5. Revise section 1.248 on the definition of self-insurance costs.
6. Modify section 1.900 to clarify applicability of policy to offset otherwise allowable costs for what should have been billed to Medicare Parts A and B as primary payor.
7. Revise sections 2.800, 3.800, and 3.810 to clarify that the over-the-counter drug allowance is limited to Medicaid costs and Medicaid patient days.
8. Modify sections 3.400 and 5.710 to change the computation of the property tax allowance.
9. Modify section 3.525 (a) on the minimum useful life schedules used for major remodeling, new construction, bed additions, and bed deletions.
10. Revise section 1.270 on the payment parameters for working capital debt.
11. Revise section 6.110 to clarify that the chart of accounts basis for preparing the uniform cost report must be acceptable to the Department.
12. Modify policies affected by section 4.000 to address payment rate modifications and adjustments effective July 1, 1996.
13. Revise section 3.115 on the reclassification of Medicare patient days to Intensive Skilled Nursing patient days.
14. Modify section 3.775 to update the Intergovernmental Transfer Program provisions.
15. Modify section 1.281 to adjust payments for therapy space to ensure that Medicaid is secondary payor to Medicare and payments reflect equitable share of overhead-related payments.
16. Revise section 3.110 to permit separate ICF 1 and ICF 2 rates.
17. Revise section 3.110 to allow setting a composite rate for ICF 3 and ICF 4 residents.
Copies of the Proposed Changes
Copies of the proposed changes are available free of charge by writing to:
Attention: Nursing Home State Payment Plan
Bureau of Health Care Financing
Division of Health
PO Box 309
Madison, WI 53701-0309
The proposed changes may be reviewed at the main office at any county department of social services or human services.
Written Comments/Meetings
Written comments on the proposed changes may be sent to the Bureau of Health Care Financing, Division of Health, at the above address. The comments will be available for public review between the hours of 7:45 a.m. and 4:30 p.m. daily in Room 250 of the State Office Building, 1 West Wilson Street, Madison, Wisconsin. Revisions may be made in the proposed changes based on comments received. There will also be public meetings to seek input on the proposed plan amendment. If you would like to be sent a public meeting notice, please write to the above address. Revisions may also be made in the proposed changes based on comments received at the public meetings.
Public Notice
Health & Social Services
(Medical Assistance Reimbursement of Hospitals)
The State of Wisconsin reimburses hospitals for medical services provided to low-income persons under the authority of Title XIX of the Federal Social Security Act and ss. 49.43 to 49.47, Wisconsin Statutes. Medicaid or Medical Assistance (MA) is administered by the State's Department of Health and Social Services (which will be renamed the Department of Health and Family Services effective July 1, 1996). Federal statutes and regulations require state plans, one for outpatient services and one for inpatient services, which provide the methods and standards for paying for hospital outpatient and inpatient services.
State plans are now in effect for the reimbursement of outpatient hospital services and inpatient hospital services. The Department is proposing to make several changes in these plans effective July 1, 1996.
Proposed changes in the state plan for reimbursement for outpatient hospital services may include:
1. Revision of the rural hospital adjustment percentages to ensure that payments do not exceed authorized funds.
2. Modification of the retrospective final settlement of outpatient reimbursement to include the rural hospital adjustment in the reimbursement which is limited to the hospital's cost of providing outpatient services in order to comply with s. 49.45 (3) (e) 4.,Wisconsin Statutes.
3. For outpatient services provided by hospitals not located in Wisconsin, reduction of payment to reflect the level of payment provided instate hospitals.
4. For hospitals not located in Wisconsin, clarification that reimbursement for outpatient laboratory services is limited to the laboratory fee schedule of the Medicaid program.
5. Modification of qualifying criteria, as mandated by the state's 1995-1997 biennial budget, to allow a hospital not operated by a county to receive an indigent care allowance if the hospital contracts with a county-administered general assistance program to serve persons covered by the county's general assistance program and provides a significant proportion of its services to such persons.
6. To carry out mandates of the 1995-1997 biennial budget, adjustment of the criteria for determining that a hospital provides a significant proportion of its services to low-income persons and modification of the methodology for determining the indigent care allowance.
7. For hospitals that combine into one hospital operation either through merger or consolidation or for a hospital that absorbs the operation of another hospital through purchase or donation, establishment of a methodology to combine the financial and statistical data of the individual hospitals to determine if the combined or absorbing hospital qualifies for the indigent care allowance in order to implement mandates of the 1995-1997 biennial budget.
8. Adjustment of the maximum funding for indigent care allowances to that available under the 1995-1997 biennial budget and modification of the methodology for determining indigent care allowances to maintain compliance with federal payment limits.
9. Modification of supplemental payments to essential access city hospitals (EACH) to maintain compliance with federal upper-limits on payments to hospitals.
10. With Medicaid and Medicare cost reporting encompassed in the same cost reporting form, changing the due date by which a hospital must submit its cost report to coincide with Medicare due date requirements to promote administrative efficiency of hospitals.
11. Modification of administrative adjustment procedures for outpatient reimbursement and elimination of the administrative adjustments committee, in order to promote administrative efficiency by eliminating procedural requirements which are not needed under the current rate-setting methodology.
12. To promote administrative efficiency, addition of policies and procedures by which a hospital would be required to request review and modification of how Department staff are carrying out provisions of the outpatient rate setting methodology before the hospital could pursue legal review through administrative hearing or court appeal.
13. Modification of the calculation for a case mix administrative adjustment to more appropriately recognize the cost of a change in outpatient case mix.
Proposed changes in the state plan for reimbursement for inpatient hospital services may include:
1. For the payment system which is based on diagnosis-related groups (DRGs), adjustment of DRG weighting factors, standard DRG base rates, area wage indices, and capital and medical education payments to implement the average rate adjustment provided by the 1995-1997 biennial budget.
2. Adjustment of payment rates and payment maximums for AIDS treatment, ventilator care and brain injury treatment to implement the average rate adjustment provided by the 1995-1997 biennial budget.
3. Revision of the rural hospital adjustment percentages to ensure that payments do not exceed authorized funds.
4. Updating the disproportionate share adjustment parameters to recognize the more current proportion of services provided by hospitals to Medicaid recipients.
5. Modification of supplemental payments to essential access city hospitals (EACH) to maintain compliance with federal upper-limits on payments to hospitals.
6. Modification of qualifying criteria, as mandated by the state's 1995-1997 biennial budget, to allow a hospital not operated by a county to receive an indigent care allowance and a general assistance disproportionate share supplement if the hospital contracts with a county-administered general assistance program to serve persons covered by the county's general assistance program and provides a significant proportion of its services to such persons.
7. Adjustment of the criteria for determining that a hospital provides a significant proportion of its services to low-income persons and modification of the methodology for determining the indigent care allowance and the general assistance disproportionate share supplement to implement mandates of the 1995-1997 biennial budget.
8. For hospitals that combine into one hospital operation either through merger or consolidation or for a hospital that absorbs the operation of another hospital through purchase or donation, establishment of a methodology to combine the financial and statistical data of the individual hospitals to determine if the combined or absorbing hospital qualifies for the indigent care allowance and a general assistance disproportionate share supplement in order to implement mandates of the 1995-1997 biennial budget.
9. Modification of the ceiling amounts for the general assistance disproportionate share supplement and modification of the methodology for determining the supplement to assure compliance with federal disproportionate share payment ceilings.
10. For the indigent care allowance, adjustment of the maximum funding to that available under the 1995-1997 biennial budget and modification of the methodology for determining the allowance to maintain compliance with federal payment limits.
11. Modification of the payment rates for state-operated mental health hospitals for additional funding provided by the 1995-1997 biennial budget which may include establishment of a supplemental disproportionate share hospital payment for state-operated mental health hospitals.
12. For hospitals that combine or have combined into one hospital operation either through merger or consolidation or for a hospital that absorbs or has absorbed the operation of another hospital through purchase or donation, modification of the method for establishing capital cost payment by limiting payment to the capital cost incurred by the combined or absorbing hospital and by limiting payment to that allowed by federal regulations in order to maintain program expenditures within available funding and to assure compliance with federal regulations.
13. For hospitals that combine or have combined into one hospital operation either through merger or consolidation or for a hospital that absorbs or has absorbed the operation of another hospital through purchase or donation, modification of the method for establishing direct medical education payment to limit payment to the amount incurred by the combined or absorbing hospital and to base the indirect medical educational payment adjustment on the size of the graduate medical education program of the combined or absorbing hospital to maintain program expenditures within available funding.
14. Modification of the methodology for establishing capital cost payment and direct medical education payment for major border-status hospitals so that the methodology is more comparable to that used for establishing instate hospital payments.
15. Establishment of a supplemental adjustment for a disproportionate share acute care hospital not in Milwaukee County that:
(a) Has a significantly high proportion of inpatient days for newborns;
(b) Is in a county that has, or is scheduled to have, mandatory or optional enrollment in Medicaid managed care for the next year; and
(c) Participates as a major provider of Medicaid HMO services in the county, in order to assure sufficient availability of hospital services through the Medicaid program.
16. Modification of administrative adjustment procedures for inpatient reimbursement and elimination of the administrative adjustments committee, in order to promote administrative efficiency by eliminating procedural requirements that are not needed or are rarely used under the current rate-setting methodology.
17. To promote administrative efficiency, addition of policies and procedures by which a hospital would be required to request review and modification of how Department staff are carrying out provisions of the inpatient rate setting methodology before the hospital could pursue legal review through administrative hearing or court appeal.
Implementation of the above changes to the State Plans for inpatient hospital services and outpatient hospital services are expected to increase annual expenditures of the Wisconsin Medical Assistance Program by $11.7 million all funds ($6.9 million federal financial participation and $4.8 million general purpose revenue) for the state fiscal year 1996-1997.
Copies of Proposed Changes
Copies of the proposed changes will be sent to every county social services or human services department main office where they will be available for public review. For more information, interested people may fax or write to:
Hospital Reimbursement Unit
FAX (608) 266-1096
Bureau of Health Care Financing
Division of Health
P. O. Box 309
Madison, WI 53701-0309
Written Comments
Written comments on the proposed changes are welcome and should be sent to the above address. The comments received on the changes will be available for public review between the hours of 7:45 a.m. and 4:30 p.m. daily at:
Bureau of Health Care Financing
Room 265, State Office Building
One West Wilson Street
Madison, WI
