Texas Administrative Code › Title 1 - ADMINISTRATION › Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION › Chapter 355 - REIMBURSEMENT RATES › Subchapter J - PURCHASED HEALTH SERVICES › Division 4 - MEDICAID HOSPITAL SERVICES › Section 355.8066 - State Payment Cap and Hospital-Specific Limit Methodology

Current through Reg. 49, No. 28; July 12, 2024
(a) Introduction. The Texas Health and Human
					 Services Commission (HHSC) uses the methodology described in this section to
					 calculate a hospital-specific limit for each Medicaid hospital participating in
					 either the Disproportionate Share Hospital (DSH) program, described in
					 §355.8065 of this division (relating to Disproportionate Share Hospital
					 Reimbursement Methodology), or in the Texas Healthcare Transformation and
					 Quality Improvement Program (the waiver), described in §
											355.8201 of this subchapter
					 (relating to Waiver Payments to Hospitals for Uncompensated Care) and §
											355.8212 of this subchapter
					 (relating to Waiver Payments to Hospitals for Uncompensated Charity
					 Care).
(b) Definitions.
(1) Adjudicated claim--A hospital claim for
					 payment for a covered Medicaid service that is paid or adjusted by HHSC or
					 another payor.
(2) Centers for
					 Medicare and Medicaid Services (CMS)--The federal agency within the United
					 States Department of Health and Human Services responsible for overseeing and
					 directing Medicare and Medicaid, or its successor.
(3) Data year--A 12-month period that is two
					 years before the program year from which HHSC will compile data to determine
					 DSH or uncompensated-care waiver program qualification and payment.
(4) Demonstration Year--The time period
					 described in the definition for "Demonstration year" in §
												355.8212 of this
					 subchapter.
(5) Disproportionate
					 share hospital (DSH)--A hospital identified by HHSC that meets the DSH program
					 conditions of participation and that serves a disproportionate share of
					 Medicaid or indigent patients.
(6)
					 DSH and Uncompensated Care (UC) Application--The HHSC data collection tool
					 completed by each hospital applying for participation in DSH or UC and used by
					 HHSC to calculate the state payment cap and hospital-specific limit, as
					 described in this section, and to estimate the hospital's DSH and UC payments
					 for the program year, as described in §355.8065 of this division (relating
					 to Disproportionate Share Hospital Reimbursement Methodology) and §
												355.8212 of this subchapter. A
					 hospital may be required to complete multiple applications due to different
					 data requirements between the state payment cap and hospital-specific limit
					 calculations.
(7) DSH and UC
					 Application Request Form--An online survey sent to hospitals or its
					 representatives to request a DSH and UC application and to collect information
					 necessary to prepopulate the DSH and UC application.
(8) Dually eligible patient--A patient who is
					 simultaneously enrolled in Medicare and Medicaid.
(9) Federal Fiscal Year (FFY)--The 12-month
					 period beginning October 1 and ending September 30. The period also corresponds
					 to the waiver demonstration year.
(10) Full-Offset Payment Ceiling--The maximum
					 payment cap derived using the full-offset methodology as described in
					 subsection (c)(1) of this section.
(11) HHSC--The Texas Health and Human
					 Services Commission or its designee.
(12) Hospital-specific limit--The maximum
					 payment amount authorized by Section 1923(g) of the Social Security Act that a
					 hospital may receive in reimbursement for the cost of providing
					 Medicaid-allowable services to individuals who are Medicaid-eligible or
					 uninsured for payments made during a prior program year. The amount is
					 calculated as described in subsection (d) of this section using actual cost and
					 payment data from that period. The term does not apply to payment for costs of
					 providing services to non-Medicaid-eligible individuals who have third-party
					 coverage; and costs associated with pharmacies, clinics, and physicians. The
					 calculation of the hospital-specific limit must be consistent with federal
					 law.
(13) Inflation update
					 factor--Cost of living index based on the annual CMS Prospective Payment System
					 Hospital Market Basket Index.
(14)
					 Institution for mental diseases (IMD)--A hospital that is primarily engaged in
					 providing psychiatric diagnosis, treatment, or care of individuals with mental
					 illness, defined in §1905(i) of the Social Security Act. IMD hospitals are
					 reimbursed as freestanding psychiatric facilities under §355.8060 of this
					 division (relating to Reimbursement Methodology for Freestanding Psychiatric
					 Facilities) and §
												355.761 of this chapter (relating
					 to Reimbursement Methodology for Institutions for Mental Diseases
					 (IMD)).
(15) Medicaid
					 contractor--Fiscal agents and managed care organizations with which HHSC
					 contracts to process data related to the Medicaid program.
(16) Medicaid cost-to-charge ratio (inpatient
					 and outpatient)--A Medicaid cost report-derived cost center ratio calculated
					 for each ancillary cost center that covers all applicable hospital costs and
					 charges relating to inpatient and outpatient care for that cost center. This
					 ratio is used in calculating the hospital-specific limit and does not
					 distinguish between payor types such as Medicare, Medicaid, or private
					 pay.
(17) Medicaid cost
					 report--Hospital and Hospital Health Care Complex Cost Report (Form CMS 2552),
					 also known as the Medicare cost report.
(18) Medicaid hospital--A hospital meeting
					 the qualifications set forth in §
												354.1077 of this title (relating to
					 Provider Participation Requirements) to participate in the Texas Medicaid
					 program.
(19) Medicaid payor
					 type--The categories of payors on Medicaid claims. These are categorized in the
					 DSH and UC application as Medicaid, where Medicaid is the sole payor, Medicare,
					 for claims associated with the care of dually eligible patients, and other
					 insurance, for claims for which the hospital received payment from a
					 third-party payor for a Medicaid-enrolled patient.
(20) Outpatient charges--Amount of gross
					 outpatient charges related to the applicable data year and used in the
					 calculation of a payment limit or cap.
(21) Program year--The 12-month period
					 beginning October 1 and ending September 30. The period corresponds to the
					 waiver demonstration year.
(22)
					 Recoupment Prevention Payment Ceiling--The maximum payment cap derived using
					 the methodology described in subsection (c)(2) of this section that considers
					 Medicaid only costs and payments in the methodology.
(23) State payment cap--The maximum payment
					 amount, as applied to interim payments that will be made for the program year,
					 that a hospital may receive in reimbursement for the cost of providing
					 Medicaid-allowable services to individuals who are Medicaid-eligible or
					 uninsured. The amount is calculated as described in subsection (c) of this
					 section using interim cost and payment data from the data year. The term does
					 not apply to payment for costs of providing services to non-Medicaid-eligible
					 individuals who have third-party coverage or costs associated with pharmacies,
					 clinics, and physicians.
(24) The
					 waiver--The Texas Healthcare Transformation and Quality Improvement Program, a
					 Medicaid demonstration waiver under §1115 of the Social Security Act that
					 was approved by CMS. Pertinent to this section, the waiver establishes a
					 funding pool to assist hospitals with uncompensated-care costs.
(25) Third-party coverage--Creditable
					 insurance coverage consistent with the definitions in 45 Code of Federal
					 Regulations (CFR) Parts 144 and 146, or coverage based on a legally liable
					 third-party payor.
(26) Total state
					 and local subsidies--Total state and local subsidies is defined in
					 §355.8065 of this division.
(27) Uncompensated Care Hospital--A hospital
					 identified by HHSC that meets the UC program eligibility criteria to receive a
					 payment as defined in §
												355.8212 of this
					 subchapter.
(28) Uncompensated-care
					 waiver payments--Payments to hospitals participating in the waiver that are
					 intended to defray the uncompensated costs of eligible services provided to
					 eligible individuals.
(29)
					 Uninsured cost--The cost to a hospital of providing inpatient and outpatient
					 hospital services to uninsured patients as defined by CMS.