Health and Family 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 Chapter 49.43 to 49.47, Wisconsin Statutes. The Wisconsin Department of Health and Family Services administers this program that is called Medicaid or Medical Assistance (MA). Federal statutes and regulations require state plans, one for outpatient services and one for inpatient services, that 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 changes to the provisions contained in the inpatient and outpatient plan effective July 1, 2006 to implement proposed provisions and maintain compliance with federal payment limits, and for administrative efficiencies.
Outpatient Hospital Services
Proposed changes in the state plan for reimbursement for outpatient services may include:
1. Excluding from the final cost settlement for critical access hospitals (CAH), the cost of physical, occupational and speech therapy services that are payable at the Wisconsin Medicaid Program's maximum fee schedule for such services in order to conform reimbursement with provisions of the 2005-2007 State Budget.
2. Allowing adjustments for critical access hospitals (CAH), to current interim payments based on more current information than is available in past audited cost reports in order to better estimate the final cost settlement for the respective CAH.
3. Reimbursing all OP lab services on a max fee schedule Effective January 1, 2007, to simplify final cost settlements.
Implementation of the above changes to the State Plan for outpatient services are expected to be budget neutral.
Inpatient Hospital Services
Proposed changes in the state plan for reimbursement for inpatient services may include:
1. Not requiring hospitals, including IMDs, to contact the external review organization for pre-admission review or obtain a case-specific control number prior to a substance abuse or mental health admission.
2. Modifying the criteria for a hospital to qualify for the general assistance disproportionate share supplement. Also, modification of the methodology for distributing the available funds to qualifying hospitals in order to maintain compliance with federal payment limits and to implement provisions of the 2005-2007 state budget act.
3. Removing the Critical Access Hospitals (CAHs) from the appendix for hospitals qualifying for exemption from capital cost reduction. This calculation does not affect the CAHs.
4. Allowing adjustments to current interim payments based on more current information than is available in past audited cost reports in order to better estimate the final cost settlement for the respective CAH.
5. Allowing, For the year July 1, 2006 to June 30, 2007 only, for not annually revising DRG weights based on more current claim and cost report information. Provide for retaining the DRG weights in effect in the prior year July 1, 2005 to June 30, 2006 to allow for timely payment of claims. Individual hospital rates will change and any new DRGs will have weights calculated.
Implementation of the above changes to the State Plan for inpatient services are expected to be budget neutral.
Copies of Proposed Changes and Proposed Payment Rates
Copies of the proposed changes will be sent to every county social services or human service department main office where they will be available for public review. For more information, interested persons may fax or write to:
Hospitals, Physicians and Clinics Section
Division of Health Care Financing
P.O. Box 309
Madison, WI 53701-0309
Fax: (608) 266-1096
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. at:
Division of Health Care Financing
Room 350, State Office Building
One West Wilson Street