below the poverty
			 level and outpatient uncompensated care
			 costs above the poverty level as represented on the ODM 02930, schedule F.
(13) "Total
			 uncompensated care costs for patients without insurance" for each hospital
			 means the sum of the total inpatient uncompensated care costs for people
			 without insurance in paragraph (A)(5) of this rule and the total outpatient
			 uncompensated care costs for people without insurance in paragraph (A)(12) of this
			 rule.
(14) "Total FFS
			 medicaid days" means, for each hospital, the amount on the ODM 02930, schedule
			 C, column 6, line 49 .
(15)
									 "MCP days" mean for each hospital, the
			 amount on the ODM 02930, schedule I, column 2, line 204.
(16) "Total
			 medicaid days" for each hospital means the sum of total medicaid FFS days as
			 defined in paragraph (A)(14) of this rule and MCP days as defined in
			 (A)(15)
			 of this rule.
(17) "High federal
			 disproportionate share hospital" means a hospital with a ratio of total
			 medicaid days as defined in paragraph (A)(16) of this rule
			 to total facility days as defined in paragraph (A)(19) of this rule
			 greater than the statewide mean ratio of the sum of total medicaid days to the
			 sum of total facility days plus one standard deviation.
(18)
			 "Total medicaid FFS  payments" for each hospital means the sum
			 of the total medicaid  inpatient payments, total medicaid outpatient payments, and
			 the medicaid 
			 settlement amounts as reported on the ODM 02930, schedule H, column 1, lines 7,
			 15, and 26.
(19) "Total facility
			 days" means for each hospital the amount reported on the ODM 02930, schedule C,
			 column 4, line 49.
(20) "Medicaid
			 utilization rate" for each hospital means the rate calculated by dividing the
			 sum of total medicaid days as defined in paragraph (A)(16) of this rule
			 by the total facility days as defined in paragraph (A)(19) of this
			 rule.
(21) "Total medicaid
			 MCP costs" for each hospital means the actual cost to the hospital of care
			 rendered to medical assistance recipients enrolled in a MCP that has entered
			 into a contract with the department of medicaid and is the amount on ODM 02930,
			 schedule I, column 3, line 202 and column 5, line 202.
(22)
			 "Medicaid MCP inpatient payments" for each hospital means the amount on ODM
			 02930 schedule I, column 2, line 208.
(23) "Medicaid MCP
			 outpatient payments" for each hospital means the amount on ODM 02930 schedule
			 I, column 4, line 208.
(24) "Total medicaid
			 MCP payments" for each hospital is the sum of the amount calculated in
			 paragraph (A)(22) of this rule, and the amount calculated in
			 paragraph (A)(23) of this rule.
(25) "Adjusted total
			 facility costs" for each hospital means the amount described in paragraph (A)
			 of rule
			 5160-2-08
			 of the Administrative Code.
(26) "Rural
			  Hospital (RH)"
			 means a
			 hospital geographically located in an Ohio county that
			 is not
									 classified
			 
									into a
			 core based statistical area (CBSA) as designated in the
			 inpatient prospective payment system (IPPS) case-mix and wage index table as
			 published October first of each program year
									 by the centers for medicare and
			 medicaid services (CMS).
(27) "Critical Access
			 Hospital (CAH)" means a hospital that is certified as a critical access
			 hospital by CMS and that has notified the Ohio department of health and the
			 Ohio department of medicaid of such certification. 
									The Ohio department of
			 medicaid must receive notification of critical access hospital certification by
			 the first day of October, the start of the program year, in order for the
			 hospital to be considered a critical access hospital for disproportionate share
			 payment purposes. Hospitals shall notify the Ohio department of medicaid of any
			 change in their critical access hospital status, including continued CAH
			 designations, immediately following notification from CMS.
(28)
			 "Hospital-specific disproportionate share limit" for each hospital means the
			 limit on disproportionate share and indigent care payments made to a specific
			 hospital as defined in paragraph (J)(2) of this rule.
(29)
			 "Children's hospitals" are those hospitals that meet the definition in
			 paragraph (A)(3) of rule 5160-2-05 of the Administrative
			 Code.
(30) "Inpatient upper
			 limit payment" for each hospital means the amount reported on ODM 02930,
			 schedule H, section I, column 1, line 5.
(31)
			 "Outpatient upper limit payment" for each hospital means the amount reported on
			 ODM 02930, schedule H, section II, column 1, line 14.
(32)
			 "Total program amount" means the sum of the amounts in paragraphs (K) (2) and
			 (K)(3) of this rule.
(33) "Obstetric
			 services requirements (OSR)" means for each hospital that satisfies the federal
			 statute of having at least two obstetricians who have staff privileges at the
			 hospital that agreed to provide obstetric services to medicaid eligible
			 individuals during the cost-reporting year as defined in paragraph (B) of rule
			 5160-2-08
			 of the Administrative Code. For rural hospitals as defined in paragraph
			 (A))(26)
			 of this rule, this requirement includes any physician with staff privileges at
			 the hospital to perform non-emergency obstetric procedures. This requirement
			 shall not apply to a hospital whose inpatients are predominantly individuals
			 under eighteen years of age or a hospital which did not offer non-emergency
			 obstetric services to the general population as of December 22, 1987, the date
			 the federal statute was enacted.