471 NAC 46-012. DISPROPORTIONATE SHARE HOSPITALS (DSH). A hospital qualifies as a disproportionate share hospital (DSH) if the hospital meets the definition of a disproportionate share hospital (DSH) and submits the required information completed, dated, and signed as follows with their Medicare cost report:

012. DISPROPORTIONATE SHARE HOSPITALS (DSH). A hospital qualifies as a disproportionate share hospital (DSH) if the hospital meets the definition of a disproportionate share hospital (DSH) and submits the required information completed, dated, and signed as follows with their Medicare cost report: (A) The names of at least two obstetricians who have staff privileges at the hospital and who have agreed to provide obstetric services to individuals who are eligible for Nebraska Medicaid. This requirement does not apply to a hospital; (i) The inpatients of which are predominantly individuals under 18 years of age; (ii) Which does not offer non-emergency obstetric services to the general population ; or (iii) For a hospital located in a rural area, the term obstetrician includes any physician with staff privileges at the hospital to perform non-emergency obstetric procedures; (B) Only Nebraska hospitals which have a current enrollment with Nebraska Medicaid will be considered for eligibility as a disproportionate share hospital (DSH); and (C) When notified by Nebraska Medicaid that the hospital qualifies as a disproportionate share hospital (DSH), each hospital must certify to Nebraska Medicaid that it has incurred costs for the delivery of uncompensated care which are equal to or exceed the amount of the disproportionate share hospital (DSH) payment. 012.01 DISPROPORTIONATE SHARE ELIGIBILITY CALCULATION. To calculate eligibility, proxy data will be used from each hospital's fiscal year ending in the calendar year preceding the state fiscal year. Eligibility as a disproportionate share hospital (DSH) will be calculated using the following data. 012.01(A) NEBRASKA MEDICAID INPATIENT UTILIZATION RATE. To determine the Nebraska Medicaid inpatient utilization rate, the denominator will be the total days as reported on the Medicare cost report. The numerator will be the sum of each hospital's Nebraska Medicaid days, which includes the Nebraska Medicaid management information system non-managed care claims file data run 150 days after each hospital's fiscal year end, managed care days for hospitals that submit a disproportionate share hospital (DSH) survey, and out-of-state days reported before the federal fiscal year for which the determination is made. 012.01(B) LOW INCOME UTILIZATION RATE. To determine the low-income utilization rate, data from the Nebraska accounting system will be used to calculate the low-income utilization rate for state-owned institutions for mental disease (IMD). For all other hospitals, the hospital's certified report of total revenue, Nebraska Medicaid inpatient revenue, cash subsidies, uncompensated care charges, and total inpatient charges minus any disproportionate share payment will be used. 012.02 DISPROPORTIONATE SHARE HOSPITAL (DSH) UPPER PAYMENT LIMIT AND UNCOMPENSATED CARE CALCULATION. The disproportionate share hospital (DSH) upper payment limit and the uncompensated care calculation is the sum of the Nebraska Medicaid shortfall plus the cost of uninsured care. (A) Nebraska Medicaid will calculate the Nebraska Medicaid shortfall as follows: (i) Nebraska Medicaid will determine the costs of Nebraska Medicaid fee-for-service and managed care inpatient services by: (1) Calculating a hospital's routine cost per day for each cost center from the Centers for Medicare & Medicaid Services (CMS) cost report by dividing the total costs by the total days; and (2) Multiplying the cost per day times the number of Nebraska Medicaid allowable days provided during the same fiscal year as the filed cost report and paid up to 150 days after the end of the fiscal year; (ii) Nebraska Medicaid will determine costs of Nebraska Medicaid fee-for-service and managed care outpatient services by: (1) Calculating a hospital's ancillary cost-to-charge ratio (CCR) from the Centers for Medicare & Medicaid Services (CMS) cost report; and (2) Multiplying the total Nebraska Medicaid allowable charges times the ancillary cost-to-charge ratio (CCR); (iii) The total Nebraska Medicaid cost is the sum of the inpatient and outpatient costs for each hospital; and (iv) The Nebraska Medicaid shortfall is determined by subtracting the total allowable Nebraska Medicaid payments from the total Nebraska Medicaid cost. (B) Nebraska Medicaid will calculate the cost of uninsured care by using each hospital's charges for services provided to uninsured beneficiaries as filed and certified to Nebraska Medicaid for the same fiscal year as the Centers for Medicare & Medicaid Services (CMS) cost report used in determining costs. Nebraska Medicaid will convert each hospital's charges to cost for uninsured patients by multiplying the charges by the overall cost-to-charge ratio (CCR) determined using each hospital's Centers for Medicare & Medicaid Services (CMS) report for the same fiscal year used in determining cost. (C) The Nebraska Medicaid upper payment limit and the uncompensated care amount shall be the sum of the Nebraska Medicaid shortfall plus the cost of uninsured care. 012.03 DISPROPORTIONATE SHARE PAYMENTS. Disproportionate share payments will be made each federal fiscal year following receipt of all required data by Nebraska Medicaid. The total of all disproportionate share payments must not exceed the limits on disproportionate share hospital (DSH) funding established for this State by the Centers for Medicare & Medicaid Services (CMS) in accordance with federal law . Payments determined for each federal fiscal year will be considered payment for that year, and not for the year from which proxy data used in the calculation was taken. To calculate payment, proxy data will be used from each hospital's fiscal year ending in the calendar year preceding the state fiscal year which coincides most closely to the federal fiscal year for which the determination will be applied. 012.03(A) METHODS. Nebraska Medicaid will make a disproportionate share hospital (DSH) payment to hospitals that qualify for a payment under one of the following Pool distribution methods. 012.03(A)(i) BASIC DISPROPORTIONATE SHARE PAYMENT POOL 1. Pool 1 consists of eligible hospitals in Peer Groups 2 Urban Acute Care & Regional Rural Referral Hospitals, 3 Rural Acute Care Hospitals, and 7 Critical Access Hospitals (CAH) that are not eligible under Pool 6. 012.03(A)(i)(1) POOL 1 FUNDING. Total funding to Pool 1 will be $1,000,000. In federal fiscal year 2008 and following years, this amount will be increased by the percentage change in the consumer price index for all urban consumers, all items, United States city average. Nebraska Medicaid will calculate the payment for Pool 1 as follows: first, each hospital's Nebraska Medicaid days, which include days from the Nebraska Medicaid management information system claims file data run 150 days after each hospital's fiscal year end, managed care days, and out-of-state days reported before the federal fiscal year for which the determination is made, will be divided by the sum of the Nebraska Medicaid inpatient days of all hospitals which qualify for a payment in Pool 1. Second, the ratio resulting from such division will be multiplied times the total funding for Pool 1 to determine each hospital's payment. If payment to a hospital exceeds the federally determined disproportionate share hospital (DSH) payment limit, the payment will be reduced and the additional funds will be redistributed pro rata to eligible hospitals within Pool 1. 012.03(A)(ii) BASIC DISPROPORTIONATE SHARE PAYMENT POOL 2. Pool 2 consists of eligible hospitals in Peer Groups 1 Metro Acute Care Hospitals, 2 Urban Acute Care & Regional Rural Referral Hospitals, and 3 Rural Acute Care Hospitals that are also eligible under Pool 6. 012.03(A)(ii)(1) POOL 2 FUNDING. For federal fiscal year 2009 and following years, the total funding will be the amount for federal fiscal year 2008 with an annual increase by the percentage change in the consumer price index for all urban consumers, all items, United States city average. Nebraska Medicaid will calculate the payment for Pool 2 as follows. First, each hospital's Nebraska Medicaid days, which include days from the Nebraska Medicaid management information system claims file data run 150 days after each hospital's fiscal year end, managed care days, and out-of-state days reported before the federal fiscal year for which the determination is made, will be divided by the sum of the Nebraska Medicaid inpatient days of all hospitals which qualify for a payment in Pool 2. Second, the ratio resulting from such division will be multiplied times the total funding for Pool 2 to determine each hospital's payment. If payment to a hospital exceeds the federally determined disproportionate share hospital (DSH) payment limit, the payment will be reduced and the additional funds will be redistributed pro rata to eligible hospitals within Pool 2. 012.03(A)(iii) DISPROPORTIONATE SHARE PAYMENT FOR HOSPITALS THAT PRIMARILY SERVE CHILDREN POOL 3. Pool 3 consists of the eligible hospital in Peer Group 10 Children’s Hospitals that has the greatest number of Nebraska Medicaid days. 012.03(A)(iii)(1) POOL 3 FUNDING. For federal fiscal year 2009 and following years, the total funding will be the amount for federal fiscal year 2008 with an annual increase by the percentage change in the consumer price index for all urban consumers, all items, United States city average. A hospital eligible for payment under this Pool will not be eligible for payment under any other Pool. If payment to the hospital exceeds the federally determined disproportionate share hospital (DSH) payment limit, the payment will be reduced. 012.03(A)(iv) DISPROPORTIONATE SHARE PAYMENT FOR STATE OWNED INSTITUTIONS FOR MENTAL DISEASE (IMD) HOSPITALS AND FOR ELIGIBLE HOSPITALS IN PEER GROUP 5 POOL 4. Pool 4 consists of state-owned institutions for mental disease (IMD) and other eligible hospitals in Peer Group 5 Mental Health or Psychiatric Inpatient Hospitals . 012.03(A)(iv)(1) POOL 4 FUNDING. Total funding for Pool 4 will be $1,811,337 annually. Each eligible hospitals must certify in writing to the Nebraska Medical Assistance Program its charges for uncompensated care for the hospital's fiscal year ending in the calendar year preceding the federal fiscal year for which the determination is applied. Charges for uncompensated care will be converted to cost using the hospitals cost-to-charge ratio (CCR). Payment to each hospital will be equal to the cost of its uncompensated care. If the total of all disproportionate share payment amounts for Pool 4 exceeds the federally determined disproportionate share hospital (DSH) limit for Nebraska, the disproportionate share hospital (DSH) payments will be reduced pro rata. 012.03(A)(v) NON-PROFIT ACUTE CARE TEACHING HOSPITAL AFFILIATED WITH A STATE-OWNED UNIVERSITY MEDICAL COLLEGE POOL 5. Pool 5 consists of the non-profit acute care teaching hospital, subsequently referred to as the state teaching hospital, that has an affiliation with the University Medical College owned by the State of Nebraska. A hospital eligible for payment under this Pool may be eligible for payment under Pool 6. 012.03(A)(v)(1) POOL 5 FUNDING. Total funding to Pool 5 will be $15,000,000. For federal fiscal year 2008 and following years the funding will be increased annually by the percentage change in the consumer price index for all urban consumers, all items, United States city average. Nebraska Medicaid will calculate the disproportionate share hospital (DSH) payment to Pool 5 as an amount equal to the cost of its uncompensated care. If the payment to the hospital exceeds the federally determined disproportionate share payment limit, the payment will be reduced. 012.03(A)(vi) UNCOMPENSATED CARE POOL 6. Pool 6 consists of hospitals that provide services to low-income persons covered by a county administered general assistance program; or hospitals that provide services to low-income persons served by the behavioral health regions . 012.03(A)(vi)(1) POOL 6 FUNDING. Total funding to Pool 6 will be the remaining federal and state balance of the disproportionate share hospital (DSH) total funding minus the funding for Pools 1, 2, 3, 4, and 5. Nebraska Medicaid will calculate payments as follows: disproportionate share hospital (DSH) payments to a hospital under all other Pools will be subtracted from the hospital's disproportionate share hospital (DSH) upper payment limit before allocating payments under Pool 6. The costs for uncompensated care resulting from participation county administered general assistance program will be reported by the county; and costs for the state administered public behavioral health system will be reported by each hospital and funding will be transferred to Nebraska Medicaid. Reported costs will be subject to audit by Nebraska Medicaid. The total computable payment will be commensurate with the charges for uncompensated care resulting from participation in county administered general assistance program; or the behavioral health regions . If payment to the hospital exceeds the federally determined disproportionate share payment limit, the payment will be reduced to the payment limit. If payments to hospitals under this Pool exceed the total allotment to Nebraska, the payments will be reduced pro rata. 012.03(B) LIMITATIONS ON DISPROPORTIONATE SHARE PAYMENTS. No payments made under this section will exceed any federally determined applicable limitations upon such payments . Disproportionate share hospital (DSH) payments to all qualified hospitals for a year will not exceed the federally determined State disproportionate share hospital (DSH) payments limit. .