Pennsylvania Code › Title 55 - HUMAN SERVICES › Part III - MEDICAL ASSISTANCE MANUAL › Chapter 1163 - INPATIENT HOSPITAL SERVICES › Subchapter A - ACUTE CARE GENERAL HOSPITALS UNDER THE PROSPECTIVE PAYMENT SYSTEM › PAYMENT FOR HOSPITAL SERVICES › Section 1163.67 - 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 acute care general
					 hospitals, exclusive of distinct part units, by the method in subsections
					 (f)-(i).
(b) A hospital that meets
					 at least one of the requirements under 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 for units covered under Subchapter B and Chapter 1151
					 (relating to hospitals and units covered under cost reimbursement principles;
					 and inpatient psychiatric services), as well as days covered under this
					 subchapter. The Department will include in the database MA administrative days,
					 days of care provided to recipients in other states' Medicaid Programs, MA
					 Health Maintenance Organization (HMO) days and MA Health Insuring Organization
					 (HIO) days.
(2) The hospital's low
					 income utilization rate, as defined under
					 42 U.S.C.A. §
													1396 r-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 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 for units covered
					 under Subchapter B and Chapter 1151, as well as days covered under this
					 subchapter. 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 ratio
					 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 Subchapter B or under Chapter 1151. The Department will
					 include in the database discharges related to other states' Medicaid
					 Programs.