§ 1163.459. Disproportionate share payments.
(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 freestanding rehabilitation hospitals and distinct part rehabilitation units of acute care general hospitals by the method in subsections (f)—(i).
(b) A hospital that meets at least one of the requirements under subsection (d) qualifies 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 Subchapter A and Chapter 1151 (relating to acute care general hospitals under the prospective payment system; 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 section 1923 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 Subchapter A 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.
(c) The Department will utilize the following data sources in making disproportionate share eligibility determinations:
(1) For Fiscal Year 1993-94, the Department will utilize data from Fiscal Year 1991-92 Cost Reports (MA 336) and from Fiscal Year 1991-92 for services provided to recipients enrolled in MA HMO Programs and MA HIO Programs. To determine the Title XIX percentage of total MA days, the Department will utilize the most currently available data.
(2) For Fiscal Year 1994-95, the Department will utilize data from Fiscal Year 1992-93 Cost Reports (MA 336) and from Fiscal Year 1992-93 for services provided to recipients enrolled in MA HMO Programs and MA HIO Programs. To determine the Title XIX percentage of total MA days, the Department will utilize the most currently available data.
(d) To qualify for disproportionate share payments, a hospital shall meet at least one of the following requirements:
(1) The hospital shall be a children’s hospital, as defined under § 1163.2 (relating to definitions).
(2) The hospital shall have at least two physicians with staff privileges who have agreed to provide obstetric services to individuals entitled to those services under the MA Program.
(3) The hospital has not since December 21, 1987, offered nonemergency obstetric services to the general population.
(e) To determine hospitals that qualify for disproportionate share payments based on the ratio of Title XIX inpatient days to total inpatient days, the Department will:
(1) Identify the total number of MA inpatient days from the hospital’s Cost Report (MA 336), including days of care provided to recipients in other states’ Medicaid Programs, and to that number:
(i) Add the hospital’s number of inpatient days for MA recipients enrolled in MA HMO Programs and MA HIO Programs.
(ii) Add the hospital’s number of MA administrative days from the hospital’s Cost Report (MA 336).
(iii) Subtract the hospital’s number of days of care provided to General Assistance recipients.
(2) Divide the days determined under paragraph (1) by the total number of inpatient days from the hospital’s Cost Report (MA 336) to determine the hospital’s ratio of Title XIX inpatient days to total inpatient days.
(3) Array the hospitals, from high to low, according to the ratios determined under paragraph (2) and determines the mean and standard deviation of the array.
(4) Identify as disproportionate share providers hospitals with a ratio of Title XIX inpatient days to total inpatient days equal to or greater than one standard deviation above the mean.
(f) Once the Department determines which hospitals qualify as disproportionate share providers under this section, the Department will calculate annual payments to qualifying freestanding rehabilitation hospitals and distinct part rehabilitation units of acute care general hospitals by:
(1) Arraying the qualifying rehabilitation hospitals and units from high to low according to each hospital’s ratio of Title XIX inpatient days to total inpatient days.
(2) For Fiscal Years 1990-91—1992-93, for each hospital or unit covered by this subchapter and included in the array, prospectively calculating the annual disproportionate share percentage, which is 0.5%, plus 8.0% multiplied by a fraction, the numerator of which is the ratio of Title XIX inpatient days to total inpatient days of the qualifying hospital or unit, minus the ratio of Title XIX inpatient days to total inpatient days of the lowest hospital in the array; and the denominator of which is the ratio of Title XIX inpatient days to total inpatient days of the highest hospital in the array, minus the ratio of Title XIX inpatient days to total inpatient days of the lowest hospital in the array.
(3) For Fiscal Years 1993-94 and 1994-95, for each hospital or unit covered by this subchapter and included in the array, prospectively calculating the annual disproportionate share percentage which is 1.0%, plus 9.0% multiplied by a fraction, the numerator of which is the ratio of Title XIX inpatient days to total inpatient days of the qualifying hospital or unit, minus the ratio of Title XIX inpatient days to total inpatient days of the lowest hospital in the array; and the denominator of which is the ratio of Title XIX inpatient days to total inpatient days of the highest hospital in the array, minus the ratio of Title XIX inpatient days to total inpatient days of the lowest hospital in the array.
(4) Multiplying the following:
(i) The facility’s disproportionate share percentage determined under paragraph (2) or (3).
(ii) The facility’s base per diem rate in effect on July 1 of the fiscal year, except that the Department will use the new base rate for a hospital whose rate changes during the fiscal year for any reason except for the annual inflationary increase.
(iii) The facility’s projected Title XIX inpatient days determined as follows:
(A) For Fiscal Year 1993-94, the number of Title XIX inpatient days based on the hospital’s Fiscal Year 1991-92 Cost Report (MA 336) increased by 3.52% and then by 2.8%.
(B) For Fiscal Year 1994-95, the number of Title XIX inpatient days based on the hospital’s Fiscal Year 1992-93 Cost Report (MA 336) increased by utilization increase factors consistent with the Governor’s Fiscal Year 1994-95 budget proposal.
(5) For Fiscal Years 1993-94 and 1994-95 for hospitals that do not receive an inflationary increase on July 1, further inflating one-half of the amount calculated under paragraph (4) by the annual inflation increase.
(g) Effective with Fiscal Year 1993-94, the Department will pay the interim disproportionate share amounts, determined under subsection (f)(4), in equal monthly installments.
(h) The Department will determine final semiannual disproportionate share amounts for hospitals and units under this subchapter by multiplying the following:
(1) The facility’s disproportionate share percentage determined under subsection (f)(2) or (3).
(2) The facility’s final audited per diem rate for the period.
(3) The facility’s final audited Title XIX inpatient days for the period.
(i) The Department will add the semiannual disproportionate share payments calculated under subsection (h) and reconcile any difference between the final payment and the interim payment determined under subsection (f)(4) at cost settlement for the fiscal year.
(j) The Department will publish annually a notice in the Pennsylvania Bulletin listing the qualifying hospitals and their annual disproportionate share payment percentages.
Authority The provisions of this § 1163.459 amended under sections 201 and 443.1(1) of the Public Welfare Code (62 P. S. § § 201 and 443.1(1)).
Source The provisions of this § 1163.459 adopted June 1, 1990, effective retroactively to July 1, 1988, 20 Pa.B. 2913; amended June 18, 1993, effective July 1, 1993, 23 Pa.B. 2917; amended October 29, 1993, effective July 1, 1990, 23 Pa.B. 5241. Immediately preceding text appears at serial pages (181882) to (181885).
Cross References This section cited in 55 Pa. Code § 1163.452 (relating to payment methods and rates).
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