HAR §17-1739-53. REPEALED

[R 09/30/13] §17-1739-54 Provider participation requirements for acute care facilities. Medicaid reimbursement for acute care services shall be limited to those facilities which have: (1) Applied to and been approved by the department of medicaid participation; (2) Received certification or recertification from the state department of health under federal standards in force; (3) Been licensed by the state department of health; and (4) Entered into a nontransferable provider agreement with the department for no more than twelve months coterminous with the state department of health's certification period. [Eff 11/13/95 ] (Auth: HRS §346-59) (Imp: 42 C.F.R. §447.252) §17-1739-55 Payment for acute care services - general provisions. (a) The Hawaii medicaid program shall reimburse qualified providers for inpatient institutional services based solely on the prospective payment rates developed for each facility as determined in accordance with this subchapter. The estimated UNOFFICIAL 1739-5 average proposed payment rate under this subchapter is reasonably expected to pay no more in the aggregate for inpatient hospital services than the amount that the department reasonably estimates would be paid for those services under Medicare principles of reimbursement. (b) A hospital-specific retrospective settlement adjustment shall be made for those providers whose medicaid charges are less than medicaid payments on the cost report and do not qualify as nominal charge providers under Medicare principles of reimbursement. (c) Prospective rates shall be derived from historical facility costs, and facilities shall be classified based on discharge volume and participation in an approved intern and resident teaching program. (d) Providers which average fewer than 250 medicaid discharges per year shall be classified as classification I facilities and shall receive payment based on either an all-inclusive psychiatric services per diem rate or an all-inclusive nonpsychiatric services per diem rate, which includes an adjustment for capital, disproportionate share, and medical education and, for proprietary facilities, return on equity and gross excise tax. (e) Providers which average two hundred fifty medicaid discharges or more per year shall be separated into two facility classifications (classifications II and III) and shall receive payment based upon the type of services required by the patient. Psychiatric services will be paid on the basis of an all-inclusive per diem rate. Nonpsychiatric claims will be designated as requiring either surgical, medical, or maternity care and will be paid on the basis of a routine per diem rate for the service type plus an ancillary per discharge rate for the service type. The per diem and per discharge rates shall include adjustments for capital, medical education, disproportionate share, and for proprietary facilities, return on equity and gross excise tax. (f) The freestanding rehabilitation hospital shall be excluded from classifications I, II, and III and shall receive payment based on either an all- inclusive psychiatric services per diem rate or an all- inclusive nonpsychiatric services per diem rate, with the same adjustments noted above. (g) Claims for payment shall be submitted following discharge of a patient, except as follows: UNOFFICIAL 1739-6 (1) Claims for nonpsychiatric inpatient stays which exceed $35,000 shall be submitted in accordance with section 17-1739-72; (2) If a patient is hospitalized in the freestanding rehabilitation hospital for more than thirty days, the facility may submit an interim claim for payment every thirty days until discharge. The final claim for payment shall cover services rendered on all those days not previously included in an interim claim. (h) The prospective payment rates shall be paid in full for each medicaid discharge. Hospitals may not separately bill the patient or the medicaid program for medical services rendered during an inpatient stay, except for outlier payments and as provided in section 17-1739-56 below. (i) At the point that a patient reaches outlier status, the facility is eligible for interim payments computed pursuant to section 17-1739-72. [Eff 11/13/95 ] (Auth: HRS §346-59) (Imp: 42 C.F.R. §447.252) §17-1739-56 Services included in the prospective payment rate. The prospective payment rate shall include all services provided in an acute inpatient setting except: (1) Professional component including physician services or any other professional fees excluded under Part A Medicare; (2) Ambulance; and (3) Durable medical equipment that is a take home item except for implanted devices. [Eff 11/13/95 ] (Auth: HRS §346-59) (Imp: 42 C.F.R. §447.252) §17-1739-57 Preparation of data for prospective payment rate calculation. (a) The calculation of prospective payment rates shall be based on facility-specific claims and cost data. Cost data shall be abstracted at the time the rate calculation begins from finally-settled uniform cost reports submitted to the department by each participating provider in accordance with federal medicaid requirements. Except for the disproportionate share adjustment, the cost report used for each facility UNOFFICIAL 1739-7 shall be the facility's report which ended during the state fiscal year selected as the base year. For the first year of the prospective payment system, cost data shall be abstracted from the medicaid target amount computation (TAC) cost report. This cost report incorporates the adjustments made solely for the purpose of target amount determination in addition to adjustments made for final settlement. Supplemental cost reporting forms submitted by providers shall be used as necessary. Claims data shall be derived from claims submitted by participating providers for medicaid reimbursement. For the initial calculation of base year rates, claims from 1982 and 1983 facility fiscal years paid by December 31, 1984 shall be considered base year claim data. For subsequent calculation of rates by reference to a new base year, the latest available claims data for a two fiscal year period shall be used. Claims that are paid by December 31 of the year following the year in which the last fiscal year included in the data collection effort ends shall be considered as paid in the fiscal year when the service was rendered. (b) Additional cost data supplied by participating providers shall be utilized to update cost data only as specified in this subchapter. For subsequent calculation of rates by reference to a new base year, providers will be given an opportunity to submit cost data similar in nature to that included in the TAC cost reports, excluding capital related costs. (c) An inflation factor shall be based on the latest available actual (or estimated if actual is not available) national index for acute care facilities prepared by Data Resources, Inc. This factor shall project the change in the cost of delivering inpatient hospital services from one year to the next. The inflation factor shall be published annually by the department. [Eff 11/13/95 ] (Auth: HRS §346- 59) (Imp: 42 C.F.R. §447.252) §17-1739-58 Classification of acute inpatient facilities. (a) For purposes of establishing prospective payment rates, acute inpatient facilities shall be classified into the following four mutually exclusive groups: (1) Classification I - facilities averaging less than two hundred fifty medicaid discharges per year; UNOFFICIAL 1739-8 (2) Classification II - facilities averaging two hundred fifty medicaid discharges per year or more, which do not participate in approved intern and resident teaching programs; (3) Classification III - facilities averaging two hundred fifty medicaid discharges per year or more, which participate in approved intern and resident teaching programs; and (4) Classification IV - The freestanding rehabilitation hospital. (b) If a facility changes classification in accordance with the definitions in subsection (a), rates established under this subchapter shall continue to apply until the department recalculates the rates using new base year data. Facility classification changes shall only be recognized at the time of such rebasing. A facility that adds an approved intern and resident teaching program, however, may seek rate reconsideration under section 17-1739-78(a)(3). [Eff 11/13/95 ] (Auth: HRS §346-59) (Imp: 42 C.F.R. §447.252)