N.Y. Comp. Codes R. & Regs. Tit. 10 §§ 86-1.35

Current through Register Vol. 46, No. 45, November 2, 2024

Section 86-1.35 - Disproportionate share limitations

(a) Disproportionate share payment distributions made to general hospitals pursuant to article 28 of the Public Health Law shall be limited in accordance with the provisions of this section. The latest available annual cost report submitted by a hospital prior to the disproportionate share distribution period shall be used to determine eligibility pursuant to subdivision (b) of this section and for projected limits pursuant to subdivision (e) of this section. Annual cost reports having an end date in the applicable annual disproportionate share distribution period, or for certain State-operated general hospitals, annual cost reports having an end date in the subsequent annual disproportionate share distribution period, shall be used to reconcile limits pursuant to subdivision (f) of this section.

(b) General hospitals whose inpatient Medicaid eligible patient days are less than one percent of total inpatient patient days shall not be eligible to receive disproportionate share distributions.

(c) No general hospital shall receive in total from disproportionate share payment distributions an amount which exceeds the costs incurred during the periods described in subdivision (a) of this section for furnishing inpatient and ambulatory hospital services to individuals who are eligible for medical assistance benefits pursuant to title XIX of the Federal Social Security Act (hereinafter referred to as "Medicaid cost") or to individuals who have no health insurance for the services provided or other source of third party coverage (hereinafter referred to as "self-pay cost"), reduced by medical assistance payments made pursuant to title XIX of the Federal Social Security Act (hereinafter referred to as "Medicaid revenue"), other than disproportionate share payments, and payments by uninsured patients. For purposes of this section, payments to a general hospital for services provided to indigent patients made by the State or a unit of local government within the State shall not be considered a source of third party payment.

(d) In order to ensure the continued flow of disproportionate share payments to hospitals, the commissioner shall make projections of each hospital's disproportionate share limitation based on the most current data available from the hospital's annual cost reports. The commissioner shall use annual cost reports in accordance with the provisions of subdivision (e) of this section to estimate Medicaid and self-pay costs in the projection methodology for a particular rate year. This shall be referred to as the "projection methodology". Subsequent to the receipt of a hospital's annual cost report having an end date in the applicable annual disproportionate share distribution period, or for certain State-operated general hospitals whose annual cost reports have an end date within the subsequent annual period, each hospital's disproportionate share limitation shall be reconciled to the actual rate year data. This shall be referred to as the "reconciliation methodology".

(e)Projection methodology.

Each hospital's projected disproportionate share limitation for each rate year shall be the sum of its inpatient and outpatient Medicaid and uninsured gains/(losses) as calculated using reported base year data and statistics from the year two years immediately preceding the rate year and as used for projection methodology purposes for that prior year.

(f)Reconciliation methodology.

The commissioner shall revise the projected limitation based on actual data reported to the commissioner for such rate year in accordance with the following and in accordance with final regulations issued by the Federal Department of Health and Human Services implementing 42 USC section 1396r-4. The commissioner shall revise the projected limitations for each hospital within eight months from the date required reports are submitted to the department, except if such reports are determined to be unacceptable by the department. For hospitals which have submitted unacceptable reports, the commissioner shall revise the projected limitations within eight months from the date acceptable reports have been resubmitted to the department.

(1) Each hospital shall submit, by the same date the annual cost reports are required to be filed pursuant to section 86-1.2 of this Subpart, a disproportionate share limitation schedule in a form and manner prescribed by the commissioner within which the hospital shall calculate, in accordance with the instructions, its inpatient and outpatient Medicaid and self-pay gains/(losses) during the cost reporting year. The disproportionate share limitation schedule shall be accompanied by a certification by the hospital's independent public accountant which provides the commissioner sufficient assurance as to the accuracy of the information contained in such schedule.

(i) The final limit shall be calculated by excluding inpatient and outpatient Medicaid revenue impacts resulting from prospective adjustments to rates for periods prior to the implementation of the Federal hospital specific disproportionate share payment limits from the inpatient and outpatient Medicaid and self-pay gains/(losses) reported on the disproportionate share payment limitation schedule.

(2) Failure of a hospital to submit the information required by this section in a form acceptable to the commissioner shall result in the immediate withholding of all subsequent disproportionate share distributions. Such withholding shall continue until the hospital complies with the reporting requirements of this subdivision.

N.Y. Comp. Codes R. & Regs. Tit. 10 §§ 86-1.35

Amended, New York State Register, Volume XXXVI, Issue 27, effective 7/9/2014