New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 311 - HOSPITAL SERVICES › Part 3 - METHODS AND STANDARDS FOR ESTABLISHING PAYMENT - INPATIENT HOSPITAL SERVICES › Section 8.311.3.13 - DISPROPORTIONATE SHARE HOSPITALS

Current through Register Vol. 35, No. 13, July 16, 2024
To take into account the situation of hospitals serving a
				  disproportionate number of low-income patients with special needs, a payment
				  will be made to qualifying hospitals.
A.
Criteria for deeming hospitals
				eligible for a disproportionate share payment:
(1) Determination of each hospital's
				eligibility for a disproportionate share payment for the MAD inpatient
				utilization rate as listed below, will be done annually by the department's
				audit agent, based on the hospital's most recently filed cost report. Hospitals
				which believe they qualify under the low income utilization rate must submit
				documentation justifying their qualification. This documentation should be
				submitted to the department by March 31 of each year.
(2) In the case of a DRG hospital with a PPS
				exempt specialty unit, data from the entire facility will be considered to
				determine DSH status.
(3) The
				following criteria must be met before a hospital is deemed to be eligible:
(a) Minimum criteria: The hospital must have:
(i) a MAD inpatient utilization rate greater
				than the mean MAD inpatient utilization rate for hospitals receiving MAD
				payments in the state; or
(ii) a
				low-income utilization rate exceeding twenty-five percent; (refer to
				Subparagraph (b) of Paragraph (3) of Subsection A of
				8.311.3.13
				NMAC for definitions of these criteria).
(iii) The hospital must have at least two
				obstetricians with staff privileges at the hospital who have agreed to provide
				obstetric services to eligible recipients entitled to such services under MAD;
				in the case of a hospital located in a rural area (defined as an area outside
				of a metropolitan statistical area (MSA), as defined by the United States
				executive office of management and budget), the term "obstetrician" includes
				any physician with staff privileges at the hospital to perform non-emergency
				obstetric procedures.
(iv) Item
				(iii) of Subparagraph (a) of Paragraph (3) of Subsection A of
				8.311.3.13
				NMAC does not apply to a hospital which meets the following criteria: the
				inpatients are predominantly individuals under 18 years of age; or the hospital
				did not offer non-emergency obstetric services as of December 22,
				1987;
(v) the hospital must have,
				at a minimum, a MAD inpatient utilization rate (MUR) of one percent.
(b)
Definitions of
				criteria:
(i) MAD inpatient
				utilization: For a hospital, the total number of its MAD inpatient days in a
				cost reporting period, divided by the total number of the hospital's inpatient
				days in the same period. These include both MAD managed care and non-managed
				care MAD inpatient days.
(ii)
				Low-income utilization rate: For a hospital, the sum (expressed as a
				percentage) of the following fractions: the sum of total MAD inpatient and
				outpatient net revenues (this includes MAD managed care and non-managed care
				revenues) paid to the hospital, plus the amount of the cash subsidies received
				directly from state and local governments in a cost reporting period, divided
				by the total amount of net revenues of the hospital for inpatient and
				outpatient services (including the amount of such cash subsidies) in the same
				cost reporting period; and the total amount of the hospital's charges for
				inpatient hospital services attributable to charity care (care provided to
				individuals who have no source of payment, third-party or personal resources)
				in a cost reporting period, less the amount of the cash subsidies received
				directly from the state and local governments in that period reasonably
				attributable to inpatient hospital services, divided by the total amount of the
				hospital's charges for inpatient services in the hospital in the same period.
				If this number is zero or less than zero, then it is assumed to be zero. The
				total inpatient charges attributed to charity care shall not include
				contractual allowances and discounts (other than for indigent patients not
				eligible for medical assistance under an approved MAD state plan), that is,
				reductions in charges given to other third-party payers, such as HMOs,
				medicare, or Blue Cross.
(iii) The
				medicaid utilization rate (MUR) is computed as follows:
MUR % = 100 x M/T
M = hospital's number of inpatient days attributable to
				  eligible recipients under the MAD state plan; these include MAD managed care
				  and non-managed care days
T = hospital's total inpatient days.
(iv) Newborn days, days in specialized wards,
				and administratively necessary days are included in this calculation.
				Additionally, days attributable to individuals eligible for medicaid in another
				state are included. MAD inpatient days includes both MAD managed care and
				non-managed care patient days.
(v)
				The numerator (M) does not include days attributable to recipients 21 or older
				in institutions for mental disease (IMD) as these patients are not eligible for
				MAD coverage in IMDs under the New Mexico state plan and cannot be considered a
				MAD day.