New York Codes, Rules and Regulations › Title 10 - DEPARTMENT OF HEALTH › Chapter II - Administrative Rules and Regulations › Subchapter L - Hospitals and Related Facilities › Part 86 - Reporting and Rate Certifications for Facilities › Subpart 86-1 - Medical Facilities › Section 86-1.35 - Disproportionate share limitations

Current through Register Vol. 46, No. 28, July 10, 2024
(a) Disproportionate share payment
					 distributions made to general hospitals pursuant to article 28 of the Public
					 Health Law shall be limited in accordance with the provisions of this section.
					 The latest available annual cost report submitted by a hospital prior to the
					 disproportionate share distribution period shall be used to determine
					 eligibility pursuant to subdivision (b) of this section and for projected
					 limits pursuant to subdivision (e) of this section. Annual cost reports having
					 an end date in the applicable annual disproportionate share distribution
					 period, or for certain State-operated general hospitals, annual cost reports
					 having an end date in the subsequent annual disproportionate share distribution
					 period, shall be used to reconcile limits pursuant to subdivision (f) of this
					 section.
(b) General hospitals
					 whose inpatient Medicaid eligible patient days are less than one percent of
					 total inpatient patient days shall not be eligible to receive disproportionate
					 share distributions.
(c) No general
					 hospital shall receive in total from disproportionate share payment
					 distributions an amount which exceeds the costs incurred during the periods
					 described in subdivision (a) of this section for furnishing inpatient and
					 ambulatory hospital services to individuals who are eligible for medical
					 assistance benefits pursuant to title XIX of the Federal Social Security Act
					 (hereinafter referred to as "Medicaid cost") or to individuals who have no
					 health insurance for the services provided or other source of third party
					 coverage (hereinafter referred to as "self-pay cost"), reduced by medical
					 assistance payments made pursuant to title XIX of the Federal Social Security
					 Act (hereinafter referred to as "Medicaid revenue"), other than
					 disproportionate share payments, and payments by uninsured patients. For
					 purposes of this section, payments to a general hospital for services provided
					 to indigent patients made by the State or a unit of local government within the
					 State shall not be considered a source of third party payment.
(d) In order to ensure the continued flow of
					 disproportionate share payments to hospitals, the commissioner shall make
					 projections of each hospital's disproportionate share limitation based on the
					 most current data available from the hospital's annual cost reports. The
					 commissioner shall use annual cost reports in accordance with the provisions of
					 subdivision (e) of this section to estimate Medicaid and self-pay costs in the
					 projection methodology for a particular rate year. This shall be referred to as
					 the "projection methodology". Subsequent to the receipt of a hospital's annual
					 cost report having an end date in the applicable annual disproportionate share
					 distribution period, or for certain State-operated general hospitals whose
					 annual cost reports have an end date within the subsequent annual period, each
					 hospital's disproportionate share limitation shall be reconciled to the actual
					 rate year data. This shall be referred to as the "reconciliation
					 methodology".
(e)
Projection
					 methodology.
Each hospital's projected disproportionate share
						limitation for each rate year shall be the sum of its inpatient and outpatient
						Medicaid and uninsured gains/(losses) as calculated using reported base year
						data and statistics from the year two years immediately preceding the rate year
						and as used for projection methodology purposes for that prior
						year.
(f)
Reconciliation methodology.
The commissioner shall revise the projected limitation
						based on actual data reported to the commissioner for such rate year in
						accordance with the following and in accordance with final regulations issued
						by the Federal Department of Health and Human Services implementing
						42
						USC section 1396r-4. The commissioner shall
						revise the projected limitations for each hospital within eight months from the
						date required reports are submitted to the department, except if such reports
						are determined to be unacceptable by the department. For hospitals which have
						submitted unacceptable reports, the commissioner shall revise the projected
						limitations within eight months from the date acceptable reports have been
						resubmitted to the department.
(1)
					 Each hospital shall submit, by the same date the annual cost reports are
					 required to be filed pursuant to section
					 86-1.2 
					 of this Subpart, a disproportionate share limitation schedule in a form and
					 manner prescribed by the commissioner within which the hospital shall
					 calculate, in accordance with the instructions, its inpatient and outpatient
					 Medicaid and self-pay gains/(losses) during the cost reporting year. The
					 disproportionate share limitation schedule shall be accompanied by a
					 certification by the hospital's independent public accountant which provides
					 the commissioner sufficient assurance as to the accuracy of the information
					 contained in such schedule.
(i) The final
					 limit shall be calculated by excluding inpatient and outpatient Medicaid
					 revenue impacts resulting from prospective adjustments to rates for periods
					 prior to the implementation of the Federal hospital specific disproportionate
					 share payment limits from the inpatient and outpatient Medicaid and self-pay
					 gains/(losses) reported on the disproportionate share payment limitation
					 schedule.