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37.86.2925    INPATIENT HOSPITAL REIMBURSEMENT, DISPROPORTIONATE SHARE HOSPITAL (DSH) PAYMENTS

(1) Routine disproportionate share hospitals (RDSH) shall receive an additional payment amount equal to the product of the hospital's prospective base rate times the adjustment percentage of:

(a) 4% for rural hospitals; or

(b) 10% for urban hospitals.

(2) Subject to federal approval and the availability of sufficient state special revenue, all supplemental disproportionate share hospitals shall receive a supplemental disproportionate share hospital payment. In order to maintain access and quality in the most rural areas in Montana, critical access hospitals shall receive an increased portion of the available funding. The supplemental disproportionate share hospital payment shall be calculated using the formula: SDSH=(M/D)*P.

(a) For the purposes of the determining supplemental disproportionate share hospital payment amounts, following definitions apply:

(i) "SDSH" represents the calculated supplemental disproportionate share hospital amount.

(ii) "M" represents the number of weighted Medicaid paid inpatient days provided by the hospital for which the payment amount is being calculated.

(A) For critical access hospitals, weighted Medicaid inpatient days shall equal the number of Medicaid inpatient days provided multiplied by 3.8.

(B) For all other hospitals, weighted Medicaid inpatient days equals the number of Medicaid paid inpatient days provided.

(iii) "D" equals the total number of weighted Medicaid paid inpatient days provided by all supplemental disproportionate share hospitals in Montana.

(iv) "P" equals the unexpended, unencumbered disproportionate share hospital allotment for Montana, as determined by CMS according to section 1923 of the Social Security Act, remaining after routine disproportionate share hospital payments have been calculated according to (1), plus the state financial participation.

(v) The figures used in (2)(a)(ii) and (iii) must be from the department's paid claims data for the hospital's fiscal year that ended in the most recent calendar year that ended at least 12 months prior to the calculation of the HRA payments.

(3) Disproportionate share hospital payments, including routine disproportionate share hospital payments and supplemental disproportionate share hospital payments will be limited to the cap established by the federal Centers for Medicare and Medicaid Services (CMS) for the state of Montana. The adjustment percentages specified in this rule shall be ratably reduced as determined necessary by the department to avoid exceeding the cap.

(a) The department will submit an independent certified audit to CMS for each completed Medicaid state plan rate year, consistent with 42 CFR Part 455, Subpart D.

(b) To the extent that audit findings demonstrate that DSH payments exceed the documented hospital-specific limits, the department will collect overpayments and redistribute DSH payments.

(c) Beginning with state fiscal year (SFY) 2011, based on audit findings, should the department determine that there is an overpayment to a provider, the department will:

(i) recover the overpayment from the provider;

(ii) redistribute the amount in overpayment to providers that had not exceeded the hospital-specific limit during the period in which the DSH payments were determined; and

(iii) ensure all payments will be subject to hospital-specific limits.

(d) Should the DSH overpayment exceed the aggregate hospital-specific limit, the federal amount of overpayment will be returned to the Center for Medicare and Medicaid Services (CMS).

(e) Beginning with SFY 2011, facilities choosing not to participate in the annual DSH audit will forfeit 100% of their DSH payment allocated for that year. This allocation will be deemed an overpayment and will be recovered from the provider.

(f) Disproportionate share payments must not exceed the DSH state allotment, except as otherwise required by the Social Security Act. In no event is the department obligated to use state Medicaid funds to pay more than the state Medicaid allotment of DSH payments due a provider.

(4) Eligibility for routine disproportionate share hospital and supplemental disproportionate share hospital payments will be determined based on a provider's year-end reimbursement status.

History: 2-4-201, 53-2-201, 53-6-113, MCA; IMP, 2-4-201, 53-2-201, 53-6-101, 53-6-111, 53-6-113, MCA; NEW, 2004 MAR p. 482, Eff. 2/27/04; AMD, 2008 MAR p. 1983, Eff. 10/1/08; AMD, 2010 MAR p. 1534, Eff. 7/1/10; AMD, 2012 MAR p. 624, Eff. 4/1/12.

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