D.C. Mun. Regs. tit. 29, r. 29-903

Current through Register Vol. 71, No. 49, December 6, 2024

Rule 29-903 - OUTPATIENT AND EMERGENCY ROOM SERVICES

903.1

The purpose of this section is to set forth the requirements governing Medicaid reimbursement of outpatient hospital services.

903.2

All hospitals that deliver outpatient hospital services to Medicaid-eligible individuals and are enrolled as providers under the Department of Health Care Finance's (DHCF) Medicaid program shall be reimbursed under a prospective payment system (PPS) under the Enhanced Ambulatory Patient Grouping (EAPG) classification system.

903.3

The EAPG payment system shall be applicable to the following hospitals enrolled as Medicaid providers:

(a) In-District General Hospitals;

(b) Specialty Hospitals; and

(c) Out-of-District Hospitals with the exception of Maryland hospitals.

903.4

The EAPG is a visit-based classification system that uses a grouping algorithm for outpatient services to characterize the amount and type of resources used during a hospital outpatient visit for patients with similar clinical characteristics.

903.5

Except as provided in Subsection 903.7, DHCF shall update the EAPG grouper/pricer software version every two (2) years, or more often when necessary. These updates shall be effective on October 1st of the applicable year. The first update shall be implemented in FY 2017, beginning on October 1, 2016.

903.6

DHCF shall use the national relative weights of the EAPG grouper/pricer software and update the EAPG relative weights at a minimum of every two (2) years to coincide with the grouper version upgrades, or more frequently as needed.

903.7

DHCF shall update the EAPG grouper/pricer software on a quarterly basis to accommodate changes in the national Current Procedural Terminology (CPT)/HealthCare Common Procedure Coding System (HCPCS) code sets.

903.8

The EAPG payment system shall apply to all hospital claims for dates of service on or after October 1, 2014.

903.9

Payment for an outpatient hospital claim under the EAPG payment system shall be based on the following formula:

Adjusted EAPG relative weight x policy adjustor (if applicable)

x

Conversion factor

903.10

Each EAPG shall be assigned a national relative weight, which shall be adjusted by the applicable payment mechanisms including discounting, packaging, and/or consolidation.

903.11

DHCF may also use policy adjustors, as appropriate, to ensure that Medicaid beneficiaries maintain access to certain services and adequate provider networks based on review and analysis.

903.12

Effective October 1, 2014, a pediatric policy adjustor in the amount of 1.25 shall be applied to the national weight for all outpatient visits for children under the age of twenty-one (21). Thereafter, the policy adjustor rate shall be evaluated during the annual rate review.

903.13

The EAPG payment system shall utilize one of the following conversion factors:

(a) An In-District rehabilitation hospital factor;

(b) A District-wide conversion factor for other in-District and out-of-District hospitals (except Maryland hospitals); or

(c) A District-wide conversion factor increased by two percent (2%) for outpatient services provided by hospitals located in an Economic Development Zone (EDZ).

903.14

A factor that is two percent (2%) higher than the District-wide conversion factor shall be applicable to hospitals whose primary location is in an area identified as an Economic Development Zone and certified by the District Department of Small and Local Business Development as a Developmental Zone Enterprise (DZE) pursuant to D.C. Official Code § 2-218.37.

903.15

The conversion factors shall be dependent upon DHCF's budget target, and shall be calculated using outpatient hospital paid claims data from DHCF's most recent and available fiscal year.

903.16

The base year data for the conversion factors effective Fiscal Year 2015, beginning on October 1, 2014, shall be historical claims data for outpatient hospital services from the DHCF Fiscal Year 2013, for dates of service beginning on October 1, 2012 through September 30, 2013.

903.17

The base year shall change when the EAPG payment system is rebased and recalibrated with a grouper version and EAPG relative weights update every other year.

903.18

DHCF shall utilize a budget target for Fiscal Year 2015 which will be based on seventy-seven percent (77%) of Fiscal Year 2013 costs that will be inflated to Fiscal Year 2015 using the CMS Inpatient Prospective Payment System (IPPS) Hospital Market Basket Rate.

903.19

DHCF shall reduce the budget target for Fiscal Year 2015 by five percent (5%) in anticipation of more complete and accurate coding by hospitals upon implementation of the EAPG payment system.

903.20

The budget target shall be subject to change each year. Initially, DHCF shall monitor claim payments at least biannually during DHCF Fiscal Years 2015 and 2016 to ensure that expenditures do not significantly exceed or fall below the budget target and shall make adjustments to the conversion factors as necessary. DHCF shall provide written notification to the hospitals of the initial conversion factors and any future adjustments to the conversion factors.

903.21

DHCF shall analyze claims data annually to determine the need for an update of the conversion factors. The conversion factors in subsequent years shall be based on budget implications or other factors deemed necessary by DHCF.

903.22

New hospitals shall receive the District-wide conversion factor on an interim basis until the conversion factor annual review during which conversion factors for all hospitals shall be analyzed and subject to adjustment. Any changes in rates shall be effective on October 1st of each year.

903.23

Each CPT/HCPCS procedure code on a claim line shall be assigned to the appropriate EAPG at the claim line level. The total reimbursement amount shall be the sum of all claim lines.

903.24

Prospective payments using the EAPG classification system shall be considered final and there shall be no retrospective cost settlements.

903.25

Coverage and payment for specific services shall be made as follows:

(a) Payment of laboratory and radiology shall be processed and paid by EAPG, subject to consolidation, packaging, or discounting;

(b) Physical therapy, occupational therapy, speech therapy, and hospital dental services shall be processed and paid by EAPGs, subject to consolidation, discounting, and packaging; and

(c) Observation services shall be processed and paid by EAPG. In order to receive reimbursement for services with an observation status, claims shall include at least eight (8) consecutive hours (billed as units of service). Any hours in excess of forty-eight (48) shall not be covered.

903.26

All DHCF policies for outpatient hospital services requiring prior authorization shall be applicable under the EAPG payment system.

903.27

Exceptions to reimbursement under the EAPG payment system shall include the following:

(a) Vaccines for children that are currently paid under the federal government's Vaccine for Children (VFC) program;

(b) Professional services provided by physicians; and

(c) Claims originating from Maryland hospitals, St. Elizabeths Hospital, and managed care organizations.

903.28

With the exception of Specialty hospitals and Maryland hospitals, outpatient diagnostic services provided by a hospital one (1) to three (3) days prior to an inpatient admission at the same hospital shall not be covered under the EAPG payment system and shall be considered as part of the inpatient stay.

903.29

With the exception of Specialty hospitals and Maryland hospitals, outpatient diagnostic services that occur on the same day as an inpatient admission at the same hospital shall be considered part of the inpatient stay.

903.30

The EAPG payment system shall be utilized for any Medicaid payment adjustments for Provider Preventable Conditions as set forth in Chapter 92 of Title 29 of the District of Columbia Municipal Regulations.

903.31

Beginning FY 2020, each eligible hospital shall receive a supplemental hospital access payment calculated as set forth below:

(a) For visits and services beginning November 30, 2019 and ending on September 30, 2029, quarterly access payments shall be made to each eligible private hospital;

(b) Each payment shall be in an amount equal to each hospital's outpatient Medicaid payments for the three (3) District Fiscal Years prior to the current District Fiscal Year, divided by the total in-District private hospital outpatient Medicaid payments for the same District Fiscal Year, multiplied by one fourth (1/4^th) of the total outpatient private hospital access payment pool.

(c) The total outpatient private hospital access payment pool shall be equal to the total available spending room under the private hospital outpatient Medicaid upper payment limit for the corresponding District year, as determined by the State Medicaid agency;

(d) Applicable private hospital outpatient Medicaid payments shall include all outpatient Medicaid payments to Medicaid participating hospitals located within the District of Columbia except for the United Medical Center; and

(e) For visits and services beginning November 30, 2019 and ending on September 30, 2029, quarterly access payments shall be made to the United Medical Center as follows:

(1) Each payment shall be equal to one fourth(1/4^th) of the total outpatient public hospital access payment pool; and

(2) The total outpatient public hospital access payment pool shall be equal to the total available spending room under the District-operated hospital outpatient Medicaid upper payment limit for the corresponding District Fiscal Year;

(f) Payments shall be made fifteen (15) business days after the end of the quarter for the Medicaid visits and services rendered during that quarter; and

(g) For purposes of this section, the term District Fiscal Year shall mean dates beginning on October 1st and ending on September 30th.

D.C. Mun. Regs. tit. 29, r. 29-903

Final Rulemaking published at 29 DCR 4132 (September 17, 1982); as amended by Final Rulemaking published at 29 DCR 4551 (October 15, 1982); as amended by Final Rulemaking published at 61 DCR 2119 (March 14, 2014); amended by Final Rulemaking published at 62 DCR 14077 (10/30/2015); amended by Final Rulemaking published at 63 DCR 6946 (5/6/2016; amended by Final Rulemaking published at 63 DCR 015765 (12/23/2016); amended by Final Rulemaking published at 64 DCR 406 (1/19/2018); amended by Final Rulemaking published at 65 DCR 13954 (12/28/2018); amended by Final Rulemaking published at 67 DCR 3711 (4/3/2020)

Authority: An Act to enable the District of Columbia to receive federal financial assistance under Title XIX of the Social Security Act for a medical assistance program and for other purposes, approved December 27, 1967 (81 Stat. 744; D.C. Official Code § 1-307.02 (2012 Repl. & 2013 Supp.)) and the Department of Health Care Finance Establishment Act of 2007, effective February 27, 2008 (D.C. Law 17-109; D.C. Official Code § 7-771.05(6) (2012 Repl.)).