(a) In addition to the payment rates established pursuant to State Plan Amendments 4.19A, Part 1, Addendum 1, and 4.19B, Addendum 1-Page 24A, a DSH shall be entitled to a disproportionate share payment computed pursuant to this section.
(b) Determination of eligibility for disproportionate share payment. To be eligible for disproportionate share payment a hospital shall meet both of the following criteria: - (i) Have a Wyoming Medicaid utilization rate of not less than five percent (5%), defined as the percentage resulting from dividing Medicaid patient days by total patient days, based on the most current available information; and
- (ii) Have at least two (2) obstetricians with staff privileges at the hospital who have agreed to provide obstetric services to individuals entitled to such services under the Medicaid State Plan. In the case of a hospital located in a rural area (that is, an area located outside of a Metropolitan Statistical Area as defined by the Executive Office of Management and Budget), the obstetrician includes any physician with staff privileges at the hospital to perform nonemergency obstetric procedures.
(c) Determination of the Medicaid payment deficit. - (i) For each DSH, the Department shall determine total hospital payments for covered services as follows:
- (A) Calculate the hospitals inpatient and outpatient Medicaid payments for furnishing covered services during a payment period;
- (B) Calculate any amounts payable to the hospital by other third parties and beneficiaries for Medicaid covered services during a payment period; and
- (C) Calculate Qualified Rate Adjustment (QRA) payments pursuant to State Plan Amendments 4.19A, Part 1, Addendum 1 and 4.19B Addendum 1-Page 24A.
- (D) The results of paragraphs (A), (B), and (C) shall be summed to determine the total payments for covered services for each hospital.
- (ii) For each DSH, the Department shall determine hospital Medicaid costs as follows:
- (A) Calculate the hospital-specific ancillary department cost-to-charge ratios and the ratio of Medicaid allowable costs to billed charges using the hospitals most recently available Medicare cost report.
- (B) Inflate hospital ancillary billed charges to the midpoint of the payment period using the CMS-PPS Hospital Market Basket index.
- (C) Multiply the cost-to-charge ratios by the hospitals inflated billed charges reported on Medicaid claims paid during the most recently ended State fiscal year.
- (D) Calculate hospital-specific routine department per diems using the hospitals most recently available Medicare cost report.
- (E) Inflate hospital-specific routine department per diems to the midpoint of the payment period using the CMS-PPS Hospital Market Basket Index.
- (F) Multiply the inflated routine per diems by the number of days reported on Medicaid claims paid during the most recently ended State fiscal year.
- (G) Sum the product determined in subsection (c)(ii)(C) and subsection (c)(ii)(F) to determine a hospitals allowable Medicaid costs for furnishing covered services during the most recently completed payment period.
- (iii) For each DSH, the Department shall determine the Medicaid payment deficit as the difference between total payments in subsection (c)(i)(D) and Medicaid costs of services in subsection (c)(ii)(G).
(d) Determination of hospital-specific preliminary disproportionate share payment. For each DSH, the Department shall calculate a preliminary disproportionate share payment as follows: - (i) Calculate the ratio of the hospitals Medicaid payment deficit to the hospitals total payments to determine the hospital-specific Medicaid payment deficit percentage.
- (ii) Calculate a percentage to represent each DSHs payment deficit as a percentage of all DSHs payment deficits by dividing the hospital-specific Medicaid payment deficit percentage by the sum of all DSHs Medicaid payment deficit percentages.
- (iii) Multiply the percentage obtained in subsection (d)(ii) for each DSH by Wyomings federal fiscal year allotment to determine each hospitals preliminary disproportionate share payment.
(e) Determination of preliminary hospital-specific disproportionate share payment upper limit. Disproportionate share payments shall be limited to no more than one hundred percent (100%) of costs related to caring for Medical Assistance patients and uncompensated costs related to caring for indigent patients. For each DSH, the Department shall test the hospital-specific disproportionate share payment using the hospital-specific disproportionate share hospital upper limit as follows: - (i) Sum total payments from subsection (c)(i)(D) and the preliminary disproportionate share payment from subsection (d)(iii) and compare the total to Medicaid costs determined in subsection (c)(ii)(G).
- (A) If a DSHs Medicaid costs as calculated in subsection (c)(ii)(G) are greater than the sum of total payments as calculated in subsection (c)(i)(D) and the preliminary disproportionate share payment for the hospital as calculated in subsection (d)(iii), then the hospital has not exceeded the hospital-specific disproportionate share hospital upper limit.
- (B) If a DSHs Medicaid costs as calculated in subsection (c)(ii)(G) are less than the sum of total payments as calculated in subsection (c)(i)(D) and the preliminary disproportionate share payment for the hospital as calculated in subsection (d)(iii), then the hospital has exceeded the hospital-specific disproportionate share hospital upper limit.
(f) Determination of final hospital-specific disproportionate share payments. For each DSH, the Department shall determine the final disproportionate share payment as follows: - (i) Use the Medicaid payment deficit amount as calculated in subsection (c)(iii) to substitute the disproportionate share payment amount determined in subsection (d)(iii) for DSHs that reach the hospital-specific disproportionate share hospital upper limit in subsection (e)(i)(B).
- (ii) Distribute unallocated disproportionate share payments. The Department shall distribute any disproportionate share hospital allotment amounts that are not allocated due to the hospital-specific disproportionate share hospital upper limit test to the remaining DSHs that have not exceeded the hospital-specific disproportionate share hospital upper limit as follows:
- (A) The Department shall sum the preliminary disproportionate share payments allocated to each DSH; and
- (B) Subtract the amount determined in subsection (f)(ii)(A) from Wyomings federal fiscal year allotment for disproportionate share payments to calculate the unallocated disproportionate share payments.
- (C) For each hospital that has not exceeded its hospital-specific disproportionate share hospital upper limit the Department shall allocate any remaining disproportionate share hospital payment allotment as calculated from subsection (f)(ii)(B) as follows:
- (I) Calculate a percentage to represent each DSHs payment deficit as a percentage of all DSHs payment deficits by dividing the hospital-specific Medicaid payment deficit percentage by the sum of all DSHs Medicaid payment deficit percentages, excluding the payment deficits for each DSH that has reached the hospital-specific disproportionate share hospital upper limit.
- (II) Multiply subsection (f)(ii)(C)(I) by the unallocated disproportionate share hospital allotment pursuant to subsection (f)(ii)(B) to determine the additional disproportionate share hospital allocation.
- (III) Sum total payments from subsection (c)(i)(D), the preliminary disproportionate share payment from subsection (d)(iii), and the additional disproportionate share hospital payment from subsection (f)(ii)(C)(II) and compare the total to Medicaid costs from subsection (c)(ii)(G) to perform the hospital-specific upper payment limit test described in subsection (e).
- (iii) The Department shall follow the steps outlined in subsection (f) until the entire disproportionate share hospital allotment is distributed to DSHs or until each DSH has been allocated disproportionate share payments up to its hospital-specific disproportionate share hospital upper limit.
(g) In conformity with OBRA '93, the Department shall not establish disproportionate share payments greater than each hospitals unreimbursed costs for services rendered to Title XIX patients and uninsured patients. The Department shall review cost and payment information annually for each hospital receiving disproportionate share payments. The annual review shall consist of comparing providers proposed disproportionate share payments to their unreimbursed costs for services rendered to Title XIX patients and uninsured patients.
(h) If a providers proposed disproportionate share payments are less than or equal to unreimbursed costs, then the providers disproportionate share payments conform with OBRA '93 and shall not be adjusted. If a providers proposed disproportionate share payments are greater than the providers unreimbursed costs, the Department shall reduce the providers proposed disproportionate share payments to equal the unreimbursed costs. The Department shall calculate unreimbursed costs by applying provider-specific cost-to-charge ratios to charges for services provided to Title XIX and uninsured patients and subtracting payments from the costs of those services. For purposes of the cost-to-charge ratio calculation, the Department shall use cost and charge data from the same cost reports as those used to calculate the disproportionate share payments. This calculation shall occur following the most recently ended state fiscal year.
(i) Disproportionate share payments for hospitals located outside Wyoming. - (i) Request. Hospitals certified as DSHs by the Medicaid agency in a state other than Wyoming may submit a request for consideration for disproportionate share payments.
- (ii) Time and contents of request. A request for disproportionate share payments shall be sent to the Department, by certified mail, on or before October 1st of each year. The hospital shall submit the correct cost report with the request, if it is available. The hospital shall contact the Department before that date to determine which fiscal years cost report to submit with the request. The failure to timely submit a request, including the correct cost report, shall preclude the hospital from receiving disproportionate share payment.
- (iii) Determination of amount of payment. The amount of the disproportionate share payment shall be that proportion of the amount determined pursuant to subsection (f).
(j) Notice of disproportionate share payment. - (i) The Department shall notify all Wyoming hospitals providing inpatient hospital services of whether they are entitled to disproportionate share payments.
- (ii) Such notice shall:
- (B) Be mailed by certified mail, return receipt requested; and
- (C) Include the hospitals right to request reconsideration of the determination of disproportionate share payments or the denial of disproportionate share payments, pursuant to Chapter 16.
048-32 Wyo. Code R. § 32-5