Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1151 - INPATIENT PSYCHIATRIC SERVICES › PAYMENT FOR INPATIENT PSYCHIATRIC SERVICES › Section 1151.54 - Disproportionate share payments

Current through Register Vol. 54, No. 28, July 13, 2024
(a)
				  The Department will annually determine the acute care general hospitals
				  including their distinct part units, private psychiatric hospitals and
				  freestanding rehabilitation hospitals that qualify for disproportionate share
				  payments by the method in subsections (b)-(e). The Department will annually
				  determine the amount of disproportionate share payments for eligible private
				  psychiatric hospitals and distinct part psychiatric units of acute care general
				  hospitals by the method in subsections (f)-(h).
(b) A hospital that meets at least one of the
				  requirements in subsection (d) will qualify for disproportionate share payments
				  if one of the following applies:
(1) The
				  hospital's ratio of Title XIX inpatient days to total inpatient days is equal
				  to or greater than one standard deviation above the mean of the ratios for
				  hospitals in this Commonwealth. To determine the ratio for an acute care
				  general hospital, the Department will include inpatient days covered under
				  Chapter 1163, Subchapter A (relating to acute care general hospitals under the
				  prospective payment system), and days covered under Chapter 1163, Subchapter B
				  (relating to hospitals and units covered under cost reimbursement principles),
				  as well as days covered under this chapter. The Department will include in the
				  database MA administrative days, days of care provided to recipients in other
				  states' Medicaid Programs, MA health maintenance organizations (HMO) days and
				  MA Health Insuring Organization (HIO) days.
(2) The hospital's low income utilization
				  rate, as defined under section 1923(d) of the Social Security Act
				  (42 U.S.C.A. §
												1396r-4(b)(3)) exceeds
				  25% under one of the following methods:
(i)
				  The hospital's low income utilization rate as reported on its cost report (MA
				  336) computation of low income utilization rate worksheet exceeds
				  25%.
(ii) The hospital's low income
				  utilization rate as determined by its ratio of Title XIX and General Assistance
				  inpatient days to total inpatient days exceeds 25%. To determine the ratio for
				  an acute care general hospital, the Department will include inpatient days
				  covered under Chapter 1163, Subchapter A, and days covered under Chapter 1163,
				  Subchapter B, as well as days covered under this chapter. The Department will
				  include in the database MA administrative days, days of care provided to
				  recipients in other states' Medicaid Programs, MA HMO days and MA HIO
				  days.
(3) The hospital is
				  an acute care general hospital which qualifies as a rural hospital or sole
				  community hospital under the Medicare Program, and its number of MA acute care
				  inpatient cases to total acute care inpatient cases is equal to or greater than
				  the 75th percentile of the ratios for acute care general hospitals in this
				  Commonwealth. The Department will not include cases for a unit covered under
				  Chapter 1163, Subchapter B, or under this chapter. The Department will include
				  in the database discharges related to other states' Medicaid
				  Programs.