New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 311 - HOSPITAL SERVICES › Part 3 - METHODS AND STANDARDS FOR ESTABLISHING PAYMENT - INPATIENT HOSPITAL SERVICES › Section 8.311.3.10 - GENERAL REIMBURSEMENT POLICY

Current through Register Vol. 35, No. 13, July 16, 2024
The state of New Mexico human services department
				  (hereinafter called the department) will reimburse inpatient hospital services
				  rendered on or after October 1, 1989 in the following manner:
A. Covered inpatient services provided to
				eligible recipients admitted to in-state acute care hospitals and acute care
				units on or after October 1, 1989 will be reimbursed at a prospectively set
				rate, determined by the methodology set forth in
				8.311.3.12
				NMAC, unless the hospital or unit is classified into one of the prospective
				payment system (PPS) exempt categories outlined in Subsection C through D
				below.
B. Covered inpatient
				services provided to eligible recipients admitted to acute care hospitals and
				acute care units within hospitals located out-of-state or in border areas
				(Mexico excluded) will be reimbursed at a prospectively set rate as described
				in Paragraph (16) of Subsection C of 8.311.12 NMAC, unless the hospital or unit
				is classified into one of the prospective payment system (PPS) exempt
				categories outlined in Subsections C through D below or at a negotiated rate
				not to exceed the rate paid by federal programs such as medicare. Negotiation
				of rates will only be allowed when the department determines that the hospital
				provides a unique service required by an eligible recipient.
C. Inpatient services provided in
				rehabilitation and specialty hospitals and medicare PPS-exempt distinct part
				units within hospitals will be reimbursed using the provisions and principles
				of reimbursement set forth in Public Law 97-248. This legislation, which was
				effective October 1, 1982, is commonly referred to as TEFRA (Tax Equity and
				Finance Reduction Act) and is described in
				8.311.3.11
				NMAC.
D. Indian health services
				hospitals will be reimbursed using a per diem rate established by the federal
				government.
E. New Mexico providers
				entering the medical assistance division (MAD) program will be reimbursed at
				the peer group median rate for the applicable peer group, until such time as a
				distinct rate can be established, unless the hospital meets the criteria for
				prospective payment exemption as described in Subsections C through D
				above.
F. All hospitals which meet
				the criteria in Subsection A of
				8.311.3.13
				NMAC will be eligible for a disproportionate share adjustment.
G. Effective for discharges on or after April
				1, 1992, and in accordance with Section 4604 of the Omnibus Budget
				Reconciliation Act (OBRA) of 1990, the department provides for an outlier
				adjustment in payment amounts for medically necessary inpatient services
				involving exceptionally high costs or long lengths of stay for children who
				have not attained the age of six years in disproportionate share hospitals, and
				for infants under one year of age in all hospitals, and for individuals of any
				age in the state teaching hospital. The outlier adjustment for these cases is
				described in Subsection F of
				8.311.3.12
				NMAC.
H. MAD covered inpatient
				services provided in specialty hospitals will be reimbursed at an interim rate
				established by MAD to equal or closely approximate the final payment rates that
				apply under the cost settlement TEFRA principals. If a provider is not cost
				settled, the reimbursement rate will be at the provider's cost to charge ratio
				reported in the provider's most recently filed cost report prior to February 1,
				2012. Otherwise, rates are established after considering available cost to
				charge ratios, payment levels made by other payers, and MAD payment levels for
				services of similar cost, complexity and duration.
I. The reimbursement rates established by MAD
				using the reimbursement principles stated in 8.311.3 NMAC may be reduced or
				limited by budget availability at the department's discretion.