D.C. Mun. Regs. tit. 29, r. 29-4814
The District of Columbia's Medicaid program shall reimburse claims associated with discharges from specialty hospitals, occurring on and after October 1, 2014, in accordance with the methodology described in Sections 4814 through 4819 of these rules. A claim eligible for payment shall reflect an approved specialty inpatient hospital stay of at least one (1) day or more by a beneficiary who is eligible for Medicaid.
A specialty hospital shall be reimbursed either on a per diem (PD) or a per stay (PS) basis using the All Payer Refined-Diagnostic Related Group (APR-DRG) perspective payment system. DHCF adopted the APR-DRG classification system, as contained in the 2014 APR-DRG Classification System Definitions Manual, version 31.0, for purposes of calculating rates set forth in this section. Subsequent versions representing significant changes to the APR-DRG Classification System Definitions Manual may be adopted by DHCF at a later date.
For purposes of Medicaid reimbursement, a specialty hospital meets the definition of a "special hospital" that is set forth in 22-B DCMR § 2099. Specialty hospitals classified as psychiatric hospitals shall be eligible for reimbursement of:
For discharges occurring on or after October 1, 2014, the following types of specialty hospitals in the District shall be reimbursed on a PD basis as described at Section 4815:
For discharges occurring on or after October 1, 2014, LTCHs in the District shall be reimbursed on a PS basis as described at Section 4816.
Out-of-District hospitals that deliver services meeting the requirements set forth in Subsection 4814.3 shall be reimbursed in accordance with the requirements set forth in Sections 4813, 4814, and 4815.
A hospital entering the District of Columbia market after October 1, 2014 shall demonstrate substantial compliance with all applicable laws and policies, including licensure, prior to contacting DHCF to initiate the rate setting process, including classification as either a per diem or per stay hospital.
Each hospital classified within the specialty category shall have a hospital-specific base PD rate calculated in accordance with Section 4815 or base PS rate calculated in accordance with Section 4816. For purposes of this section, the base year period shall be Fiscal Year (FY) 2013, or October 1, 2012 through September 30, 2013.
Cost classifications and allocation methods shall be applied in accordance with the CMS Guidelines for Form CMS 2552-10 and the Medicare Provider Reimbursement Manual 15, or subsequent superseding issuances from CMS.
The hospital-specific cost-to-charge ratio (CCR) for specialty hospitals located in the District shall be calculated annually in accordance with 42 CFR § 413.53 and 42 CFR §§ 412.1 through 412.125, as reported on cost reporting Form HFCA 2552-10, Worksheet C Part I, or its successor. For purposes of specialty hospital reimbursement, organ acquisition costs shall not be included in the CCR calculation.
Effective FY 2016, beginning on October 1, 2015, and annually thereafter, except during a rebasing year, DHCF shall apply an inflation adjustment to the then current base per diem or per stay rate associated with each specialty hospital. The inflation adjustment factor shall be calculated by multiplying the cur rent base rate by the Medicare inflation factor as set forth in 42 USC § 1395ww (including multifactor productivity, statutory and any other relevant adjustments to the market basket rate of increase) to equal the adjusted base rate. DHCF shall base the inflation adjustment factor on the appropriate, hospital type specific inflation factor proposed under the Medicare program, set forth in the Hospital Inpatient Prospective Payment Systems (PPS) for general hospitals and the LTCH PPS for the same federal FY in which the rates will be effective.
Except as provided in Subsections 4814.13 and 4814.14, effective in FY 2019, which begins on October 1, 2018, and every four (4) years thereafter (i.e., quadrennially), the base rate for each specialty hospital shall be rebased as follows:
For specialty hospitals classified as rehabilitation hospitals, effective FY 2018, which begins on October 1, 2017, the base rate for each rehabilitation hospital shall be rebased using the methodology outlined in Subsection 4814.12.
Following the FY 2018 rebasing for rehabilitation hospitals described in Subsection 4814.13, the base rate for each rehabilitation hospital shall be rebased effective FY 2023, beginning on October 1, 2022, and every four (4) years thereafter (i.e., quadrennially).
Out-of-District specialty hospitals, not located in Maryland, shall be reimbursed for inpatient discharges in the same manner as general hospitals, pursuant to Sections 4800 through 4813.
In the event that an out-of-District hospital offers inpatient specialty services that are distinct from services offered by other hospitals, DHCF may consider alternative reimbursement for those specialty inpatient services, provided the needs of Medicaid beneficiaries cannot be met by an in-District hospital.
Maryland hospitals shall be reimbursed for specialty inpatient hospital services in accordance with Subsection 4800.12.
All specialty hospital inpatient stays and non-emergency transfers shall be prior authorized pursuant to Subsection 4800.5.
A specialty hospital located in an EDZ shall receive an increased reimbursement rate pursuant to Subsection 4810.1.
Reimbursement of same-day discharges shall occur in accordance with Subsections 4812.1 through 4812.2.
D.C. Mun. Regs. tit. 29, r. 29-4814