La. Admin. Code tit. 50 § V-7903

Current through Register Vol. 50, No. 11, November 20, 2024

Section V-7903 - [Effective until 3/15/2025] Reimbursement Methodology

A. Effective for dates of service on or after September 16, 2024, reimbursement rates paid to other rural, non-state hospitals for outpatient hospital services shall be as follows.

1. Surgery Services. The reimbursement amount for outpatient hospital surgery services shall be an interim payment equal to the Medicaid fee schedule amount on file for each service, and a final reimbursement amount of 95 percent of allowable Medicaid cost as calculated through the cost report settlement process.

2. Clinic Services. The reimbursement amount for outpatient hospital facility fees for clinic services shall be an interim payment equal to the Medicaid fee schedule amount on file for each service, and a final reimbursement amount of 95 percent of allowable Medicaid cost as calculated through the cost report settlement process.

3. Laboratory Services. The reimbursement amount for outpatient clinical diagnostic laboratory services shall be the Medicaid fee schedule amount on file for each service.

4. Rehabilitation Services. The reimbursement amount for outpatient rehabilitation services shall be an interim payment equal to the Medicaid fee schedule amount on file for each service, and a final reimbursement amount of 95 percent of allowable Medicaid cost as calculated through the cost report settlement process.

5. Other Outpatient Hospital Services. The reimbursement amount for outpatient hospital services other than surgery services, clinic services, clinical diagnostic laboratory services, and rehabilitation services shall be an interim payment equal to 95 percent of allowable Medicaid cost as calculated through the cost report settlement process.

B. If a qualifying hospital's outpatient costs is greater in subsequent cost reporting periods than the initial implementation year cost report period's cost, outpatient costs shall be subjected to a cap prior to determination of cost settlement amount. Calculation of reimbursable costs shall be as follows.

1. An average cost per Medicaid outpatient unduplicated encounter per day shall be established using Medicaid cost report and paid claims data from the initial cost report period of implementation. The average unduplicated encounter cost per day shall be calculated by dividing the total outpatient allowable costs for all Medicaid outpatient services by the number of paid unduplicated encounters per day. Clinical diagnostic laboratory services and vaccines are not included in this calculation.

2. To determine the capped limit for each subsequent year's allowable cost settlement reimbursement, the base year outpatient per unduplicated encounter per day cost shall be multiplied by the unduplicated encounters from the applicable subsequent cost reporting period's Medicaid paid claims data and then increased by 3 percent cumulatively for each year subsequent to the initial implementation year.

3. Final reimbursement shall be 95 percent multiplied by the lesser of capped cost amount calculated per §7903.B.2 or allowable reimbursable cost calculated per §7903.A.

C. A 3 percent cost increase threshold shall be applied to reimbursement after the initial year of implementation. Calculation shall be as follows.

1. An outpatient per unit cost shall be established using Medicaid cost report and paid claims data from the initial year of implementation. The outpatient per unit cost shall be calculated by dividing the total outpatient reimbursable costs (95 percent of allowable costs) for all Medicaid outpatient services by the number of paid claim units. Clinical diagnostic laboratory services are not included in this calculation.

2. To determine the threshold for each subsequent year's allowable cost settlement reimbursement, the base year outpatient per unit cost shall be multiplied by the units from current Medicaid cost report and paid claims data and then increased by 3 percent for each year subsequent to the initial implementation year.

3. Reimbursement shall be the lesser of 95 percent of allowable Medicaid cost as calculated through the cost report settlement process for the applicable year or the threshold calculated per §7903.B.2.

La. Admin. Code tit. 50, § V-7903

Promulgated by the Department of Health, Bureau of Health Services Financing, LR 51, exp. 3/15/2025 (Emergency).

AUTHORITY NOTE: Promulgated in accordance with R.S. 36:254 and Title XIX of the Social Security Act.