South Dakota Administrative Rules › Title 67 - Department of Social Services › Article 67:16 - Covered medical services › Chapter 67:16:03 - Hospital services › Section 67:16:03:06 - Basis of reimbursement - Inpatient services - Hospitals with more than 30 Medicaid discharges

Current through Register Vol. 51, page 10, July 15, 2024
Reimbursement for services provided to a patient admitted to an
	 in-state acute care hospital that had more than 30 Medicaid discharges during
	 the hospital's fiscal year ending after June 30, 1996, and before July 1, 1997,
	 is based on DRGs and weight factors, the hospital's target amount, and capital
	 and education costs per day. A hospital's base target amount is calculated from
	 the cost report submitted to the Medicare program for the hospital's fiscal
	 year ending after June 30, 1996, and before July 1, 1997, and adjusted annually
	 for inflation as appropriated by the Legislature and changes to the DRG weight
	 factors. A list of the DRGs and their associated weight factors may be obtained
	 on the department's fee schedule website.
The department shall use the following method to calculate the amount
	 of reimbursement:
(1) Multiply the
  hospital's target amount by the weight factor of the DRG assigned to the
  claim;
(2) Multiply the daily
  capital and education cost for the hospital by the number of days the patient
  was in the hospital; and
(3) Add
  the products of subdivisions (1) and (2) of this section.
In addition to the regular DRG reimbursement, the department shall pay
	 for a cost outlier if the claim qualifies for the cost outlier as defined in
	 §
										67:16:03:01. The amount of the
	 cost outlier payment is equal to 90 percent of the cost outlier.
When calculating the rate of reimbursement, the department uses only
	 those diagnosis codes adopted in §
										67:16:01:26 that reflect the
	 services furnished to or on behalf of the eligible individual and the
	 conditions that affected the treatment or extended the length of the
	 individual's stay.
If a patient is transferred, referred, or discharged to another
	 hospital or another type of special care facility and the transfer, referral,
	 or discharge is medically necessary or if a patient leaves the hospital against
	 medical advice, reimbursement is on a per diem basis. To determine the rate of
	 reimbursement, multiply the hospital's target amount by the weight factor of
	 the DRG assigned to the claim, divide the result by the geometric mean length
	 of stay, multiply the result by the number of days the individual was an
	 inpatient, and add the hospital's daily capital and education cost. The amount
	 paid may not exceed 100 percent of the allowed DRG reimbursement.
For inpatient costs for Medicaid Access Critical facilities the
	 department uses the facility's cost report to determine whether any adjustment
	 to reimbursement is necessary for amounts due the provider.
General Authority:
SDCL
		28-6-1(2),
		28-6-1.1.
Law Implemented:
SDCL
		28-6-1(2),
		28-6-1.1.
Reference: South Dakota Medicaid State Plan,
Attachment
		4.19-A, page 1. Copies may be obtained from the Department of Social Services,
		Division of Medical Services, 700 Governors Drive, Pierre, South Dakota
		57501.
Basis of reimbursement -- Outpatient services other than outpatient
		laboratory and outpatient surgical procedures, § 67:16:03:06.01.
Basis of payment -- Inpatient services -- Hospitals with less than 30
		Medicaid discharges, § 67:16:03:06.03.
Reimbursement of outpatient laboratory services, §
		67:16:03:06.07.