Medicaid-Only Hospitals

2053 - Medicaid-Only Hospitals (Rev. 123, Issued: 10-03-14, Effective: 10-03-14, Implementation: 10-03-14) Many hospitals choose to participate in both the Medicare and Medicaid programs. However, a hospital may choose to only participate in Medicaid. Medicaid regulations at 42 CFR 440.10 and 42 CFR 440.140(a) require a hospital or psychiatric hospital (also referred to in Medicaid as an “institution for mental disease,” which is defined at 42 CFR 435.1010) participating in Medicaid to meet the requirements for participation in Medicare in order to receive Medicaid payment. These regulations do not require a hospital or psychiatric hospital to enroll in the Medicare program in order to demonstrate compliance with Medicare participation requirements. The provider agreement rules at 42 CFR 489.10 establish the basic Medicare participation requirements for providers, including requirements for hospital participation. These requirements include, but are not limited to, complying with the following: applicable hospital Conditions of Participation (CoPs) at 42 CFR Part 482; specified Office of Civil Rights requirements; and the advanced directive requirements at 42 CFR 489.100 and 42 CFR 489.102. 2053A- Initial Certification of Medicaid-Only Hospitals (Rev. 123, Issued: 10-03-14, Effective: 10-03-14, Implementation: 10-03-14) Hospitals seeking initial certification to participate in the Medicaid program only must contact the State Agency (SA), in accordance with §§1902(a)(9)(A) and 1902(a)(33) of the Act, to initiate the certification process. Requirements for this process are established in the Medicaid State Plan’s required written agreement (or formal written intra-agency arrangement) between the State Medicaid Agency (SMA) and the SA (See 42 CFR 431.610(f). The SMA must approve the hospital’s request for enrollment into the Medicaid program prior to the initiation of the certification process by the SA. 2053B - Certification Surveys of Medicaid-Only Hospitals (Rev. 123, Issued: 10-03-14, Effective: 10-03-14, Implementation: 10-03-14) Following verification by the SMA that the enrollment application process has been initiated by the hospital, the SA must determine if the hospital seeking Medicaid-only certification demonstrates compliance with requirements for Medicare participation, including all applicable CoPs, through the completion of an on-site survey. Hospitals have the option of establishing compliance with applicable CoPs through accreditation under 42 CFR 488.6(b) by a nationally recognized Accreditation Organization (AO) with a CMS-approved Medicare hospital or psychiatric hospital program. Hospitals choosing this option must provide the SA with a letter issued by the AO confirming its accreditation under a CMS-approved Medicare accreditation program and recommending deemed status as a Medicaid-only hospital. (As with Medicare-participating hospitals, it is possible that a hospital might be accredited, but not have deemed status. The AO letter must indicate the hospital is recommended for deemed status.) However, regardless of whether the survey is conducted by the SA or a CMS-approved AO, the SA must issue a determination to the SMA as to whether the hospital has met all Medicare participation requirements for Medicaid-only hospital participation. Upon receipt of the SA’s determination, the SMA issues an effective date for the hospital’s participation in the State Medicaid program. The SA then compiles and forwards a Medicaid-only certification packet to the RO. This packet consists of the hospital’s request for an applicable Medicaid-only hospital or psychiatric hospital CMS Certification Number (CCN), the SA’s certification of compliance with Medicare CoPs, and the SMA-issued State Medicaid program effective date. After review of all documentation, the RO issues the appropriate Medicaid-only hospital CCN. 2053C - Change in Certification (Rev. 123, Issued: 10-03-14, Effective: 10-03-14, Implementation: 10-03-14) If the hospital decides to seek participation in Medicare as well as Medicaid, see Section 2777D3. 2053D - Termination (Rev. 123, Issued: 10-03-14, Effective: 10-03-14, Implementation: 10-03-14) The SMA must terminate the hospital’s Medicaid agreement when the SA determines that the hospital does not meet the applicable requirements. See Section 3005C-3. 2053E - Complaint Investigation (Rev. 123, Issued: 10-03-14, Effective: 10-03-14, Implementation: 10-03-14) All allegations of non-compliance with Federal or State requirements in Medicaid-only hospitals must be referred to the SA. Under 42 CFR 431.610, the SA in collaboration with the SMA must determine the policies and procedures for the intake, triage and investigation of all allegations of non- compliance in both deemed and non-deemed Medicaid-only hospitals. The SA is solely responsible for reporting complaint investigation findings to the SMA, including a determination whether a Medicaid-only hospital meets Medicare CoPs and other federal requirements in accordance with §1902(a)(33)(B) of the Act.