37.86.3015    OUTPATIENT HOSPITAL REIMBURSEMENT, OUTPATIENT HOSPITAL REIMBURSEMENT ADJUSTOR

(1) The outpatient hospital reimbursement adjustor (HRA) payment is payable to a PPS hospital or critical access hospital, as those terms are defined in 50-5-101, MCA, that provides outpatient hospital services. Eligibility to receive the outpatient HRA is based on a hospital's year-end reimbursement status.

(2) An individual hospital's outpatient HRA payment will be based upon total hospital Medicaid outpatient charges and will be computed as follows: HRA = (J ÷ D) x P.

(a) "HRA" represents the calculated hospital specific outpatient HRA payment.

(b) "J" equals the total outpatient hospital charges billed to Medicaid by the hospital for which the payment is calculated.

(c) "D" equals the total outpatient hospital charges billed to Medicaid by all hospitals eligible to receive an outpatient HRA payment.

(d) "P" equals the distributable revenue generated by the outpatient hospital utilization fee plus applicable federal financial participation.

(3) Data sources for the department to determine which hospitals meet the criteria to receive an outpatient HRA payment and the amount of the payment may include, but are not limited to:

(a) the Montana Hospital Association (MHA) database;

(b) the Medicaid paid claims database for the most recent calendar year;

(c) filed or settled cost reports; and

(d) reports from the Licensure Bureau of the Quality Assurance Division.

(4) Eligibility evaluations, payment calculations, and payments will be made annually.

(5) The Montana State Hospital or a hospital or facility operated by the state, a political subdivision of the state, the United States, or an Indian Tribe or any facility authorized under the Indian Health Care Improvement Act are not eligible for the HRA payment.

 

History: 2-4-201, 53-2-201, 53-6-113, MCA; IMP, 2-4-201, 53-2-201, 53-6-101, 53-6-113, 53-6-149, MCA; NEW, 2019 MAR p. 2382, Eff. 1/1/20.