§ 1396r-4. Adjustment in payment for inpatient hospital services furnished by disproportionate share hospitals
(a)
Implementation of requirement
(1)
A State plan under this subchapter shall not be considered to meet the requirement of section
1396a
(a)(13)(A)(iv) of this title (insofar as it requires payments to hospitals to take into account the situation of hospitals which serve a disproportionate number of low income patients with special needs), as of July 1, 1988, unless the State has submitted to the Secretary, by not later than such date, an amendment to such plan that—
(2)
(A)
In order to be considered to have met such requirement of section
1396a
(a)(13)(A) of this title as of July 1, 1989, the State must submit to the Secretary by not later than April 1, 1989, the State plan amendment described in paragraph (1), consistent with subsection (c) of this section, effective for inpatient hospital services provided on or after July 1, 1989.
(B)
In order to be considered to have met such requirement of section
1396a
(a)(13)(A) of this title as of July 1, 1990, the State must submit to the Secretary by not later than April 1, 1990, the State plan amendment described in paragraph (1), consistent with subsections (c) and (f) of this section, effective for inpatient hospital services provided on or after July 1, 1990.
(C)
If a State plan under this subchapter provides for payments for inpatient hospital services on a prospective basis (whether per diem, per case, or otherwise), in order for the plan to be considered to have met such requirement of section
1396a
(a)(13)(A) of this title as of July 1, 1989, the State must submit to the Secretary by not later than April 1, 1989, a State plan amendment that provides, in the case of hospitals defined by the State as disproportionate share hospitals under paragraph (1)(A), for an outlier adjustment in payment amounts for medically necessary inpatient hospital services provided on or after July 1, 1989, involving exceptionally high costs or exceptionally long lengths of stay for individuals under one year of age.
(D)
A State plan under this subchapter shall not be considered to meet the requirements of section
1396a
(a)(13)(A)(iv) of this title (insofar as it requires payments to hospitals to take into account the situation of hospitals that serve a disproportionate number of low-income patients with special needs), as of October 1, 1998, unless the State has submitted to the Secretary by such date a description of the methodology used by the State to identify and to make payments to disproportionate share hospitals, including children’s hospitals, on the basis of the proportion of low-income and medicaid patients (including such patients who receive benefits through a managed care entity) served by such hospitals. The State shall provide an annual report to the Secretary describing the disproportionate share payments to each such disproportionate share hospital.
(3)
The Secretary shall, not later than 90 days after the date a State submits an amendment under this subsection, review each such amendment for compliance with such requirement and by such date shall approve or disapprove each such amendment. If the Secretary disapproves such an amendment, the State shall immediately submit a revised amendment which meets such requirement.
(b)
Hospitals deemed disproportionate share
(1)
For purposes of subsection (a)(1) of this section, a hospital which meets the requirements of subsection (d) of this section is deemed to be a disproportionate share hospital if—
(2)
For purposes of paragraph (1)(A), the term “medicaid inpatient utilization rate” means, for a hospital, a fraction (expressed as a percentage), the numerator of which is the hospital’s number of inpatient days attributable to patients who (for such days) were eligible for medical assistance under a State plan approved under this subchapter in a period (regardless of whether such patients receive medical assistance on a fee-for-service basis or through a managed care entity), and the denominator of which is the total number of the hospital’s inpatient days in that period. In this paragraph, the term “inpatient day” includes each day in which an individual (including a newborn) is an inpatient in the hospital, whether or not the individual is in a specialized ward and whether or not the individual remains in the hospital for lack of suitable placement elsewhere.
(3)
For purposes of paragraph (1)(B), the term “low-income utilization rate” means, for a hospital, the sum of—
(A)
the fraction (expressed as a percentage)—
(i)
the numerator of which is the sum (for a period) of
(I)
the total revenues paid the hospital for patient services under a State plan under this subchapter (regardless of whether the services were furnished on a fee-for-service basis or through a managed care entity) and
(II)
the amount of the cash subsidies for patient services received directly from State and local governments, and
(B)
a fraction (expressed as a percentage)—
(i)
the numerator of which is the total amount of the hospital’s charges for inpatient hospital services which are attributable to charity care in a period, less the portion of any cash subsidies described in clause (i)(II) of subparagraph (A) in the period reasonably attributable to inpatient hospital services, and
(ii)
the denominator of which is the total amount of the hospital’s charges for inpatient hospital services in the hospital in the period.
The numerator under subparagraph (B)(i) shall not include contractual allowances and discounts (other than for indigent patients not eligible for medical assistance under a State plan approved under this subchapter).
(4)
The Secretary may not restrict a State’s authority to designate hospitals as disproportionate share hospitals under this section. The previous sentence shall not be construed to affect the authority of the Secretary to reduce payments pursuant to section
1396b
(w)(1)(A)(iii) of this title if the Secretary determines that, as a result of such designations, there is in effect a hold harmless provision described in section
1396b
(w)(4) of this title.
(c)
Payment adjustment
Subject to subsections (f) and (g) of this section, in order to be consistent with this subsection, a payment adjustment for a disproportionate share hospital must either—
(1)
be in an amount equal to at least the product of
(A)
the amount paid under the State plan to the hospital for operating costs for inpatient hospital services (of the kind described in section
1395ww
(a)(4) of this title), and
(B)
the hospital’s disproportionate share adjustment percentage (established under section
1395ww
(d)(5)(F)(iv) of this title);
(2)
provide for a minimum specified additional payment amount (or increased percentage payment) and (without regard to whether the hospital is described in subparagraph (A) or (B) of subsection (b)(1) of this section) for an increase in such a payment amount (or percentage payment) in proportion to the percentage by which the hospital’s medicaid utilization rate (as defined in subsection (b)(2) of this section) exceeds one standard deviation above the mean medicaid inpatient utilization rate for hospitals receiving medicaid payments in the State or the hospital’s low-income utilization rate (as defined in paragraph [1] (b)(3) of this section); or
(3)
provide for a minimum specified additional payment amount (or increased percentage payment) that varies according to type of hospital under a methodology that—
(B)
results in an adjustment for each type of hospital that is reasonably related to the costs, volume, or proportion of services provided to patients eligible for medical assistance under a State plan approved under this subchapter or to low-income patients,
except that, for purposes of paragraphs (1)(B) and (2)(A) of subsection (a) of this section, the payment adjustment for a disproportionate share hospital is consistent with this subsection if the appropriate increase in the rate or amount of payment is equal to at least one-third of the increase otherwise applicable under this subsection (in the case of such paragraph (1)(B)) and at least two-thirds of such increase (in the case of paragraph (2)(A)). In the case of a hospital described in subsection (d)(2)(A)(i) of this section (relating to children’s hospitals), in computing the hospital’s disproportionate share adjustment percentage for purposes of paragraph (1)(B) of this subsection, the disproportionate patient percentage (defined in section
1395ww
(d)(5)(F)(vi) of this title) shall be computed by substituting for the fraction described in subclause (I) of such section the fraction described in subclause (II) of that section. If a State elects in a State plan amendment under subsection (a) of this section to provide the payment adjustment described in paragraph (2), the State must include in the amendment a detailed description of the specific methodology to be used in determining the specified additional payment amount (or increased percentage payment) to be made to each hospital qualifying for such a payment adjustment and must publish at least annually the name of each hospital qualifying for such a payment adjustment and the amount of such payment adjustment made for each such hospital.
(d)
Requirements to qualify as disproportionate share hospital
(1)
Except as provided in paragraph (2), no hospital may be defined or deemed as a disproportionate share hospital under a State plan under this subchapter or under subsection (b) of this section unless the hospital has at least 2 obstetricians who have staff privileges at the hospital and who have agreed to provide obstetric services to individuals who are entitled to medical assistance for such services under such State plan.
(2)
(B)
In the case of a hospital located in a rural area (as defined for purposes of section
1395ww of this title), in paragraph (1) the term “obstetrician” includes any physician with staff privileges at the hospital to perform nonemergency obstetric procedures.
(3)
No hospital may be defined or deemed as a disproportionate share hospital under a State plan under this subchapter or under subsection (b) or (e) of this section unless the hospital has a medicaid inpatient utilization rate (as defined in subsection (b)(2) of this section) of not less than 1 percent.
(e)
Special rule
(1)
A State plan shall be considered to meet the requirement of section
1396a
(a)(13)(A)(iv) of this title (insofar as it requires payments to hospitals to take into account the situation of hospitals which serve a disproportionate number of low income patients with special needs) without regard to the requirement of subsection (a) of this section if
(A)
(B)
the aggregate amount of the payment adjustments under the plan for such hospitals is not less than the aggregate amount of such adjustments otherwise required to be made under such subsection, and
(C)
the plan meets the requirement of subsection (d)(3) of this section and such payment adjustments are made consistent with the last sentence of subsection (c) of this section.
(2)
In the case of a State that used a health insuring organization before January 1, 1986, to administer a portion of its plan on a statewide basis, beginning on July 1, 1988—
(A)
the requirements of subsections (b) and (c) of this section (other than the last sentence of subsection (c) of this section) shall not apply if the aggregate amount of the payment adjustments under the plan for disproportionate share hospitals (as defined under the State plan) is not less than the aggregate amount of payment adjustments otherwise required to be made if such subsections applied,
(f)
Limitation on Federal financial participation
(1)
In general
Payment under section
1396b
(a) of this title shall not be made to a State with respect to any payment adjustment made under this section for hospitals in a State for quarters in a fiscal year in excess of the disproportionate share hospital (in this subsection referred to as “DSH”) allotment for the State for the fiscal year, as specified in paragraphs (2) and (3).
(2)
State DSH allotments for fiscal years 1998 through 2002
Subject to paragraph (4), the DSH allotment for a State for each fiscal year during the period beginning with fiscal year 1998 and ending with fiscal year 2002 is determined in accordance with the following table:
| State or District | DSH Allotment (in millions of dollars) | FY 98 | FY 99 | FY 00 | FY 01 | FY 02 |
|---|---|---|---|---|---|---|
| Alabama | ||||||
| 293 | ||||||
| 269 | ||||||
| 248 | ||||||
| 246 | ||||||
| 246 | ||||||
| Alaska | ||||||
| 10 | ||||||
| 10 | ||||||
| 10 | ||||||
| 9 | ||||||
| 9 | ||||||
| Arizona | ||||||
| 81 | ||||||
| 81 | ||||||
| 81 | ||||||
| 81 | ||||||
| 81 | ||||||
| Arkansas | ||||||
| 2 | ||||||
| 2 | ||||||
| 2 | ||||||
| 2 | ||||||
| 2 | ||||||
| California | ||||||
| 1,085 | ||||||
| 1,068 | ||||||
| 986 | ||||||
| 931 | ||||||
| 877 | ||||||
| Colorado | ||||||
| 93 | ||||||
| 85 | ||||||
| 79 | ||||||
| 74 | ||||||
| 74 | ||||||
| Connecticut | ||||||
| 200 | ||||||
| 194 | ||||||
| 164 | ||||||
| 160 | ||||||
| 160 | ||||||
| Delaware | ||||||
| 4 | ||||||
| 4 | ||||||
| 4 | ||||||
| 4 | ||||||
| 4 | ||||||
| District of Columbia | ||||||
| 23 | ||||||
| 23 | ||||||
| 49 | ||||||
| 49 | ||||||
| 49 | ||||||
| Florida | ||||||
| 207 | ||||||
| 203 | ||||||
| 197 | ||||||
| 188 | ||||||
| 160 | ||||||
| Georgia | ||||||
| 253 | ||||||
| 248 | ||||||
| 241 | ||||||
| 228 | ||||||
| 215 | ||||||
| Hawaii | ||||||
| 0 | ||||||
| 0 | ||||||
| 0 | ||||||
| 0 | ||||||
| 0 | ||||||
| Idaho | ||||||
| 1 | ||||||
| 1 | ||||||
| 1 | ||||||
| 1 | ||||||
| 1 | ||||||
| Illinois | ||||||
| 203 | ||||||
| 199 | ||||||
| 193 | ||||||
| 182 | ||||||
| 172 | ||||||
| Indiana | ||||||
| 201 | ||||||
| 197 | ||||||
| 191 | ||||||
| 181 | ||||||
| 171 | ||||||
| Iowa | ||||||
| 8 | ||||||
| 8 | ||||||
| 8 | ||||||
| 8 | ||||||
| 8 | ||||||
| Kansas | ||||||
| 51 | ||||||
| 49 | ||||||
| 42 | ||||||
| 36 | ||||||
| 33 | ||||||
| Kentucky | ||||||
| 137 | ||||||
| 134 | ||||||
| 130 | ||||||
| 123 | ||||||
| 116 | ||||||
| Louisiana | ||||||
| 880 | ||||||
| 795 | ||||||
| 713 | ||||||
| 658 | ||||||
| 631 | ||||||
| Maine | ||||||
| 103 | ||||||
| 99 | ||||||
| 84 | ||||||
| 84 | ||||||
| 84 | ||||||
| Maryland | ||||||
| 72 | ||||||
| 70 | ||||||
| 68 | ||||||
| 64 | ||||||
| 61 | ||||||
| Massachusetts | ||||||
| 288 | ||||||
| 282 | ||||||
| 273 | ||||||
| 259 | ||||||
| 244 | ||||||
| Michigan | ||||||
| 249 | ||||||
| 244 | ||||||
| 237 | ||||||
| 224 | ||||||
| 212 | ||||||
| Minnesota | ||||||
| 16 | ||||||
| 16 | ||||||
| 33 | ||||||
| 33 | ||||||
| 33 | ||||||
| Mississippi | ||||||
| 143 | ||||||
| 141 | ||||||
| 136 | ||||||
| 129 | ||||||
| 122 | ||||||
| Missouri | ||||||
| 436 | ||||||
| 423 | ||||||
| 379 | ||||||
| 379 | ||||||
| 379 | ||||||
| Montana | ||||||
| 0.2 | ||||||
| 0.2 | ||||||
| 0.2 | ||||||
| 0.2 | ||||||
| 0.2 | ||||||
| Nebraska | ||||||
| 5 | ||||||
| 5 | ||||||
| 5 | ||||||
| 5 | ||||||
| 5 | ||||||
| Nevada | ||||||
| 37 | ||||||
| 37 | ||||||
| 37 | ||||||
| 37 | ||||||
| 37 | ||||||
| New Hampshire | ||||||
| 140 | ||||||
| 136 | ||||||
| 130 | ||||||
| 130 | ||||||
| 130 | ||||||
| New Jersey | ||||||
| 600 | ||||||
| 582 | ||||||
| 515 | ||||||
| 515 | ||||||
| 515 | ||||||
| New Mexico | ||||||
| 5 | ||||||
| 5 | ||||||
| 9 | ||||||
| 9 | ||||||
| 9 | ||||||
| New York | ||||||
| 1,512 | ||||||
| 1,482 | ||||||
| 1,436 | ||||||
| 1,361 | ||||||
| 1,285 | ||||||
| North Carolina | ||||||
| 278 | ||||||
| 272 | ||||||
| 264 | ||||||
| 250 | ||||||
| 236 | ||||||
| North Dakota | ||||||
| 1 | ||||||
| 1 | ||||||
| 1 | ||||||
| 1 | ||||||
| 1 | ||||||
| Ohio | ||||||
| 382 | ||||||
| 374 | ||||||
| 363 | ||||||
| 344 | ||||||
| 325 | ||||||
| Oklahoma | ||||||
| 16 | ||||||
| 16 | ||||||
| 16 | ||||||
| 16 | ||||||
| 16 | ||||||
| Oregon | ||||||
| 20 | ||||||
| 20 | ||||||
| 20 | ||||||
| 20 | ||||||
| 20 | ||||||
| Pennsylvania | ||||||
| 529 | ||||||
| 518 | ||||||
| 502 | ||||||
| 476 | ||||||
| 449 | ||||||
| Rhode Island | ||||||
| 62 | ||||||
| 60 | ||||||
| 58 | ||||||
| 55 | ||||||
| 52 | ||||||
| South Carolina | ||||||
| 313 | ||||||
| 303 | ||||||
| 262 | ||||||
| 262 | ||||||
| 262 | ||||||
| South Dakota | ||||||
| 1 | ||||||
| 1 | ||||||
| 1 | ||||||
| 1 | ||||||
| 1 | ||||||
| Tennessee | ||||||
| 0 | ||||||
| 0 | ||||||
| 0 | ||||||
| 0 | ||||||
| 0 | ||||||
| Texas | ||||||
| 979 | ||||||
| 950 | ||||||
| 806 | ||||||
| 765 | ||||||
| 765 | ||||||
| Utah | ||||||
| 3 | ||||||
| 3 | ||||||
| 3 | ||||||
| 3 | ||||||
| 3 | ||||||
| Vermont | ||||||
| 18 | ||||||
| 18 | ||||||
| 18 | ||||||
| 18 | ||||||
| 18 | ||||||
| Virginia | ||||||
| 70 | ||||||
| 68 | ||||||
| 66 | ||||||
| 63 | ||||||
| 59 | ||||||
| Washington | ||||||
| 174 | ||||||
| 171 | ||||||
| 166 | ||||||
| 157 | ||||||
| 148 | ||||||
| West Virginia | ||||||
| 64 | ||||||
| 63 | ||||||
| 61 | ||||||
| 58 | ||||||
| 54 | ||||||
| Wisconsin | ||||||
| 7 | ||||||
| 7 | ||||||
| 7 | ||||||
| 7 | ||||||
| 7 | ||||||
| Wyoming | ||||||
| 0 | ||||||
| 0 | ||||||
| 0.1 | ||||||
| 0.1 | ||||||
| 0.1. |
(3)
State DSH allotments for fiscal year 2003 and thereafter
(A)
In general
Except as provided in paragraph (6) and subparagraph (E), the DSH allotment for any State for fiscal year 2003 and each succeeding fiscal year is equal to the DSH allotment for the State for the preceding fiscal year under paragraph (2) or this paragraph, increased, subject to subparagraphs (B) and (C) and paragraph (5) by the percentage change in the consumer price index for all urban consumers (all items; U.S. city average), for the previous fiscal year.
(B)
Limitation
The DSH allotment for a State shall not be increased under subparagraph (A) for a fiscal year to the extent that such an increase would result in the DSH allotment for the year exceeding the greater of—
(C)
Special, temporary increase in allotments on a one-time, non-cumulative basis
The DSH allotment for any State (other than a State with a DSH allotment determined under paragraph (5))—
(i)
for fiscal year 2004 is equal to 116 percent of the DSH allotment for the State for fiscal year 2003 under this paragraph, notwithstanding subparagraph (B); and
(ii)
for each succeeding fiscal year is equal to the DSH allotment for the State for fiscal year 2004 or, in the case of fiscal years beginning with the fiscal year specified in subparagraph (D) for that State, the DSH allotment for the State for the previous fiscal year increased by the percentage change in the consumer price index for all urban consumers (all items; U.S. city average), for the previous fiscal year.
(D)
Fiscal year specified
For purposes of subparagraph (C)(ii), the fiscal year specified in this subparagraph for a State is the first fiscal year for which the Secretary estimates that the DSH allotment for that State will equal (or no longer exceed) the DSH allotment for that State under the law as in effect before December 8, 2003.
(E)
Temporary increase in allotments during recession
(i)
In general
Subject to clause (ii), the DSH allotment for any State—
(I)
for fiscal year 2009 is equal to 102.5 percent of the DSH allotment that would be determined under this paragraph for the State for fiscal year 2009 without application of this subparagraph, notwithstanding subparagraphs (B) and (C);
(4)
Special rule for fiscal years 2001 and 2002
(A)
In general
Notwithstanding paragraph (2), the DSH allotment for any State for—
(5)
Special rule for low DSH States
(A)
For fiscal years 2001 through 2003 for extremely low DSH States
In the case of a State in which the total expenditures under the State plan (including Federal and State shares) for disproportionate share hospital adjustments under this section for fiscal year 1999, as reported to the Administrator of the Health Care Financing Administration as of August 31, 2000, is greater than 0 but less than 1 percent of the State’s total amount of expenditures under the State plan for medical assistance during the fiscal year, the DSH allotment for fiscal year 2001 shall be increased to 1 percent of the State’s total amount of expenditures under such plan for such assistance during such fiscal year. In subsequent fiscal years before fiscal year 2004, such increased allotment is subject to an increase for inflation as provided in paragraph (3)(A).
(B)
For fiscal year 2004 and subsequent fiscal years
In the case of a State in which the total expenditures under the State plan (including Federal and State shares) for disproportionate share hospital adjustments under this section for fiscal year 2000, as reported to the Administrator of the Centers for Medicare & Medicaid Services as of August 31, 2003, is greater than 0 but less than 3 percent of the State’s total amount of expenditures under the State plan for medical assistance during the fiscal year, the DSH allotment for the State with respect to—
(i)
fiscal year 2004 shall be the DSH allotment for the State for fiscal year 2003 increased by 16 percent;
(6)
Allotment adjustments for fiscal years 2007 through 2011 and the first calendar quarter of fiscal year 2012
(A)
Tennessee
(i)
In general
Only with respect to fiscal year 2007, the DSH allotment for Tennessee for such fiscal year, notwithstanding the table set forth in paragraph (2) or the terms of the TennCare Demonstration Project in effect for the State, shall be the greater of—
(I)
the amount that the Secretary determines is equal to the Federal medical assistance percentage component attributable to disproportionate share hospital payment adjustments for the demonstration year ending in 2006 that is reflected in the budget neutrality provision of the TennCare Demonstration Project; and
Only with respect to fiscal years 2008, 2009, 2010, and 2011, the DSH allotment for Tennessee for the fiscal year, notwithstanding such table or terms, shall be the amount specified in the previous sentence for fiscal year 2007. Only with respect to fiscal year 2012 for the period ending on December 31, 2011, the DSH allotment for Tennessee for such portion of the fiscal year, notwithstanding such table or terms, shall be 1/4 of the amount specified in the first sentence for fiscal year 2007.
(ii)
Limitation on amount of payment adjustments eligible for Federal financial participation
Payment under section
1396b
(a) of this title shall not be made to Tennessee with respect to the aggregate amount of any payment adjustments made under this section for hospitals in the State for fiscal year 2007, 2008, 2009, 2010, 2011, or for period [2] in fiscal year 2012 described in clause (i) that is in excess of 30 percent of the DSH allotment for the State for such fiscal year or period determined pursuant to clause (i).
(iii)
State plan amendment
The Secretary shall permit Tennessee to submit an amendment to its State plan under this subchapter that describes the methodology to be used by the State to identify and make payments to disproportionate share hospitals, including children’s hospitals and institutions for mental diseases or other mental health facilities. The Secretary may not approve such plan amendment unless the methodology described in the amendment is consistent with the requirements under this section for making payment adjustments to disproportionate share hospitals. For purposes of demonstrating budget neutrality under the TennCare Demonstration Project, payment adjustments made pursuant to a State plan amendment approved in accordance with this subparagraph shall be considered expenditures under such project.
(iv)
Offset of Federal share of payment adjustments for fiscal years 2007 through 2011 and the first calendar quarter of fiscal year 2012 against Essential Access Hospital supplemental pool payments under the TennCare Demonstration Project
(I)
The total amount of Essential Access Hospital supplemental pool payments that may be made under the TennCare Demonstration Project for fiscal year 2007, 2008, 2009, 2010, 2011, or for a period in fiscal year 2012 described in clause (i) shall be reduced on a dollar for dollar basis by the amount of any payments made under section
1396b
(a) of this title to Tennessee with respect to payment adjustments made under this section for hospitals in the State for such fiscal year or period.
(II)
The sum of the total amount of payments made under section
1396b
(a) of this title to Tennessee with respect to payment adjustments made under this section for hospitals in the State for fiscal year 2007, 2008, 2009, 2010, 2011, or for a period in fiscal year 2012 described in clause (i) and the total amount of Essential Access Hospital supplemental pool payments made under the TennCare Demonstration Project for such fiscal year or period shall not exceed the State’s DSH allotment for such fiscal year or period established under clause (i).
(B)
Hawaii
(i)
In general
Only with respect to each of fiscal years 2007 through 2011, the DSH allotment for Hawaii for such fiscal year, notwithstanding the table set forth in paragraph (2), shall be $10,000,000. Only with respect to fiscal year 2012 for the period ending on December 31, 2011, the DSH allotment for Hawaii for such portion of the fiscal year, notwithstanding the table set forth in paragraph (2), shall be $2,500,000.
(ii)
State plan amendment
The Secretary shall permit Hawaii to submit an amendment to its State plan under this subchapter that describes the methodology to be used by the State to identify and make payments to disproportionate share hospitals, including children’s hospitals and institutions for mental diseases or other mental health facilities. The Secretary may not approve such plan amendment unless the methodology described in the amendment is consistent with the requirements under this section for making payment adjustments to disproportionate share hospitals.
(g)
Limit on amount of payment to hospital
(1)
Amount of adjustment subject to uncompensated costs
(A)
In general
A payment adjustment during a fiscal year shall not be considered to be consistent with subsection (c) of this section with respect to a hospital if the payment adjustment exceeds the costs incurred during the year of furnishing hospital services (as determined by the Secretary and net of payments under this subchapter, other than under this section, and by uninsured patients) by the hospital to individuals who either are eligible for medical assistance under the State plan or have no health insurance (or other source of third party coverage) for services provided during the year. For purposes of the preceding sentence, payments made to a hospital for services provided to indigent patients made by a State or a unit of local government within a State shall not be considered to be a source of third party payment.
(B)
Limit to public hospitals during transition period
With respect to payment adjustments during a State fiscal year that begins before January 1, 1995, subparagraph (A) shall apply only to hospitals owned or operated by a State (or by an instrumentality or a unit of government within a State).
(C)
Modifications for private hospitals
With respect to hospitals that are not owned or operated by a State (or by an instrumentality or a unit of government within a State), the Secretary may make such modifications to the manner in which the limitation on payment adjustments is applied to such hospitals as the Secretary considers appropriate.
(2)
Additional amount during transition period for certain hospitals with high disproportionate share
(A)
In general
In the case of a hospital with high disproportionate share (as defined in subparagraph (B)), a payment adjustment during a State fiscal year that begins before January 1, 1995, shall be considered consistent with subsection (c) of this section if the payment adjustment does not exceed 200 percent of the costs of furnishing hospital services described in paragraph (1)(A) during the year, but only if the Governor of the State certifies to the satisfaction of the Secretary that the hospital’s applicable minimum amount is used for health services during the year. In determining the amount that is used for such services during a year, there shall be excluded any amounts received under the Public Health Service Act [42 U.S.C. 201 et seq.], subchapter V of this chapter, subchapter XVIII of this chapter, or from third party payors (not including the State plan under this subchapter) that are used for providing such services during the year.
(B)
“Hospital with high disproportionate share” defined
In subparagraph (A), a hospital is a “hospital with high disproportionate share” if—
(C)
“Applicable minimum amount” defined
In subparagraph (A), the “applicable minimum amount” for a hospital for a fiscal year is equal to the difference between the amount of the hospital’s payment adjustment for the fiscal year and the costs to the hospital of furnishing hospital services described in paragraph (1)(A) during the fiscal year.
(h)
Limitation on certain State DSH expenditures
(1)
In general
Payment under section
1396b
(a) of this title shall not be made to a State with respect to any payment adjustments made under this section for quarters in a fiscal year (beginning with fiscal year 1998) to institutions for mental diseases or other mental health facilities, to the extent the aggregate of such adjustments in the fiscal year exceeds the lesser of the following:
(A)
1995 IMD DSH payment adjustments
The total State DSH expenditures that are attributable to fiscal year 1995 for payments to institutions for mental diseases and other mental health facilities (based on reporting data specified by the State on HCFA Form
64 as mental health DSH, and as approved by the Secretary).
(B)
Applicable percentage of 1995 total DSH payment allotment
The amount of such payment adjustments which are equal to the applicable percentage of the Federal share of payment adjustments made to hospitals in the State under subsection (c) of this section that are attributable to the 1995 DSH allotment for the State for payments to institutions for mental diseases and other mental health facilities (based on reporting data specified by the State on HCFA Form
64 as mental health DSH, and as approved by the Secretary).
(2)
Applicable percentage
(A)
In general
For purposes of paragraph (1), the applicable percentage with respect to—
(B)
1995 percentage
The percentage determined under this subparagraph is the ratio (determined as a percentage) of—
(i)
the Federal share of payment adjustments made to hospitals in the State under subsection (c) of this section that are attributable to the 1995 DSH allotment for the State (as reported by the State not later than January 1, 1997, on HCFA Form
64, and as approved by the Secretary) for payments to institutions for mental diseases and other mental health facilities, to
(C)
State 1995 DSH spending amount
For purposes of subparagraph (B)(ii), the “State 1995 DSH spending amount”, with respect to a State, is the Federal medical assistance percentage (for fiscal year 1995) of the payment adjustments made under subsection (c) of this section under the State plan that are attributable to the fiscal year 1995 DSH allotment for the State (as reported by the State not later than January 1, 1997, on HCFA Form
64, and as approved by the Secretary).
(i)
Requirement for direct payment
(1)
In general
No payment may be made under section
1396b
(a)(1) of this title with respect to a payment adjustment made under this section, for services furnished by a hospital on or after October 1, 1997, with respect to individuals eligible for medical assistance under the State plan who are enrolled with a managed care entity (as defined in section
1396u–2
(a)(1)(B) of this title) or under any other managed care arrangement unless a payment, equal to the amount of the payment adjustment—
(j)
Annual reports and other requirements regarding payment adjustments
With respect to fiscal year 2004 and each fiscal year thereafter, the Secretary shall require a State, as a condition of receiving a payment under section
1396b
(a)(1) of this title with respect to a payment adjustment made under this section, to do the following:
(1)
Report
The State shall submit an annual report that includes the following:
(2)
Independent certified audit
The State shall annually submit to the Secretary an independent certified audit that verifies each of the following:
(A)
The extent to which hospitals in the State have reduced their uncompensated care costs to reflect the total amount of claimed expenditures made under this section.
(B)
Payments under this section to hospitals that comply with the requirements of subsection (g) of this section.
(C)
Only the uncompensated care costs of providing inpatient hospital and outpatient hospital services to individuals described in paragraph (1)(A) of such subsection are included in the calculation of the hospital-specific limits under such subsection.