Section 7 AAC 150.110 - Methodology and criteria for proportionate share payments to privately owned or operated hospitals(a) To implement the provisions of 42 U.S.C. 1396 b regarding federal financial participation under Medicaid, and subject to legislative appropriations for that purpose, the department will make a private hospital proportionate share payment to, and will require under (2) - (4) of this subsection that specific services be performed by, a hospital that qualifies under (1) of this subsection in order to ensure continued access to hospital services, and in order to secure for the state in accordance with AS 47.07.040 the optimum federal participation for inpatient hospital services in the state's medical assistance program. The following procedures and requirements apply to a proportionate share payment under this subsection: (1) to qualify to receive a private hospital proportionate share payment under this subsection, a hospital must(A) be enrolled as a Medicaid provider of inpatient hospital services;(B) be located within the state;(C) be a privately owned facility; and(D) submit to the department the Medicaid reporting forms for the qualifying year from the Medicaid Hospital and Long-Term Care Facility Reporting Manual, adopted by reference in 7 AAC 160.900;(2) a qualifying hospital may receive proportionate share payments allocated to one or more of the following private hospital proportionate share classifications, if that hospital meets any additional criteria applicable to that classification, and subject to the limitations set out in (5) - (6) of this subsection: (A) each qualifying hospital may receive payments for rural hospital assistance (RHA), if the qualifying hospital enters into an agreement with the department to provide support services in accordance with (4) of this subsection through a rural hospital and complies with the requirements of that agreement;(B) each qualifying hospital may receive payments for rural hospital clinic assistance (RHCA), if the qualifying hospital enters into an agreement with the department to provide support services in accordance with (4) of this subsection through a rural clinic and complies with the requirements of that agreement;(C) each qualifying hospital may receive payments for mental health clinic assistance (MHCA), if the qualifying hospital enters into an agreement with the department to provide mental health services through a mental health clinic and complies with the requirements of that agreement;(D) each qualifying hospital may receive payments for single-point-of-entry psychiatric assistance (SPEP), if the qualifying hospital enters into an agreement with the department to provide single-point-of-entry psychiatric services and complies with the requirements of that agreement;(E) each qualifying hospital may receive payments for designated evaluation and treatment assistance (DET), if the qualifying hospital (i) is designated as an evaluation and treatment facility as required by 7 AAC 72; and(ii) enters into an agreement with the department to provide designated evaluation and treatment services and complies with the requirements of that agreement;(F) each qualifying hospital may receive payments for children's medical care assistance (CMC), if the qualifying hospital enters into an agreement with the department for health and hospital care expenses for children and complies with the requirements of that agreement;(G) each qualifying hospital may receive payments for institutional community health care assistance (ICHC), if the qualifying hospital enters into an agreement with the department for health and hospital care expenses for individuals in institutions who are not Medicaid-eligible, and complies with the requirements of that agreement;(H) each qualifying hospital may receive payments for substance abuse treatment provider assistance (SATP), if the qualifying hospital enters into an agreement with the department to provide substance abuse treatment through a substance abuse treatment provider and complies with the requirements of that agreement;(3) in an agreement under (2) of this subsection, the department may authorize the qualifying hospital to provide the required services directly, through the purchase of services, or through a person, clinic, or hospital designated by the department; a payment made under this section is not an allowable cost under the facility rate setting methodology set out in 7 AAC 150.010 - 7 AAC 150.040 and 7 AAC 150.130 - 7 AAC 150.210;(4) for purposes of an agreement under (2)(A) or (B) of this subsection, the support services that a qualifying hospital provides must include one or more of the following: (A) health services at the rural hospital site or rural clinic site; the qualifying hospital may include, as services, the services of a primary care provider, nurse midwife services, obstetrical services, and pediatrician's services;(B) assistance in arranging safe transport for those who require emergency transport and services;(C) other health services agreed to by the qualifying hospital and the department;(5) the total amount available for distribution as private hospital proportionate share payments under this subsection will be established by the department each year, based on the department's projection of hospital expenditures and within the payment limits of 42 C.F.R. 447.271 - 447.272; subject to legislative appropriation, payment of the amount the department determines to be available for private hospital proportionate share payments will be apportioned among qualifying hospitals;(6) beginning August 11, 2004, the department will allocate the following percentage of the private hospital proportionate share payments for each payment year by proportionate share classification: (A) to the rural hospital assistance (RHA) private hospital classification, one percent;(B) to the rural health clinic assistance (RHCA) private hospital classification, 54 percent;(C) to the mental health clinic assistance (MHCA) private hospital classification, 23 percent;(D) to the single-point-of-entry psychiatric (SPEP) private hospital classification, six percent;(E) to the designated evaluation and treatment (DET) private hospital classification, one percent;(F) to the children's medical care (CMC) private hospital classification, eight percent;(G) to the institutional community health care (ICHC) private hospital classification, one percent;(H) to the substance abuse treatment provider (SATP) private hospital classification, six percent;(7) each payment for the private hospital proportionate share classifications will be calculated within each classification based on the number of encounters to be performed by the qualifying hospital for that classification, as specified in the agreement required under (2) of this subsection for that classification, divided by the total number of encounters to be performed by all qualifying hospitals within that classification, as specified in the agreements required for that classification; the resulting percentage will be multiplied by the allocation amount applicable to that classification, as calculated in (5) - (6) of this subsection;(8) on or before the qualification date, the department will send to each privately owned hospital a list of the qualifying hospitals and the amount of the payments for the upcoming payment year; the total amount available for distribution as private hospital proportionate share payments under this subsection will be established by the department each year, based on the department's projection of hospital expenditures and within the payment limits of 42 C.F.R. 447.271 - 447.272; the department's determination under this paragraph is the department's final administrative action regarding (A) whether a hospital is a qualifying hospital, unless a request for reconsideration is filed under (10) of this subsection; and(B) the amount of a qualifying hospital's proportionate share payment under this subsection, unless a request for reconsideration is filed under (11) of this subsection;(9) to optimize, consistent with AS 47.07 and this chapter, the use of federal money allotted to private hospital proportionate share payments, the department may enter into other agreements under (2)(A) - (H) of this subsection, if (A) the amount of the federal allotment is greater than the sum of payments listed under (8) of this subsection;(B) the part of the federal allotment allocated under (6) of this subsection to a particular classification is not fully used within that classification; or(C) after issuance of the list under (8) of this subsection, part of the federal allotment becomes available for distribution because an agreement or other criterion required under (2) of this subsection was not reached or satisfied;(10) a hospital aggrieved by the department's decision under (8) of this subsection, regarding whether a hospital is a qualifying hospital, may request reconsideration of the decision by filing a request with the department, and sending a copy of the request to each qualifying hospital, no more than 10 days after the date of the department's list under (8) of this subsection; a request for reconsideration under this paragraph must state the facts in the record that support a reversal of the initial decision; a qualifying hospital to which a request for reconsideration was sent may file with the department, no more than 10 days after the date the request was sent, a response to the request for reconsideration; the response must be based on facts in the record; the department's decision on reconsideration under this paragraph is the department's final administrative action on a reconsideration request under this paragraph; if the department does not issue a decision on reconsideration 30 days or less after the deadline for filing a response to the request for reconsideration, and does not waive the 30-day deadline, the request is considered denied by the department; the denial is the department's final administrative action on a reconsideration request under this paragraph;(11) a hospital aggrieved by the department's decision under (8) of this subsection, regarding the amount of a qualifying hospital's proportionate share payment under this subsection, may request reconsideration of the decision by filing a request with the department, and sending a copy of the request to each of the other qualifying hospitals, no more than 10 days after the date of the department's list under (8) of this subsection; if the department has made the private hospital proportionate share payment under this subsection to the qualifying hospital, the department will accept and consider a request for reconsideration under this paragraph only after return of any unearned portion of the payment is made; a request for reconsideration under this paragraph must state the facts in the record that support a change in the payment amount; a qualifying hospital to which a request for reconsideration was sent may file with the department, no more than 10 days after the date the request was sent, a response to the request for reconsideration; the response must be based on facts in the record; the department's decision on reconsideration under this paragraph is the department's final administrative action on a reconsideration request under this paragraph; if the department does not issue a decision on reconsideration 30 days or less after the deadline for filing a response to the request for reconsideration, and does not waive the 30-day deadline, the request is considered denied by the department; the denial is the department's final administrative action on a reconsideration request under this paragraph;(12) the administrative appeal process provided by 7 AAC 150.220 and the exceptional relief process set out in 7 AAC 150.240 are not available to a hospital disputing an item on the department's list under (8) of this subsection of qualifying hospitals and amounts;(13) unless the department considers it impractical, the department will recalculate and reallocate the proportionate share eligibility and payments for all hospitals and will recoup payments from all hospitals on a prorated basis if the(A) proportionate share eligibility and payment for any private hospital will be recalculated as a result of a decision under (10) or (11) of this subsection or of a court decision; or(B) outcome of a decision under (10) or (11) of this subsection or of a court decision would cause the total private hospital proportionate share payments to exceed the federal allotment for the federal fiscal year in which the payment rate was in effect.(b) In this section, unless the context requires otherwise,(1) "encounter" means a unit of service, visit, or face-to-face contact that is a covered service under an agreement with the department as required under this section;(2) "payment year" means the state fiscal year;(3) "qualification date" means July 1 of each year;(4) "qualifying hospital" means a hospital that qualifies under (a)(1) of this subsection for a private hospital proportionate share payment;(5) "qualifying year" means the hospital's most recent fiscal year that the department determines complete.Eff. 2/1/2010, Register 193Authority:AS 47.05.010
AS 47.07.030
AS 47.07.040
AS 47.07.070