Ala. Admin. Code r. 560-X-23-.09

Current through Register Vol. 43, No. 1, October 31, 2024

Section 560-X-23-.09 - Medicare Catastrophic Coverage Act Day And Cost Outliers

(1) Day Outliers - The Alabama Medicaid Agency does not impose durational limits for medically necessary inpatient services provided to children under the age of 6 years in hospitals deemed by the Agency as disproportionate and under the age of 1 in all hospitals. Because we pay for all medically necessary days of care for these children, we meet the day outlier requirement of the Medicare Catastrophic Coverage Act and no additional payments are available.

(2) Cost Outliers

(a) A cost outlier for an extremely costly length of stay for a child under age 6 receiving medically necessary services in a hospital deemed by the Alabama Medicaid Agency as disproportionate share and under age 1 in all hospitals, is defined as a claim for payment for a discharged child for allowable services rendered from the date of admission to the date of discharge which meets the following criteria:

(b) The Medicaid allowed charges per day for the length of stay for Medicaid eligible children as outlined above must exceed four times the hospital's mean total charge per day as established by Medicaid from Agency paid claim data.

(c) Payment of Cost Outliers. The sum of allowed charges in excess of four times the mean total charge per day shall be multiplied by the hospital's current rate period percent of total Medicaid cost to total Medicaid charges (per Worksheet C of the Medicaid Cost Report) to establish the amount to be paid as a cost outlier. The outlier payment per Medicaid eligible child as outlined above shall be limited to $10,000 per discharge and a total of $50,000 during the per diem rate cycle October 1 through September 30.

Ala. Admin. Code r. 560-X-23-.09

Rule effective June 9, 1986. Repealed and New Rule: Filed November 10, 2010; effective December 15, 2010.

(See history note at end of chapter.)

Author: Keith Boswell, Director, Provider Audit/Reimbursement

Statutory Authority: State Plan; Title XIX, Social Security Act; 42 C.F.R. §§401, et seq.