§ 1163.67. 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 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.
(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 cases or 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 cases or 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 the hospitals that qualify for disproportionate share payments based on the ratio of Title XIX inpatient days to total inpatient days, the Department will do the following:
(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 MA days to total inpatient days.
(3) Array the hospitals, from high to low, according to the ratios determined under paragraph (2) and determine 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 subsections (b)(1) and (2) for Fiscal Year 1993-94, the Department will calculate disproportionate share percentages for acute care general hospitals, exclusive of distinct part units, by:
(1) Arraying qualifying acute care general hospitals from high to low, according to each hospital’s ratio of Title XIX inpatient days to total inpatient days.
(2) Assigning a disproportionate share percentage of 15% to the qualifying hospital with the highest ratio of Title XIX inpatient days to total inpatient days.
(3) Obtaining for other hospitals in the array, the annual disproportionate share percentage, which is 1%, plus 13% multiplied by a fraction, the numerator of which is the ratio of Title XIX inpatient days to total inpatient days of the qualifying hospital, 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 second to highest hospital in the array, minus the ratio of Title XIX inpatient days to total inpatient days of the lowest hospital in the array.
(g) Once the Department determines which rural and sole community acute care general hospitals qualify as disproportionate share providers under subsection (b)(3) for Fiscal Year 1993-94, the Department will calculate disproportionate share percentages for acute care general hospitals, exclusive of distinct part units, by:
(1) Arraying qualifying acute care general hospitals from high to low, according to each hospital’s ratio of Title XIX inpatient days to total inpatient days.
(2) Assigning a disproportionate share percentage of 10% to the qualifying hospital with the highest ratio of Title XIX inpatient days to total inpatient days.
(3) Obtaining for other hospitals in the array a disproportionate share percentage, which is 1%, plus 8% multiplied by a fraction, the numerator of which is the ratio of Title XIX inpatient days to total inpatient days of the qualifying hospital, 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 second to highest hospital in the array, minus the ratio of Title XIX inpatient days to total inpatient days of the lowest hospital in the array.
(h) The Department will assign the higher disproportionate share percentage calculated under subsections (f) and (g) to a hospital qualifying under both subsections.
(i) The Department will determine prospectively the annual disproportionate share payment amount for each qualifying acute care general hospital by:
(1) Multiplying the following:
(i) The hospital’s disproportionate share percentage determined under subsection (f) or (g).
(ii) The hospital’s base DRG 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) 1.0658 for prospective capital.
(iv) The hospital’s most currently available case mix index.
(v) The hospital’s projected MA acute care cases, determined as follows:
(A) For Fiscal Year 1993-94, the number of acute care cases reported 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 acute care cases reported 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.
(2) For Fiscal Years 1993-94 and 1994-95, for those hospitals that do not receive an inflationary increase on July 1, further inflating one-half of the amount calculated under paragraph (1) by the annual inflation increase.
(j) The Department will divide the annual disproportionate share payment amount into 12 monthly payments.
(k) The Department will publish annually, as a notice in the Pennsylvania Bulletin, a list of the qualifying hospitals and their annual disproportionate share payment percentages.
Authority The provisions of this § 1163.67 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 § 1163.67 adopted June 1, 1990, effective retroactively to July 1, 1988, 20 Pa.B. 2913; reserved June 18, 1993, effective July 1, 1993, 23 Pa.B. 2917; amended October 29, 1993, effective July 1, 1993, 23 Pa.B. 5241. Immediately preceding text appears at serial pages (181838) to (181840).
Cross References This section cited in 55 Pa. Code § 1163.51 (relating to general payment policy).
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