Texas Register, Volume 38, Number 36, Pages 5801-5944, September 6, 2013 Page: 5,865
5801-5944 p. ; 28 cm.View a full description of this periodical.
Extracted Text
The following text was automatically extracted from the image on this page using optical character recognition software:
process related to factual or calculation errors discovered
during the DSH audit process.
Response: HHSC does not believe it would be appropriate to
make the requested change upon adoption of this rule because
other stakeholders would not have had an opportunity to com-
ment on the change. HHSC will be reviewing all rule language
pertaining to the audit process prior to the first use of audited
data to make recoupments from hospitals and will consider this
comment at that time. No changes were made in response to
this comment.
HHSC made the following additional changes that were not as
a result of a comment but were made to provide clarification or
correct errors:
Language allowing HHSC to divide available DSH funds for a
program year into one or more portions of funds to allow for par-
tial payment(s) of total available DSH funds at any one time with
remaining funds to be distributed at a later date(s) was added to
the definition of "available DSH funds" in subsection (b)(2) and
throughout the rule. These changes were made to formalize and
standardize the process to be used if partial payments are made.
References to "CMS tie-in notices" were replaced with refer-
ences to "documents verifying the merger status with Medicare"
in subsections (c)(2)(E) and (e)(7) to allow other appropriate doc-
uments to verify merge status with Medicare in addition to a tie-in
notice.
Public hospital weights presented in subsection (h)(3)(A) were
updated to reflect revised data.
Subsection (h)(3)(C) was revised to allow for the updating of pub-
lic hospital weights to address changes in the hospital-specific
limits of one or more hospitals.
The amendment is adopted under Texas Government Code
531.033, which provides the Executive Commissioner of HHSC
with broad rulemaking authority; Texas Human Resources
Code 32.021 and Texas Government Code 531.021(a),
which provide HHSC with the authority to administer the federal
medical assistance (Medicaid) program in Texas; and Texas
Government Code 531.021(b), which establishes HHSC as the
agency responsible for adopting reasonable rules governing the
determination of fees, charges, and rates for medical assistance
(Medicaid) payments under Texas Human Resources Code
Chapter 32.
355.8065. Disproportionate Share Hospital Reimbursement
Methodology.
(a) Introduction. Hospitals participating in the Texas Medic-
aid program that meet the conditions of participation and that serve
a disproportionate share of low-income patients are eligible for reim-
bursement from the disproportionate share hospital (DSH) fund. The
Texas Health and Human Services Commission (HHSC) will establish
each hospital's eligibility for and amount of reimbursement using the
methodology described in this section.
(b) Definitions.
(1) Adjudicated claim--A hospital claim for payment for a
covered Medicaid service that is paid or adjusted by HHSC or another
payer.
(2) Available DSH funds--The total amount of funds that
may be distributed to eligible qualifying DSH hospitals during the DSH
program year, based on the federal DSH allotment for Texas (as deter-
mined by the Centers for Medicare and Medicaid Services) and avail-
able non-federal funds. HHSC may divide available DSH funds for aprogram year into one or more portions of funds to allow for partial
payment(s) of total available DSH funds at any one time with remain-
ing funds to be distributed at a later date(s). If HHSC chooses to make
a partial payment, the available DSH funds for that partial payment are
limited to the portion of funds identified by HHSC for that partial pay-
ment.
(3) Bad debt--A debt arising when there is nonpayment on
behalf of an individual who has third-party coverage.
(4) Centers for Medicare and Medicaid Services (CMS)--
The federal agency within the United States Department of Health and
Human Services responsible for overseeing and directing Medicare and
Medicaid, or its successor.
(5) Charity care--The unreimbursed cost to a hospital of
providing, funding, or otherwise financially supporting health care ser-
vices on an inpatient or outpatient basis to indigent individuals, either
directly or through other nonprofit or public outpatient clinics, hospi-
tals, or health care organizations. A hospital must set the income level
for eligibility for charity care consistent with the criteria established in
311.031, Texas Health and Safety Code.
(6) Charity charges--Total amount of hospital charges for
inpatient and outpatient services attributed to charity care in a DSH
data year. These charges do not include bad debt charges, contractual
allowances, or discounts given to other legally liable third-party payers.
(7) Children's hospital--A hospital within Texas that is rec-
ognized by Medicare as a children's hospital and is exempted by Medi-
care from the Medicare prospective payment system.
(8) Disproportionate share hospital (DSH)--A hospital
identified by HHSC that meets the DSH program conditions of partici-
pation and that serves a disproportionate share of Medicaid or indigent
patients.
(9) DSH data year--A twelve-month period, two years be-
fore the DSH program year, from which HHSC will compile data to
determine DSH program qualification and payment.
(10) DSH program year--The twelve-month period begin-
ning October 1 and ending September 30.
(11) Dually eligible patient--A patient who is simultane-
ously eligible for Medicare and Medicaid.
(12) Governmental entity--A state agency or a political
subdivision of the state. A governmental entity includes a hospital
authority, hospital district, city, county, or state entity.
(13) HHSC--The Texas Health and Human Services Com-
mission or its designee.
(14) Hospital-specific limit--The maximum amount appli-
cable to a DSH program year that a hospital may receive in reimburse-
ment for the cost of providing services to individuals who are Medic-
aid eligible or uninsured. The hospital-specific limit is calculated using
the methodology described in 355.8066 of this title (relating to Hos-
pital-Specific Limit Methodology).
(A) Interim hospital-specific limit--Applies to pay-
ments that will be made during the DSH program year and is calculated
using the methodology described in 355.8066 of this title using
interim cost and payment data from the DSH data year.
(B) Final hospital-specific limit--Applies to payments
made during a prior DSH program year and is calculated using the
methodology as described in 355.8066 of this title using actual cost
and payment data from the DSH program year.ADOPTED RULES September 6, 2013 38 TexReg 5865
Upcoming Pages
Here’s what’s next.
Search Inside
This issue can be searched. Note: Results may vary based on the legibility of text within the document.
Tools / Downloads
Get a copy of this page or view the extracted text.
Citing and Sharing
Basic information for referencing this web page. We also provide extended guidance on usage rights, references, copying or embedding.
Reference the current page of this Periodical.
Texas. Secretary of State. Texas Register, Volume 38, Number 36, Pages 5801-5944, September 6, 2013, periodical, September 6, 2013; Austin, Texas. (https://texashistory.unt.edu/ark:/67531/metapth342081/m1/65/: accessed April 24, 2024), University of North Texas Libraries, The Portal to Texas History, https://texashistory.unt.edu; crediting UNT Libraries Government Documents Department.