471 NAC 46-002. DEFINITIONS

002. DEFINITIONS. The following definitions apply: 002.01 ALLOWABLE COSTS. Those costs as provided in the Medicare statutes and regulations for routine service costs, inpatient ancillary costs, capital-related costs, medical education costs, and malpractice insurance cost. 002.02 ALL-PATIENT REFINED DIAGNOSIS-RELATED GROUP (APR DRG). The All- Patient Refined Diagnosis-Related Group grouper (APR DRG) is a software application that assigns patients into categories based on severity of illness and risk of mortality. 002.03 ANCILLARY SERVICES. Ancillary services are supportive or diagnostic measures that supplement and support a primary physician, nurse, or other healthcare provider in treating a patient. 002.04 BASE YEAR. The period covered by the most recent settled Medicare cost report, which will be used for purposes of calculating prospective rates. 002.05 BUDGET NEUTRALITY. Payment rates are adjusted for budget neutrality such that estimated expenditures for the current rate year are not greater than expenditures for the previous rate year, trended forward. 002.06 CAPITAL-RELATED COSTS. Those costs, excluding tax-related costs, as provided in the Medicare regulations and statutes in effect for each facility's base year. 002.07 CASE-MIX INDEX. An arithmetical index measuring the relative average resource use of discharges treated in a hospital compared to the statewide average. 002.08 COST OUTLIER. Cases which have an extraordinarily high cost as established in this chapter to be eligible for additional payments above and beyond the initial diagnosis- related group payment. 002.09 CRITICAL ACCESS HOSPITAL (CAH). A hospital licensed as a critical access hospital (CAH) by the Department of Health and Human Services, Division of Public Health, and certified for participation by Medicare as a critical access hospital (CAH). 002.10 DIAGNOSIS-RELATED GROUP (DRG). A group of similar diagnoses combined based on patient age, birth weight, procedure coding, comorbidity, and complications. 002.11 DIRECT MEDICAL EDUCATION (DME) COST PAYMENT. An add-on to the operating cost payment amount to compensate for direct medical education (DME) costs associated with approved intern and resident programs. 002.12 DISPROPORTIONATE SHARE HOSPITAL (DSH). A hospital located in Nebraska is deemed to be a disproportionate share hospital (DSH) by having: (A) A Nebraska Medicaid inpatient utilization rate equal to or above the mean Nebraska Medicaid inpatient utilization rate for hospitals receiving Nebraska Medicaid payments in Nebraska; or (B) A low-income utilization rate of 25 percent or more. 002.13 DIAGNOSIS-RELATED GROUP (DRG) WEIGHT. A number that reflects relative resource consumption as measured by the relative costs by hospitals for discharges associated with each diagnosis-related group (DRG) and severity of illness. 002.14 DISTINCT PART UNIT. A Medicare-certified hospital-based substance use disorder, psychiatric, or physical rehabilitation unit that is certified as a distinct part unit for Medicare. 002.15 HOSPITAL MERGERS. Hospitals that have combined into a single entity, and have applied for and received a single inpatient Medicare provider number and a single inpatient Nebraska Medicaid provider number. 002.16 HOSPITAL-SPECIFIC BASE YEAR OPERATING COST. Hospital-specific operating allowable cost associated with treating Nebraska Medicaid beneficiaries . Operating costs include the major moveable equipment portion of capital-related costs, but exclude the building and fixtures portion of capital-related costs, direct medical education (DME) costs, indirect medical education (IME) costs, and graduate medical education costs. 002.17 HOSPITAL-SPECIFIC COST-TO-CHARGE RATIO (CCR). Hospital-specific cost-to-charge ratio (CCR) is based on total hospital aggregate costs divided by total hospital aggregate charges. Hospital-specific cost-to-charge ratios (CCR) used for outlier cost payments and transplant diagnosis-related group cost-to-charge ratio (CCR) payments are derived from the outlier cost-to-charge ratios (CCR) in the Medicare inpatient prospective payment system. 002.18 HOSPITAL QUALITY ASSURANCE AND ACCESS ASSESSMENT. A quality assurance and access assessment imposed on hospitals as defined in these regulations. The hospital quality assurance and access assessment shall be used to fund the non-federal share of hospital directed payments throughout the statutory period allowed by law. 002.19 INDIRECT MEDICAL EDUCATION (IME) COST PAYMENT. Payment for costs that are associated with maintaining an approved medical education program, but that are not reimbursed as part of direct medical education (DME) cost payments. 002.20 LONG-TERM ACUTE CARE HOSPITAL (LTACH). A hospital that is licensed as a general acute care hospital that focuses on treating patients requiring extended hospital-level care, typically following initial treatment at a general acute care hospital. Patients treated in a long-term acute care hospital (LTACH) are not generally appropriate for lower level of care (LOC) settings, but are expected to improve to lower level of care (LOC) status. 002.21 LOW-INCOME UTILIZATION RATE. For the cost reporting period ending in the calendar year preceding the Medicaid rate period, the sum of the fractions, expressed as a percentage, calculated from acceptable data submitted by the hospital as follows: (A) The total Nebraska Medicaid inpatient revenues paid to the hospital, including fee-for-service, managed care, and primary care case management payments and excluding disproportionate share hospital (DSH) payments, plus the amount of cash subsidies received directly from state and local governments in a cost reporting period, divided by the total amount of revenues of the hospital for inpatient services in the same cost reporting period; and (B) The total amount of the hospital's charges for hospital inpatient services attributable to uncompensated care and ending in the calendar year preceding the Nebraska Medicaid rate period, less the amount of any cash subsidies identified in this section in the cost reporting period reasonably attributable to hospital inpatient services, divided by the total amount of the hospital's charges for inpatient services in the hospital for the same period. The total inpatient charges attributed to uncompensated care does not include contractual allowances and discounts, other than for uncompensated patients not eligible for Nebraska Medicaid, that is, reductions in charges given to other third-party payors. 002.22 NEBRASKA MEDICAID ALLOWABLE INPATIENT CHARGES. The total claim submitted charges less claim non-allowable amount. 002.23 NEBRASKA MEDICAID ALLOWABLE INPATIENT DAYS. The total number of covered Nebraska Medicaid inpatient days. 002.24 NEBRASKA MEDICAID INPATIENT UTILIZATION RATE. The ratio of allowable Nebraska Medicaid inpatient days, as determined by Nebraska Medicaid, to total inpatient days, as reported by the hospital on its Medicare cost report ending in the calendar year preceding the Nebraska Medicaid rate period. Inpatient days for out-of-state Medicaid patients for the same time period will be included in the computation of the ratio if reported to Nebraska Medicaid prior to the beginning of the Nebraska Medicaid rate period. 002.25 NEBRASKA MEDICAID RATE PERIOD. The period of July 1 through the following June 30. 002.26 MEDICAL REVIEW. Review of Nebraska Medicaid claims, including validation of hospital diagnosis and procedure coding information; continuation of stay; completeness; adequacy; and quality of care; appropriateness of admission; discharge and transfer; and appropriateness of prospective payment outlier cases. 002.27 MEDICARE COST REPORT. The report filed by each facility with its Medicare fiscal intermediary. A hospital that does not participate in the Medicare program will complete the Medicare cost report in compliance with Medicare principles and supporting rules, regulations, and statutes. The hospital will file the completed form with Nebraska Medicaid within five months after the end of the hospital's reporting period. A 30-day extension of the filing period may be granted if requested in writing before the end of the five-month period. Completed Medicare cost reports are subject to audit by Nebraska Medicaid or its designees. If a nursing facility is affiliated with the hospital, the nursing facility cost report must be filed as outlined in these regulations. 002.28 NATIONAL WEIGHTS. The 3M All-Patient Refined Diagnosis-Related Group grouper (APR DRG) National Weights are calculated using the Nationwide Inpatient Sample released by the Healthcare Cost and Utilization Project. 002.29 NEW OPERATIONAL FACILITY. A new operational facility is created neither by virtue of a change in ownership nor by the construction of additional beds to an existing facility. A new operating facility provides inpatient hospital care that meets one of the following criteria: (A) A licensed newly constructed facility, which either totally replaces an existing facility or which is built at a site where hospital inpatient services have not previously been provided; (B) A licensed facility which begins providing hospital inpatient services in a building at a site where those services have not previously been provided; or (C) A licensed facility which is reopened at the same location where hospital inpatient care has previously been provided but not within the previous 12 months. 002.30 NON-ACUTE ADMIN DAYS. Nebraska Medicaid coverage for hospital care when a Nebraska Medicaid beneficiary, who is an inpatient, no longer requires acute inpatient care and requires nursing facility level of care (LOC) upon discharge but is unable to be transferred to a nursing facility due to a lack of available nursing facility beds, or in cases when the transfer requires a guardian, and a guardian has not been appointed. 002.31 OPERATING COST PAYMENT AMOUNT. The calculated payment that compensates hospitals for operating cost, including the major moveable equipment portion of capital-related costs, but excluding the building and fixtures portion of capital-related costs, direct medical education (DME) costs, indirect medical education (IME) costs, and graduate medical educations costs. 002.32 PEER GROUP. A grouping of hospitals or distinct part units of a hospital for the purpose of determining payment amounts. Hospitals are grouped with similar characteristics, licenses, Medicare certification, and classifications in the Centers for Medicare & Medicaid Services (CMS) inpatient prospective payment system impact file. Hospitals are classified into the following Peer Groups: (A) Peer Group 1: Metro Acute Care Hospitals; (B) Peer Group 2: Urban Acute Care & Regional Rural Referral Hospitals; (C) Peer Group 3: Rural Acute Care Hospitals; (D) Peer Group 4: Indian Health Service (HIS) & Beatrice Development Center (BSDC) Hospitals; (E) Peer Group 5: Mental Health and Psychiatric Inpatient Hospitals; (F) Peer Group 6: Physical Rehabilitation Hospitals; (G) Peer Group 7: Critical Access Hospitals (CAH); (H) Peer Group 8: Rural Emergency Hospitals; (I) Peer Group 9: Long-Term Acute Care Hospitals (LTACH); or (J) Peer Group 10: Children’s Hospitals. 002.33 PEER GROUP BASE PAYMENT AMOUNT. A base payment per discharge or per diem amount used to calculate the operating cost payment amount. The hospitals in Peer Group 1 Metro Acute Care Hospitals, Peer Group 2 Urban & Regional Rural Referral Hospitals, Peer Group 3 Rural Acute Care Hospitals, Peer Group 5 Mental Health and Psychiatric Inpatient Hospitals, Peer Group 9 Long-Term Acute Care Hospitals (LTACH), and Peer Group 10 Children’s Hospitals will have the same base payment or per diem amount. 002.34 REPORTING PERIOD. Same reporting period as that used for the Medicare cost report. 002.35 RESOURCE INTENSITY. The relative volume and types of diagnostic, therapeutic, and bed services used in the management of a particular disease. 002.36 RISK OF MORTALITY (ROM). The likelihood of dying. 002.37 RURAL EMERGENCY HOSPITAL. A hospital licensed as a rural emergency hospital by the Department of Health and Human Services, Division of Public Health, and certified for participation by Medicare as a rural emergency hospital. A rural emergency hospital solely provides outpatient services, including emergency department services, observation care, and additional outpatient medical and health services that do not exceed an annual per patient length of stay of 24 hours on average. 002.38 SEVERITY OF ILLNESS LEVEL . The extent of physiologic decompensation or organ system loss of function. 002.39 SWING BED. Post-hospital 24-hour skilled nursing care services that must be provided by or under the direct supervision of professional or technical personnel and requires skilled knowledge, judgment observation, and assessment. 002.40 TAX-RELATED COSTS. Any real or personal property tax, sales tax, excise tax, tax enacted pursuant to federal public laws, or any amendments thereto, franchise fee, license fee, or hospital-specific tax, fee or assessment imposed by the local, state, or federal government, but not including income taxes. 002.41 TRANSPLANT DIAGNOSIS-RELATED GROUPS (DRG). Transplant diagnosis- related groups (DRG) are identified in the All-Patient Refined Diagnosis-Related Group grouper (APR DRG). Nebraska Medicaid does not recognize bone marrow transplant diagnosis-related groups in its classification with all other transplant diagnosis-related groups categorized by the All-Patient Refined Diagnosis-Related Group grouper (APR DRG). Bone marrow transplant diagnosis-related groups do not receive a transplant cost-to-charge ratio (CCR) or transplant direct medical education (DME) payment. The bone marrow transplant diagnosis-related groups per discharge payment is the sum of the operating cost payment amount, the capital-related cost payment, and when applicable a direct medical education (DME) cost payment, indirect medical education (IME) cost payment, and a cost outlier payment. 002.42 UNCOMPENSATED CARE. Uncompensated care includes the difference between costs incurred and payments received in providing services to Nebraska Medicaid beneficiaries and uninsured.