Ga. Medicaid Part II Policies & Procedures for Hospital Services § 1001

1001.1. Reimbursement Methodology

Distinct methods of reimbursement have been established for inpatient hospitals.

services provided by Georgia hospitals, for outpatient services provided by Georgia

hospitals, and for all services provided by non-Georgia.

1001.2. Inpatient Services

Inpatient services provided by in-state hospitals enrolled in Georgia Medicaid are

reimbursed through the Inpatient Prospective Payment System (IPPS).

Under the IPPS, claims are categorized into a diagnosis-related group (DRG) for

payment purposes by the All Patients Refined Diagnosis Related Grouper (APR DRG)

software within the Georgia Medicaid Management Information System (GAMMIS).

Each DRG has a payment weight assigned to it, calculated from the average cost to treat

patients with conditions that fall into that DRG.

1001.2.1. To calculate payment for the outlier payment for claims with a date of

admission on or after January 1, 2019, the following formula is used:

1001.2.1.1. ={[(Allowable Charges x Hospital-Specific Cost to

Charge Ratio) – DRG Outlier Threshold] x Outlier

Payment Percentage + Non-Outlier DRG Per Case

Payment

1001.2.2. To calculate payment for the outlier payment for claims with a date of

admission on or after January 1, 2024, the following formula is used:

1001.2.2.1. ={[(Allowable Charges x Hospital-Specific Cost to

Charge Ratio) – DRG Outlier Threshold] x Outlier

Payment Percentage + Non-Outlier DRG Per Case

Payment

Additional information on the grouper version, DRG weights, and outlier thresholds may

be found on the DCH website at: https://dch.georgia.gov/diagnosis-related-groups.

Additional instructions on the submission of outlier cases are found in Appendix L.

1001.3. Inpatient Reimbursement for New Hospitals

1001.3.1. For the purposes of inpatient hospital reimbursement, a new hospital is

defined as a hospital:

1001.3.1.1. Established by the initial issuance of a Certificate of

Need, Medicare certification, and state license, and

1001.3.1.2. For which historical base year paid claims data did not

exist.

1001.3.2. New hospitals will be reimbursed under the same inpatient payment

formulas as stated in Section 1001.1. New hospitals enrolling in Georgia

Medicaid on or after January 1, 2019 will be reimbursed utilizing the

statewide base rate and the Georgia statewide average of the cost-to-charge ratios.

1001.3.3. A hospital formed as a result of a merger, acquisition, other change of

ownership, business combination, etc. is not a new hospital. Each

hospital of this type will maintain the DRG system reimbursement

components it would otherwise be assigned. When rates are adjusted

after the transaction, the appropriate base period information will be used

in determining the hospital’s rebased reimbursement components.

1001.4. Outpatient Services

1001.4.1. Outpatient services by Georgia hospitals are reimbursed on an interim

payment basis and are subject to cash settlement as described in Section

1003. The Department captures outpatient charges used in the settlement

calculation on the Hospital Statistical and Reimbursement (HS&R)

report. The HS&R report shows the detailed allocation of charges

according to UB revenue codes billed by the hospital. Effective with

settlements completed on or after 7/1/2003, no other allocation or

methodology will be used to determine allowable and reimbursable

outpatient costs other than the HS&R report.

1001.4.2. The determination of allowable and reimbursable costs is made

retrospectively and is based on a cost report submitted by the hospital in

accordance with Section 1002 and data included in the Non-allowable

Cost Questionnaire. Only costs incurred in providing patient care are

eligible for reimbursement. In determining reimbursable cost, the lower

of costs or charges (LCC) methodology will be applied to all providers to

ensure that reimbursable costs will not include costs that exceed total

charges. This determination/methodology will be calculated at the time

of outpatient settlements using as-filed or audited cost reports.

1001.4.3. The Division will reimburse for cost-based outpatient services at 90

percent of allowable operating costs plus 90 percent of allowable capital

costs. The final determination of reimbursable costs will be made at the

time outpatient settlements are made using audited cost reports.

1001.4.4. For those hospitals that are currently reimbursed at 90% of the cost of

services provided, the reimbursement rate will be reduced to 85.6% of

costs. For those hospitals that will be subject to the reimbursement rate

of 85.6% of costs, the percentage of charges that will be used for interim

payments will be proportionally to reflect the reduction from 90% of cost

to 85.6% of cost. The Department will also use trend adjustments to

reflect ongoing changes in hospital charges compared to costs.

1001.4.5. Critical access eligible hospitals (CAH), which meet departmental

requirements, will be reimbursed at 100% of reimbursable costs at the

time initial and final outpatient settlements are made using the as-filed

and audited cost reports. State owned or operated hospitals will be

reimbursed at 100% of reimbursable costs at the time final outpatient

settlements are made using audited cost reports. Reimbursable costs,

however, cannot exceed customary charges (LCC) for any provider. (See

1001.3 (B))

1001.4.6. Historically minority-owned hospitals will be reimbursed at 100% of

reimbursable costs at the time final outpatient settlements are made using

audited cost reports. Reimbursable costs, however, cannot exceed

customary charges (LCC) for any provider. (See 1001.3 (B))

1001.4.7. Payments to hospitals that are designated as a Critical Access Hospital, a

historically minority owned hospital or as a state owned hospital will

continue to be reimbursed at 100% of costs. Interim payments made will

be made at a percentage of covered charges estimated to equal 100% of

costs. The LCC methodology will be applied to all providers when

determining the outpatient settlements. (See 1001.3(B))

1001.4.8. The amount of interim payment is calculated as a particular percentage

of covered charges submitted to the Division. This percentage of charges

is specific to each hospital and is based on the actual experience of the

hospital during the last period for which the Division has performed a

cost report review. The percentage of charges represents an estimate of a

payment rate that approximates the amount of subsequently determined

allowable cost. An interim reimbursement rate cannot exceed eighty-five-point six percent of covered charges. Interim payments are subject

to a cash settlement determination as described in Section 1003 and

cannot exceed the Medicaid maximum allowable payment. The Medicaid

maximum allowable payment is the hospital-specific DRG base rate

including the capital and graduate medical education add-ons. The

Medicaid maximum allowable payment is the hospital-specific DRG

base rate including the capital and GME add-on multiplied by eighty-five-point six percent.

1001.4.9. All clinical diagnostic laboratory services performed for outpatients and

non- patients are reimbursed at lab fees for outpatient hospitals

(excluding critical access hospitals and state-owned hospitals) and will

be paid based on the established fee schedule. Note: Reimbursement of

the clinical laboratory CPT codes is based on Medicaid’s pricing

methodology for Outpatient Lab services which reimburses the lesser of

the following: The Medicaid Allow Amount {Medicaid Rate + Hospital

Add-On Rate (Medicaid Rate x .1188) x Number of Units} OR The

Medicare Allowed Amount (Medicare Rate x Number of Units).

1001.4.10. All injectable drugs are reimbursed in accordance with the HCPCS Level

II dose and descriptions. Effective September 1, 2009, the Department

of Community Health amended the maximum allowable reimbursement

for approved drugs to the lessor of; The provider’s usual and customary

charge,

1001.4.11. Average Sales Price (ASP) plus 6% as defined January 1st of each year

or the ASP + 6% upon the drug’s initial availability in the marketplace

whichever is later; or Wholesale Acquisition Cost (WAC) for injectable

drugs that do not have ASP pricing until such time that ASP plus 6%

pricing becomes available. Drugs on the PADL that are priced without

an ASP rate are denoted by an inverted triangle [▼].

1001.4.12. Only the administration fee is reimbursable for vaccines and

immunizations supplied through the Vaccine for Children’s (VFC)

Program or the Federal Government. Effective October 1, 2023,

providers may bill vaccine administration fee for members 21 years and

older. CPT codes for vaccines and their administration are identified via

Appendix A which is available on the web portal as the PADL Fee

Schedule. Administration fee for chemotherapy drugs is covered (see

section 902). (Revised 01/2024)

1001.4.12.1. Any provider enrolled in the outpatient drug program

that purchases drugs pursuant to the 340B pricing

schedule, (Public Law 102-585, the Veterans Health

Care Act of 1992, , (Public Law 102-585, the Veterans

Health Care Act of 1992, which is codified as Section

340B of the Public Health Service Act) must bill the

claim the acquisition cost of the drug only.

1001.4.12.2. Out-of-state entities who are enrolled with Georgia

Medicaid must contact the Department at

340B@dch.ga.gov and provide notification of intent to

carve-in or carve-out Georgia Medicaid claims.

1001.4.12.3. Contract pharmacy billing arrangements that are utilized

to provide 340B drugs to Medicaid patients are not

permitted unless prior arrangements are made with the

Department of Community Health

1001.4.13. The maximum allowable payment for any outpatient hospital claim is the

total of the DRG base rate plus the hospital specific add-on amount.

When the outpatient cost-based settlements are made, claims for

outpatient services which were paid at the maximum allowable payment

will be excluded from the settlement calculations.

1001.4.14. The Division reimburses enrolled hospitals that offer (either directly or

through contract) birthing and parenting classes to Medicaid eligible

pregnant women. Services may be billed once per year per member.

1001.4.15. Reimbursement is the lower of billed charges or $70. When the

outpatient cost-based settlements are made, claims for outpatient services

for birthing and parenting classes will be excluded from the settlement

calculations.

1001.4.16. A $3 member co-payment is required on all non-emergency outpatient

hospital visits. Pregnant women, members under twenty-one (21) years

of age, nursing facility members, community care participants, hospice

care participants and persons who have both Medicare and Medicaid

coverage are not subject to the co-payment. When the outpatient cost-based settlements are made for hospital services, the co-payment plus

Medicaid payment will be compared to the allowable cost to determine

the amount of final settlement.

1001.4.17. Co-payments will apply to the groups of members outlined below who

were previously exempt from participation in co-payments.

1001.4.17.1. Acute renal dialysis members

1001.4.17.2. Medicare/Medicaid dually eligible members.

1001.4.17.3. Members in waivered services programs.

1001.4.17.4. These groups are required to co-pay beginning with

dates of service January 1, 1995, and after, for those

services designated as co-pay services.

1001.4.17.5. Maintenance dialysis services for end-stage renal disease

are not designated as co-payment services and no co-payment is required for these services.

1001.4.17.6. The professional services of certified registered nurse

anesthetists (CRNAs), pediatric nurse practitioners,

obstetrical nurse practitioners, family nurse practitioners,

and physician’s assistant anesthesiologist’s assistant

(PAAAs) will not be reimbursed through the Medicaid

cost report. CRNAs, specified nurse practitioners and

PAAAs must enroll in the Medicaid program to receive

payment for their services directly.

1001.4.17.7. Governmental facilities and Critical Access eligible

hospitals which meet departmental requirements will be

eligible for rate payment adjustments. The rate

adjustment payments are intended to provide

supplemental funding for Medicaid services to these

facilities that based on their governmental status, need

sufficient funds for their commitments to meet the

healthcare needs of all members of their communities.

1001.4.17.8. The rate payment adjustments will be subject to federal

upper payment limits. For the appropriate groupings of

State governmental facilities, non-State governmental

facilities and non-governmental facilities, aggregate rate

adjustment payments available without exceeding upper

payment limits will be determined by measuring the

difference between:

1001.4.17.9. All amounts paid for services provided to Medicaid

patients including interim Medicaid claim payments and

estimated Medicaid cost report settlement amounts,

based on data from cost report worksheet E-3 Part III,

and Estimated payment amounts for such services if

payments were based on Medicare payment principles.

Either cost based or rate payment measures may be used

as Medicare payment principles.

1001.4.17.10. Comparisons of amounts paid for services provided to

Medicaid patients and estimated payment amounts for

such services if payments were based on Medicare

payment principles will also be made for each facility to

determine facility-specific rate adjustment payments. If

an individual facility cannot be paid a portion of its full

rate adjustment payment due to a facility-specific charge

limit, this rate adjustment amount can be allocated to

other facilities that are eligible to receive additional rate

adjustment payments without exceeding facility-specific

charge limits.

1001.4.17.11. These rate payment adjustments will be made on a

monthly, quarterly or annual basis and will be

determined in a manner that will not duplicate

compensation provided from payments for individual

patient claims. UPL payments will be made on an

interim basis. These payments will be subject to a

retrospective settlement at a future date, when HS&R

report data can be prepared based on complete, paid

claims data and when audited cost reports are available.

This is necessary as a result of the care management

organizations participating in the Georgia Families

program. The interim payments will reflect reductions in

UPL payments to hospitals.

1001.4.17.12. The Medicaid maximum allowable payment is the

hospital-specific DRG base rate including capital and

graduate medical education add-ons multiplied by 85.6%

(eighty-five point six percent)

1001.5. Services Provided by Non-Georgia Hospitals

1001.5.1. Inpatient Services for Enrolled Non-Georgia Hospitals

1001.5.2. Participating (Enrolled) Non-Georgia Hospital will be reimbursed under

the same inpatient payment formulas as stated in Section 1001.1.

1001.5.3. Prior to July 1, 2015, enrolled non-Georgia hospitals will receive a

hospital specific base rate, capital add-on, cost-to-charge ratio, and a

semi-private room rate that is equal to the statewide average rate for the

appropriate peer group in which the hospital is classified.

1001.5.4. Effective for dates of admission on or after July 1, 2015, but prior to

January 1, 2019, enrolled non-Georgia hospitals will receive the

statewide average rate for the appropriate peer group without any

adjustments for indirect medical education or Medicaid utilization. In

addition, there will be no capital add-on payment as capital is

incorporated into the base rate.

1001.5.5. Effective for dates of admission on or after January 1, 2019, enrolled

non-Georgia hospitals will be reimbursed utilizing the statewide base

rate and the Georgia statewide average of the cost-to-charge ratios.

1001.5.6. Outpatient services provided by enrolled non-Georgia hospitals are

reimbursed at a rate of 65% of covered charges not to exceed the Georgia

Medicaid maximum allowable payment. The Medicaid maximum

allowable payment is the hospital-specific DRG base rate including the

capital and graduate medical education add-ons multiplied by eighty five

point six percent.

1001.5.7. For out-of-state enrolled hospitals, payments will be made at the

statewide average percentage of charges that will be paid to Georgia

hospitals being reimbursed at 85.6% of costs. The payment rate for out-of-state enrolled hospitals will not exceed 65% of covered charge

1001.6. Nonparticipating (non-enrolled) Non-Georgia Hospitals

1001.6.1. Effective with dates of admission or service of July 1, 1989, and after,

inpatient services provided by non-Georgia hospitals not enrolled in the

Georgia Medicaid program are reimbursed according to rates established

by the Medicaid program in the state in which the hospital is located for

those procedures covered by that state. If the state in which the hospital

is located reimburses DRG rates or per diem rates exceeding $999.99,

reimbursement by Georgia Medicaid will be at a rate not to exceed 65%

of covered charges. For procedures or services not covered by the state

Medicaid program in the state in which the hospital is located,

reimbursement will be at a rate of 65% of covered charges if the

procedures or services are covered by Georgia Medicaid. Georgia

Medicaid will reimburse the lesser of the above payment methodologies.

1001.6.2. For certain specialized procedures for which services may not be

available at the reimbursement rate as stated above, the Division may

approve a percentage of charges rate in excess of 65%.

1001.6.3. Outpatient services provided by non-Georgia hospitals not enrolled in the

Georgia Medicaid program will be reimbursed at a rate of 45% of

covered charges.

1001.7. Medicare Crossover Claims

1001.7.1. The maximum allowable payment to enrolled Georgia and non-Georgia

hospitals for Medicare inpatient and outpatient deductible and

coinsurance (crossover claims) will be the applicable per case rate under

the DRG payment system. The maximum allowable payment to non-Georgia hospitals not enrolled in the Georgia Medicaid program for

Medicare inpatient and outpatient crossover claims will be the weighted

average inpatient per case rate of enrolled non-Georgia hospitals.

1001.7.2. Effective with dates of admission on and after October 9, 1997, the

Division will limit payment on outpatient Medicare crossover claims as

follows:

1001.7.2.1. Multiply the allowable deductible and coinsurance

amount by the hospital- specific percent of charges rate

in effect on the date of payment;

1001.7.2.2. Compare the product from (a) to the applicable per case

rate under the DRG payment system; and

1001.7.2.3. Reimburse the lower of the two amounts in (b). The

Division will reimburse for Medicare coinsurance and

deductible obligations as follows:

1001.8. Inpatient hospital services

1001.8.1. The Medicaid maximum allowable payment is the hospital specific DRG

base rate including capital and graduate medical education add-ons

multiplied by 85.6% (eighty-five-point six percent)

1001.8.2. The Medicare coinsurance and deductible amounts for a claim are

compared to the Medicaid allowable payment minus the Medicare

payment.

1001.8.3. The actual Medicaid payment will be the lower of the amounts in item

(b), less applicable third-party liabilities and patient co-payments.

1001.8.4. The Medicaid maximum allowable payment is the hospital-specific DRG

base rate including capital and graduate medical education add-ons

multiplied by eighty-five-point six percent

1001.8.5. The Medicare coinsurance and deductible amounts are multiplied by the

hospital-specific percent of charges rate for outpatient services.

1001.8.6. The actual Medicaid payment will be the lower of the amounts in items

(a) and (b), less applicable third-party liabilities and patient co-payments.

1001.8.7. These changes would apply to services provided to all patients dually

eligible for the Medicaid and Medicare programs, including Qualified

Medicare Beneficiaries.

1001.9. Third-Party Claims

1001.9.1. Hospital providers must attempt to pursue third party resources prior to

filing a Medicaid claim. If a third party does not pay at or in excess of

the applicable Medicaid reimbursement level, a hospital may submit a

Medicaid claim and will be paid the applicable reimbursement less any

reimbursement received from third party resources. If a third party pays

at or in excess of the amount that Medicaid would pay, the hospital

should not submit a claim to the Division for payment (see Part I Section

303, Third Party Payments). If a claim is submitted, it will be excluded

from paid claims data used to establish per case rates and calculate

outpatient settlements. For newborns, once the newborn is showing as an

eligible Medicaid member, the provider should submit two separate

claims, one for the mother and one for the newborn. The payment from

the primary insurance must be reflected on both the mother and baby

claim. In the event that the

1001.9.2. primary insurance pays for a partial stay, such as the first 30 days of a

continuous hospital stay, the DOS on the claim submitted to Medicaid

must be inclusive of the entire hospital stay in which the member is

Medicaid eligible, and any prior payment from the primary insurance

must be present on the claim. The Coordination of Benefit (COB)

payment should be prorated between the mother and newborn claims.

The prorated amount is entered in field 54 on the UB-04 form (i.e., the

Prior Payments field). A copy of the EOB must be submitted with each

claim. The EOB must show the prorated COB Paid Amount and prorated

Patient Liability.

1001.10. Hospital Provider Rate (Fee) Add-On

1001.10.1. In order to recognize the Medicaid Hospital Provider Agreement Act of

2010, as amended by the Hospital Medicaid Financing Program Act of

2013:

1001.10.1.1. Effective for inpatient payments with admissions on or

after July 1, 2010, through June 30, 2030, the inpatient

DRG payment (inclusive of the capital and GME add-ons) will be multiplied by 11.88% to receive an

additional add-on payment. This payment will be the

Hospital Rate (Fee) Add-on.

1001.10.1.2. Effective for outpatient interim payments made on or

after July 1, 2010, through June 30, 2030, the outpatient

interim payment will be multiplied by 11.88% to receive

an additional add-on payment. This payment will be the

Hospital Rate (Fee) Add-on.

1001.10.1.3. Effective for outlier payments with admission dates on

or after July 1, 2010, through June 30, 2030, the outlier

supplemental payments will be multiplied by 11.88% to

receive an additional add-on payment. This payment will

be the Hospital Rate (Fee) Add-on; and

1001.10.1.4. The allowable percentage used to determine

reimbursable cost in the outpatient settlement calculation

for services on or after July 1, 2010, through June 30,

2030, will be 95.77 percent (calculated as follows: 0.856

x 1.1188) to reflect the increase in payments due to the

addition of the hospital provider fee add-on payment.

1001.10.1.5. Critical Access State Owned/State Operated, and Out of

State enrolled providers are exempt from the rate

adjustment increase.

1001.11. Cost Reporting Requirements

1001.11.1. Each participating (enrolled) hospital must submit a cost report using the

appropriate Form HCFA-2552. The Division requires hospitals to list

inpatient and outpatient costs and charges separately on Worksheet E-3

Part III or other revised forms as appropriate.

1001.11.2. A hospital with a cost reporting period ending on or after June 27, 1995,

must

1001.11.3. furnish its cost report within five months after its fiscal year end. If the

report has not been received after this five-month period and a request

for extension has not been granted, a written warning will be issued. This

warning will indicate if, after an additional month (total six months), the

cost report has not been received, a one hundred percent reduction will

be imposed on all payments made during the period that the cost report is

late.

1001.11.4. These payments will be withheld until an acceptable Medicaid cost

report is received. After the cost report is received and is determined to

be acceptable, the withheld funds will be released. If the cost report is

not received after a total of seven months from a hospital’s fiscal year

end, the hospital’s agreement of participation will be subject to

suspension or termination.

1001.11.5. When a hospital undergoes a change of ownership or voluntarily or

involuntarily terminates from the Medicare/Medicaid program, the

hospital must notify the Division and file a terminating cost report within

five (5) months of the date of termination. If a cost report is not received

within this period, all Medicaid payments will be withheld until an

acceptable cost report is received and accepted by the Division. The

Department may sanction a hospital for failure to submit the required

cost report as outlined in Section 1002.

1001.11.6. The Division has entered into a “common audit” agreement with Myers

and Stauffer, LC. The hospital’s Medicaid cost report should be sent to

the following address:

Shannon Langowski

MYERS AND STAUFFER LLC

10200 Grand Central Avenue, Suite 200

Owings Mills, MD 21117

PH 410. 581. 4643 (Direct)

PH 800. 505. 1698 (Main)

FX 410. 356. 0188

www.myersandstauffer.com

1001.11.7. In addition to the cost report, the following listing of items must also be

submitted along with the cost report in electronic format if possible.

1001.11.7.1. ECR files of submitted cost report

1001.11.7.2. Working Trial Balance

1001.11.7.3. Expense mapping for Worksheet A

1001.11.7.4. Revenue mapping for Worksheet C

1001.11.7.5. Supporting work papers for A-8 adjustments Supporting

work papers for A-6 reclassifications

1001.11.7.6. CMS Form 339

1001.11.7.7. Medicaid charge mapping Worksheets for D-4 and Part

V

1001.11.7.8. Audited Financial Statements (if available)

1001.11.7.9. As part of the cost report review process, a hospital must

make available to authorized representatives of the

Division all medical and fiscal records, including

Medicare cost reports and work papers prepared by

Medicare fiscal intermediary auditors.

1001.12. Cash Settlements

1001.12.1. As described in Subsection 1001.3 (c), a determination will be made

which may show that a hospital’s interim payments were less than or

more than a retrospectively determined settlement amount.

1001.12.2. Where the determination of reimbursable cost shows that additional

payments due to the hospital, the Division will provide payments upon

receipt, review and acceptance of an audited Medicaid cost report from

the intermediary. Tentative settlement will not be made based on an as

filed Medicaid cost report or an audited report which has not been

reviewed and accepted by the Division. Tentative settlements will only

be made for approved Critical Access Hospitals, based on an as-filed

Medicaid cost report or an audited report that has been reviewed and

accepted by the Division.

1001.12.3. Where the determination of reimbursable cost shows that an

overpayment has been made to a hospital, the hospital must refund the

overpayment as outlined in Section 304. A hospital also must refund the

Division the amount by which total Medicaid payments are in excess of

total charges for Medicaid patients, as described in Section 1011.

1001.12.4. For those hospitals that do not have a Medicare intermediary, the

Department will have the option of using the as-filed cost report as

submitted by the provider to compute the outpatient settlement or use the

submitted as-filed report audited by the Department’s assigned agent.

1001.12.5. If an authoritative unit within the department of Community Health (i.e.

Office of the Inspector General, Division of Medical Assistance, etc)

makes a determination which impacts a hospital outpatient settlement,

the hospital settlement will be amended accordingly. Amendments to the

charges and payments that appear in the original hospital outpatient

settlement are made based upon the authoritative unit’s final

determination. Concessions based upon settlement agreements are not

considered when making these recalculations.

1001.13. Room Rate Reimbursement

1001.13.1. For those hospitals subject to Subsections 1001.1 and 1001.2, the

Division does not reimburse for a private room under any circumstance.

The difference in the cost of private and semi-private rooms should be

identified and, if appropriate, excluded in the determination of allowable

cost for services provided to Medicaid patients.

1001.13.2. For those hospitals subject to Subsections 1001.4, the Division does not

reimburse for a private room under any circumstance. This provision

will, if applicable, be taken into consideration for determining the

appropriate payment for services provided to Medicaid patients.

1001.13.3. Semi-private room rate increases will be collected periodically by the

Division through a survey process. The timeframe for collecting the data

and incorporating new semi-Private room rate changes into the claims

processing system will be specified in the survey instrument. The

Division reserves the right to deny any increase that is determined to be

inappropriate

1001.14. Hospital-Based Rural Health Clinics

1001.14.1. Reimbursement for Hospital Based Rural Health Clinics will be

determined in accordance with the Policies and Procedures for Rural

Health Clinic Services manual. Please reference this manual for

additional information about this program.

1001.15. Inpatient Co-payments

1001.15.1. A co-payment of $12.50 will be imposed on hospital inpatient services.

Refer to Appendix M for the current co-payment policy and

requirements.

1001.16. Graduate Medical Education (GME) Supplemental Payment Pool

1001.16.1. Effective January 1, 2019, hospitals with accredited GME programs

receive a Graduate Medical Education Supplemental Payment. GME

supplemental payments are made in quarterly installments. The annual

amount of each GME supplemental payment is determined as follows:

1001.16.2. Determine the number of FTE residents.

1001.16.3. Determine the Medicaid Allocation Ratio (MAR). For facilities with

DSH surveys, the Medicaid Allocation Ratio is Total Medicaid Hospital

Revenue divided by Net Hospital Revenue. For facilities without DSH

surveys, the Medicaid Allocation Ratio is Total Medicaid Inpatient Cost

(Medicare Cost Report Worksheet E-3, Part VII, Title XIX, Line 1.00,

Column 1.00) divided by Total Inpatient and Outpatient Cost (Medicare

Cost Report Worksheet B, Part I, Line 118, Column 24).

1001.16.4. Determine the hospital’s base GME funding as follows: $49,000 x (FTE

resident count determined in step (a)) x (MAR determined in step (b))

1001.16.5. Hospitals with FTE residents in the residency programs listed below will

receive additional funding above the base funding allocation

1001.16.5.1. Family Medicine: $33,000/FTE Resident

1001.16.5.2. OB/GYN: $33,000/FTE Resident

1001.16.5.3. General Pediatrics: $28,500/FTE Resident

1001.16.5.4. Pediatric Specialty Programs: $13,500/FTE Resident

1001.16.5.5. General Surgery: $10,000/FTE Resident

1001.17. Disproportionate Share Hospitals (DSH) Payment

1001.17.1. Eligibility

1001.17.2. Effective for DSH payment adjustments made on or after December 1,

2007, hospitals that are eligible to receive DSH payment adjustments

under federal DSH criteria per Social Security Act Section 1923(d) will

be eligible to receive an allocation of available DSH funds.

1001.18. Federal Criteria:

1001.18.1. The hospital has a Medicaid inpatient utilization rate of at least 1%;

AND

1001.18.2. The hospital has at least two (2) obstetricians who have staff privileges at

the hospital and who have agreed to provide obstetric services to

Medicaid recipients. This requirement does not apply to a hospital of

which the inpatients are predominately individuals under 18 years of age

or to hospitals which did not offer non-emergency obstetric services to

the general population as of December 22, 1987. In the case of a hospital

located in a rural area, the term "obstetrician" includes any physician

with staff privileges at the hospital to perform non-emergency obstetric

procedures. For rural hospitals subject to a federal requirement to

provide obstetric services, as an alternative to determining whether

deliveries are provided at the hospital, the Department will consider the

following factors:

1001.19. The hospital must have two or more physicians with staff privileges that are:

1001.19.1. Enrolled in the Medicaid program.

1001.19.2. Credentialed to provide OB services at the hospital in family practice,

general practice, or obstetrics; and

1001.19.3. Located within 25 miles of the hospital or in an office in the hospital

network or must attest to attendance at the hospital on some routine

basis; and

1001.20. The hospital must be able to provide at least one obstetric service that is currently

covered by Medicaid and appropriate to be provided in a hospital-based setting.

1001.20.1. For federal DSH criteria, a hospital will be considered a rural hospital if

a hospital’s county is not in a Metropolitan Statistical Area, as defined by

the United States Office of Management and Budget, OR is a county

having a population of less than 35,000 according to the United States

decennial census; provided, however, that for counties which contain a

military base or installation, the military personnel and their dependents

living in such county shall be excluded from the total population of that

county.

1001.21. Allocation Methodology

1001.21.1. Effective for DSH payment adjustments made on or after December 1,

2007, the following methodology will be used for determining payment

amounts:

1001.21.2. For each federal fiscal year, the amount of funds available for DSH

payments will be determined based on the state’s federal allotment and

required state matching contribution.

1001.21.3. Hospitals that meet federal DSH eligibility criteria will be eligible to

receive an allocation of available DSH allotment funds.

1001.21.4. The maximum amount of DSH payments (i.e., DSH Limit) for each

hospital will be the hospital’s loss incurred for services provided to

Medicaid and uninsured patients based on federal definitions. Medicaid

costs will be determined by applying per diem costs to Medicaid

inpatient days and ratios of cost to charges to Medicaid inpatient and

outpatient charges grouped by cost center. The patient day and charge

amounts will be determined by Medicaid HS&R reports of paid claims,

while per diem costs and ratios of cost to charges will be determined by

available 2552 cost reports. Medicaid payments will include interim

claim payments, outpatient settlement estimates and non-DSH rate

adjustments.

1001.21.5. Uninsured costs will be determined by applying Medicaid inpatient and

outpatient cost to charge ratios, from available 2552 cost reports, to

charges for uninsured reported on DSH data surveys. The DSH data

surveys will also be used to determine amounts received for services

provided to uninsured patients. DSH data surveys are conducted

annually and subject to desk reviews and onsite reviews of supporting

documentation, as warranted.

1001.21.6. The amount of funds available for DSH payments will be allocated

among eligible hospitals.

1001.22. Total available DSH funds will be divided into two pools:

1001.22.1. Pool 1 – For FY 2008 DSH payments, Pool 1 will be equivalent to

$53,735,261 and used in the calculation of DSH allocations for small,

rural hospitals. For DSH payments after FY 2008, Pool 1 would change

relative to changes in the state’s federal DSH allotment as compared to

the FY 2008 state DSH allotment.

1001.22.2. Pool 2 – For FY 2008 DSH payments, Pool 2 will be equivalent to

$347,439,065 and used in the calculation of the DSH allocations for all

other, eligible hospitals. For DSH payments after FY 2008, Pool 2 would

change relative to changes in the state’s federal DSH allotment as

compared to the FY 2008 state DSH allotment.

1001.22.3. Each hospital’s DSH limit is subject to the following DSH limit

adjustments for allocation purposes

1001.22.4. For hospitals receiving Upper Payment Limit (UPL) rate adjustments, the

allocation basis will be increased by the amount of any

intergovernmental transfer or certified public expenditure provided on

behalf of the hospital.

1001.22.5. For hospitals receiving rate adjustment payments related to medical

education, neonatal services or services provided under contract with the

Georgia Department of Human Resources, the allocation basis will be

increased by the amount of such rate adjustments.

1001.22.6. The department will utilize the following steps to determine the amount

each hospital is eligible to receive in DSH payments.

1001.22.6.1. Step 1: Determine the adjusted DSH limit (as determined

in section (III) (B) (5)) as a percentage of total cost for

each hospital.

1001.22.6.2. Step 2: For each hospital, multiply the hospital-specific

percentage determined in Step 1 by the hospital’s

adjusted DSH limit. For private hospitals, the outcome

of this calculation will be multiplied by the rate of

federal matching funds for Medicaid benefit payments.

1001.22.6.3. Step 3: For each hospital, divide the hospital-specific

amount identified in Step 2 by the aggregate “step 2”

amount derived from all hospitals in the applicable pool,

as defined in section (III)(B) (4), which will result in a

hospital-specific allocation factor.

1001.22.6.4. Step 4: Apply the hospital’s allocation factor calculated

in Step 3 to the total amount of DSH funds available in

the applicable pool, as defined in section (III)(B)(4).

This will result in the hospital’s DSH payment. Should

the DSH payment amount calculated for a hospital

exceed the hospital’s DSH limit, as determined in

section (III)(B)(3), the excess amount will be

redistributed to the remaining hospitals in the applicable

allocation pool.

1001.22.6.5. To mitigate significant increases and decreases in

hospital specific DSH payments as compared to state

fiscal year 2007, the following adjustments will be

applied for the allocation of DSH funds:

1001.22.6.6. Maximum DSH allocations for all hospitals are set at

75% of their specific adjusted DSH limits; however, for

facilities ineligible for DSH payment adjustments prior

to December 1, 2007 but newly eligible under the

criteria specified in section A above or facilities who do

not receive a DSH payment prior to December 1, 2007,

their maximum DSH allocation factor, as calculated in

Section (III) (B) (6), step 2, is limited to 10% of the

calculated amount.

1001.22.6.6.1. Final DSH payment amounts for small,

rural hospitals reflects blending of 75%

of state fiscal year 2007 net DSH

payments and 25% of the allocation

calculation based on the methodology

specified in section (III)(B)(6);

1001.22.6.6.2. Final DSH payment amounts for all

other hospitals reflects blending of 50%

of state fiscal year 2007 net DSH

payments and 50% of the allocation

calculation based on the methodology

specified in section (III)(B)(6).

1001.22.7. For private hospitals that meet the eligibility requirements of Section

(III) (A) and meet Social Security Act Section 1923(b) criteria,

allocations payments will be made at 100 % of calculated allocation

amounts as determined by steps 1 through 7 of Section (III) (B). For

private hospitals that meet the eligibility requirements of Section (III)

(A) but do not meet Social Security Act Section 1923(b) criteria,

allocation payments will be made at 100% of calculated allocation

amounts as determined by steps 1 through 7 of Section (III) (B).

1001.22.8. The state share of DSH payment amounts for state governmental and

non-state governmental hospitals will come from intergovernmental

transfers made on behalf of or by the hospital.

1001.22.9. For allocation of 2008 DSH funds, provider eligibility and DSH limit

calculations will be based on information available from hospital fiscal

years ending in 2005; for hospitals not in operation during 2005, data for

2006 may be used. For allocation of DSH funds after 2008, eligibility

and DSH limit calculations will be based on the most recent year for

which comparable data would be available.

1001.22.10. Effective for DSH payment adjustments made on or after July 1, 2024,

the following methodology will be used for determining payment

amounts n For allocation of 2008 DSH funds, provider eligibility and

DSH limit calculations will be based on information available from

hospital fiscal years ending in 2005; for hospitals not in operation during

2005, data for 2006 may be used. For allocation of DSH funds after

2008, eligibility and DSH limit calculations will be based on the most

recent year for which comparable data would be available.al DSH

payment amounts for small, rural hospitals reflects blending of 75% of

state fiscal year 2007 net DSH payments and 25% of the allocation

calculation based on the methodology specified in section (III)(B)(6);

1001.22.11. Final DSH payment amounts for all other hospitals reflects blending of

50% of state fiscal year 2007 net DSH payments and 50% of the

allocation calculation based on the methodology specified in section

(III)(B)(6).

1001.22.12. For private hospitals that meet the eligibility requirements of Section

(III) (A) and meet Social Security Act Section 1923(b) criteria,

allocations payments will be made at 100 % of calculated allocation

amounts as determined by steps 1 through 7 of Section (III) (B). For

private hospitals that meet the eligibility requirements of Section (III)

(A) but do not meet Social Security Act Section 1923(b) criteria,

1001.22.13. The state share of DSH payment amounts for state governmental and

non-state governmental hospitals will come from intergovernmental

transfers made on behalf of or by the hospital.

1001.22.14. For allocation of 2008 DSH funds, provider eligibility and DSH limit

calculations will be based on information available from hospital fiscal

years ending in 2005; for hospitals not in operation during 2005, data for

2006 may be used. For allocation of DSH funds after 2008, eligibility

and DSH limit calculations will be based on the most recent year for

which comparable data would be available

1001.22.15. Effective for DSH payment adjustments made on or after July 1, 2024,

the following methodology will be used for determining payment

amounts

1001.22.15.1. For each federal fiscal year, the amount of funds

available for DSH payments will be determined based on

the state's Medicaid DSH federal allotment and required

state matching contribution.

1001.22.15.2. Hospitals that meet federal DSH eligibility criteria will

be eligible to receive an allocation of available DSH

Payments.

1001.22.15.3. The maximum amount of DSH Payments (i.e., DSH

Limit) for each hospital will be the hospital's loss

incurred for services provided to Medicaid patients, for

whom Medicaid is the primary payor, and uninsured

patients who have no health insurance or other source of

third-party coverage. Medicaid patients will be defined

as patients enrolled in either in-state or out-of-state

Medicaid fee-for-service or in-state or out-of-state

Medicaid Managed Care Organization (MCO) as their

primary insurance. Medicaid costs will be determined by

applying total per diem costs to Medicaid covered

inpatient days and total ratios of cost to charges to

Medicaid inpatient and outpatient charges grouped by

cost center. The patient day and charge amounts will be

determined by Medicaid and Medicaid MCO HS&R

reports of paid claims or internal hospital records, while

per diem costs and ratios of cost to charges will be

determined by available 2552 cost reports. Medicaid

payments will include actual claim payments related to

Medicaid days and charges, from Medicaid, and

Medicaid MCOs, patient payments, and non-claim-based

Medicaid, and Medicaid MCO, and payments related to

inpatient and outpatient hospital services, Medicaid

outpatient settlement estimates and non-DSH rate

adjustments. Uninsured costs will be determined by

applying the uninsured days and charges reported on the

DSH data survey to the same per diems and cost to

charge ratios used to calculate Medicaid costs.

Uninsured payments will include patient payments

received on uninsured services accounted for on a cash

basis. The DSH data surveys will also be used to

determine amounts received for services provided to

uninsured patients. DSH data surveys are conducted

annually and subject to desk reviews and onsite reviews

of supporting documentation, as warranted.

1001.22.16. Each hospital’s DSH limit is subject to the following DSH limit

adjustments for allocation purposes:

1001.22.16.1. For hospitals receiving Upper Payment Limit (UPL) rate

adjustments, the allocation basis will be increased by the

amount of any intergovernmental transfer or certified

public expenditure on behalf of the hospital.

1001.22.16.2. For hospitals receiving rate adjustment payments related

to medical education, neonatal services or services

provided under contract with the Georgia Department of

Human Services, the allocation basis will be increased

by the amount of such rate adjustments.

1001.22.16.3. For hospitals receiving direct payment program (DPP)

rate adjustments, the allocation basis will be increased

by the amount of any intergovernmental transfer or

certified public expenditure on behalf of the hospital,

effective for DSH payment adjustments made on or after

December 1, 2021.

1001.22.17. The amount of funds available for DSH Payments will be allocated

between two pools of eligible hospitals. If hospital directed payments

from Care Management Organizations (CMO) are more than 10 percent

of all provider payments from CMOs, then Methodology A will be

followed to determine the Allocation Pools. If hospital payments from

CMOs are less than or equal to 10 percent of all provider payments from

CMOs, then Methodology B will be followed.

1001.22.18. METHODOLOGY A

1001.22.18.1. Pool 1 will be equivalent to that amount necessary to

cover 100 percent of the DSH Limit for eligible critical

access hospitals and rural hospitals with less than 100

beds. Pool 2 will be equivalent to the remaining DSH

Payments and used in the allocation to all other eligible

hospitals.

1001.22.18.2. Maximum DSH allocations for critical access hospitals,

rural hospitals with less than 100 beds, and state-owned

and operated acute care hospitals are set at 100% of their

DSH limit. All other hospitals are set at 75% of their

Adjusted DSH Limit. Eligible hospitals in Pool 2 that are

classified as a Rural Referral Center (RRC) by the

Centers for Medicare and Medicaid Services (CMS) that

are not eligible to participate in the Advancing

Innovation to Deliver Equity (AIDE) or Strengthening

The Reinvestment Of a Necessary-workforce in Georgia

(STRONG) state directed payment programs will receive

an allocation no less than 25% of their DSH Limit. No

hospital will receive more than 100% of their DSH

Limit.

1001.22.19. METHODOLOGY B

1001.22.19.1. Pool I will be equivalent to 13.4% of available DSH

funds and used in the calculation of DSH allocations for

eligible critical access hospitals and rural hospitals with

less than 100 beds. Pool 2 will be equivalent to 86.6% of

available DSH funds and used in the calculation of the

DSH allocations for all other, eligible hospitals.

1001.22.19.2. The maximum DSH allocation for all hospitals is set at

75% of the Adjusted DSH Limit.

1001.22.20. The department will utilize the following steps to determine the amount

each hospital is eligible to receive in DSH payments when Methodology

A is followed.

1001.22.20.1. Step 1: Calculate 25% of the DSH limit (as determined

in section (III)(B)(3)) for hospitals classified as Rural

Referral Center (RRC).

1001.22.20.2. Step 2: Reduce the adjusted DSH limit (as determined in

section (III)(B)(4)) by the amount calculated in Step 1.

1001.22.20.3. Step 3: Determine the adjusted DSH limit as calculated

in Step 2 as a percentage of total cost for each hospital.

1001.22.20.4. Step 4: For each hospital, multiply the hospital-specific

percentage determined in Step 3 by the hospital's

adjusted DSH limit as calculated in Step 2. For private

hospitals, the outcome of this calculation will be

multiplied by the rate of federal matching funds for

Medicaid benefit payments.

1001.22.20.5. Step 5: For each hospital, divide the hospital-specific

amount identified in Step 4 by the aggregate "step 4"

amount derived from all hospitals in the applicable pool,

as defined in section (III)(B)(5), which will result in a

hospital-specific allocation factor.

1001.22.20.6. Step 6: Apply the hospital's allocation factor calculated

in Step 5 to the total amount of DSH funds available in

the applicable pool, as defined in section (III)(B)(5).

DSH funds available in Pool 2 will be reduced by the

amount calculated in Step 1. This will result in the

hospital's DSH payment for all hospitals except RRCs.

For RRCs the amount calculated in Step 1 will be added

to the DSH payment calculated based on the hospital’s

allocation factor. Should the DSH payment amount

calculated for a hospital exceed the hospital's DSH limit,

as determined in section (III)(B)(3), the excess amount

will be redistributed to the remaining hospita1s in the

applicable allocation pool.

1001.22.21. The department will utilize the following steps to determine the amount

each hospital is eligible to receive in DSH payments when Methodology

B is followed.

1001.22.21.1. Step 1: Determine the adjusted DSH limit (as determined

in section (III)(B)(4)) as a percentage of total cost for

each hospital.

1001.22.21.2. Step 2: For each hospital, multiply the hospital-specific

percentage determined in Step 1 by the hospital's

adjusted DSH limit. For private hospitals, the outcome

of this calculation will be multiplied by the rate of

federal matching funds for Medicaid benefit payments.

1001.22.21.3. Step 3: For each hospital, divide the hospital-specific

amount identified in Step 2 by the aggregate "step 2"

amount derived from all hospitals in the applicable pool,

as defined in section (III)(B)(5), which will result in a

hospital-specific allocation factor.

1001.22.21.4. Step 4: Apply the hospital's allocation factor calculated

in Step 3 to the total amount of DSH funds available in

the applicable pool, as defined in section (III)(B)(5).

This will result in the hospital's DSH payment. Should

the DSH payment amount calculated for a hospital

exceed the hospital's DSH limit, as determined in section

(III)(B)(3), the excess amount will be redistributed to the

remaining hospita1s in the applicable allocation pool.

1001.22.22. For allocation of DSH Payments, eligibility and DSH Limit calculations

will be based on information available from hospital fiscal years ended

during the most recent calendar year for which data is available.

1001.22.23. Audit of Disproportionate Share Payments:

1001.22.23.1. As required by Section 1923(j) of the Social Security

Act related to auditing and reporting of disproportionate

share hospital payments, the Division of Medical

Assistance will implement procedures to comply with

the Disproportionate Share Hospital Payments final rule

issued in the December 19, 2008, Federal Register, with

effective date of January 19, 2009, to ensure that the

hospital specific DSH limits have not been exceeded.

1001.22.23.2. Any funds recouped as a result of audits or other

corrections shall be redistributed to other eligible

hospitals within the state, provided each hospital remains

below their hospital specific DSH limit. Funds shall be

redistributed to hospitals within the pools, as identified

in (III)(B)(4) above, for which funds were recouped. The

recouped funds within each pool shall be redistributed to

the governmental facilities that are still below their

hospital specific DSH limit. The funds shall be allocated

to those hospitals based on their allocation factor that

was derived in (III)(B)(6)(b) above. If the redistribution

causes a hospital to exceed their hospital specific DSH

limit those excess funds will be redistributed using the

same methodology until all funds are expended.

1001.23. Adjustments to Rate (Georgia Hospitals Only)

1001.23.1. The Division will issue survey forms for completion by hospitals to

document any changes for any additional building and fixed equipment

costs associated with a Certificate of Need approved capital

improvement since the hospital’s base year. Surveys received after the

due date will not be used to increase a hospital’s capital add-on amount.

1001.23.2. Effective with per case rates calculated for dates of admission on and

after July 1, 1993, costs related to the professional services of certified

registered nurse anesthetists (CRNAs), pediatric nurse practitioners,

obstetrical nurse practitioners and family nurse practitioners will be

excluded from base year costs prior to calculating the rates. Effective

July 1, 1993, CRNAs and specified nurse practitioners must enroll in the

Medicaid program to receive payment for their services directly.

1001.23.3. The Division reviews a hospital’s cost report to verify various rate

components. The reimbursement methodology assumes that services in

the base period will continue; therefore, audited cost reports are reviewed

to determine that all services and facilities included in the base period

will continue in the reimbursement year. Additionally, all surveyed items

are subject to verification. As appropriate, the Division’s findings on

such items may cause a hospital’s rate of payment to be adjusted.

1001.23.4. Subject to the availability of funds, hospitals designated by the Georgia

Department of Human Resources as Regional Perinatal Centers will be

eligible for rate payment adjustments. These hospitals provide intensive

care to high-risk neonatal patients and incur significant unreimbursed

costs associated with the provision of such services. The payment

adjustments will be reasonably related to cost, volume or proportion of

services provided to Medicaid patients. These rate payment adjustments

will be made on a monthly or quarterly basis in lump-sum amounts.

1001.23.5. Subject to the availability of funds, hospitals will be eligible for rate

payment adjustments for providing the following program services for

the Georgia Department of Human Resources: AIDS Clinic, Poison

Control Center, Genetics/Sickle Cell Screening and Maternal and Infant

Health Services. Hospitals can incur significant unreimbursed costs

associated with the provision of such services. The payment adjustment

will be reasonably related to cost, volume or proportion of services

provided to Medicaid patients. These rate payment adjustments will be

made on a monthly or quarterly basis in lump-sum amounts.

1001.23.6. Subject to the availability of funds, hospitals participating in the

residency grant programs administered by the Georgia Board for

Physician Workforce will be eligible for rate payment adjustments.

These hospitals operate post-graduate training programs for physicians

preparing to enter family practice and other medical specialties and incur

significant graduate medical education costs associated with the

operation of such training programs. The payment adjustment will be

reasonably related to cost, volume or proportion of services provided to

Medicaid patients. These rate payment adjustments will be made on a

monthly or quarterly basis in lump-sum amounts.

1001.23.7. Subject to the availability of funds, any State owned or operated teaching

hospital will be eligible for an inpatient rate payment adjustment. Such a

hospital can incur significant unreimbursed medical education and other

operating costs. The payment adjustment will be the difference between

the hospital’s Medicaid per case reimbursement rate, exclusive of any

DSH payment adjustments, and the hospital’s calculated per case rate

using Medicare principles of reimbursement. The adjustment results in

reimbursement of reasonable cost of inpatient hospital services provided

to Medicaid patients and will be made on a monthly, quarterly or annual

basis in lump-sum amounts.

1001.23.8. For payments on or after January 1, 2001, State government-owned or

operated facilities, non-State government owned or operated facilities

and Critical Access eligible hospitals which meet departmental

requirements will be eligible for rate payment adjustments, subject to the

availability of funds. A facility’s status as government owned or operated

will be based on its ability to make direct or indirect intergovernmental

transfer payments to the State. The rate payment adjustments will be

subject to federal upper payment limits and will be based on amounts

that would be paid for services under Medicare payment principles.

These rate payment adjustments will be made on a monthly, quarterly or

annual basis in a manner that will not duplicate compensation provided

from payments for individual patient claims.

1001.24. Upper Payment Limit Rate Adjustments

1001.24.1. For payments made for services provided on or after July 1, 2005, the

following types of hospitals will be eligible for rate payment

adjustments:

1001.24.1.1. State government-owned or operated facilities.

1001.24.1.2. Non-State government owned or operated facilities.

1001.24.1.3. Federally defined Critical Access hospitals.

1001.24.1.4. Hospitals designated by the Georgia Department of

Human Resources as Regional Perinatal Centers.

1001.24.1.5. Hospitals providing the following program services for

the Georgia Department of Human Resources: AIDS

Clinic, Poison Control Center, Genetics/Sickle Cell

Screening and Maternal and Infant Health Services; and

1001.24.1.6. Hospitals participating in selected residency grant

programs administered by the Georgia Board for

Physician Workforce.

1001.24.2. The rate adjustment payments are intended to provide supplemental

funding for Medicaid services to these facilities that need sufficient funds

for their commitments to meet the healthcare needs of all members of

their communities and to ensure that these facilities receive financial

support for their participation in programs vital to the state’s healthcare

infrastructure.

1001.24.3. The rate payment adjustments will be subject to federal upper payment

limits. For the appropriate groupings of State government-owned or

operated facilities, non-State government owned or operated facilities

and all other facilities, aggregate rate adjustment payments available

without exceeding upper payment limits will be determined by

measuring the difference between:

1001.24.3.1. Amounts paid for services provided to Medicaid patients

and

1001.24.3.2. Estimated payment amounts for such services if

payments were based on Medicare payment principles.

Either cost based or rate payment measures may be used

as Medicare payment principles.

1001.24.4. Comparisons of amounts paid for services provided to Medicaid patients

and estimated payment amounts for such services if payments were

based on Medicare payment principles will also be made for each facility

to determine facility-specific rate adjustment payments. If an individual

facility cannot be paid a portion of its full rate adjustment payment due

to a payment due to a facility-specific charge limit, this rate adjustment

amount can be allocated to other facilities that are eligible to receive

additional rate adjustment payments without exceeding facility-specific

charge limits. These rate payment adjustments will be made on a

monthly, quarterly or annual basis and will be determined in a manner

that will not duplicate compensation provided from payments for

individual patient claims.

1001.24.5. UPL payments will be made on an interim basis. These payments will be

subject to a retrospective settlement at a future date, when HS&R report

data can be prepared based on complete, paid claims data and when

audited cost reports are available. This is necessary as a result of the care

management organizations participating in the Georgia Families

program. The interim payments will reflect reductions in UPL payments

to hospitals.

1001.24.6. A sample of how a rate adjustment payment is calculated is presented as

follows:

10

Cost of Medicaid services

worksheets C, Part 1

and D-1, Part II

1,661,931

11

Covered charges for Medicaid services

worksheets C, Part 1

and D-1, Part II

3,725,000

12 inpatient CCR Line 10 / line 11 0.446156

line Facility Name Comments XYZ Hospital

1

base period report period beginning

date

9/1/xxxx

2 base period report period ending date 8/31/xxxx+1

3

HS&R processing date for Medicaid

data

9/6/xxxx+2

4

adjustment factor (if period not equal

to 1 year)

1.00000

Medicaid inpatient claims paid at

amount > 0:

6 covered charges From HS&R report 3,949,268

7 payments From HS&R report 1,828,506

8 annual covered charges From HS&R report 3,949,268

9 annual payments From HS&R report 1,828,506

13 annual cost of services Line 4 x line 6 x line 12 1,761,990

adjustment factors

14

claim completion

For interim calculation

only

1.029799

15

inflation

For interim calculation

only

1.073852

1001.24.7. Settlement

1001.24.8. For inpatient payments occurring during each calendar year, a

comparison of a hospital’s total Medicaid payments and its total charges

will be made after completion of the calendar year. A refund will be due

from the hospital for any amount by which total Medicaid payments are

in excess of a hospital’s total charges for Medicaid patients. For enrolled

non-Georgia hospitals, the comparison will be made beginning with

payments and charges for admissions occurring during calendar year

1990 and after. Total Medicaid payments included in the comparison

shall not include payment adjustments made to disproportionate share

hospitals, but will include inpatient co-payment amounts that the

hospitals should collect from members. There will be no other cash

settlements except as noted in Sections 1001.3, and 1006.

1001.24.9. Effective December 1, 1999, this provision will not affect critical access

eligible

1001.24.10. Reports

1001.24.10.1. An amended audited cost report will not be recognized

by the Department for the purpose of adjusting

reimbursable costs (outpatient) unless it is received

within three (3) years after completion of the initial audit

of the cost report. (For definition purposes, this date is

established as the date of initial notification of audit

completion to the provider.) The Division’s paid claims

data (Hospital Statistical and Reimbursement Report)

used with the audited cost report will be used with the

amended audited cost report to calculate the revised

outpatient settlement. Amended audited cost reports will

not be used to adjust DRG rates and components.

1001.24.11. Transfer Cases

1001.24.11.1. If a patient is transferred from one hospital for admission

to a second hospital for medically appropriate cause and

the claims for both hospitals fall into the same DRG,

both hospitals will be eligible for payment. If the claims

would otherwise be paid under the DRG rate

methodology, each hospital’s payment will be the lesser

of the DRG rate or a rate calculated by the CCR

methodology. If a patient is transferred from one

hospital for admission to a second hospital for medically

appropriate cause and the claims for both hospitals fall

into different DRGs, each hospital’s payment will be the

amount that a non-transfer claim would be paid. All

transfers are subject to either precertification or

retrospective review.

1001.24.11.2. For transfers back to the originating hospital, the

originating facility receiving the back-transfer for lower

level of care is eligible to receive reimbursement for

both confinements. To ensure accurate claim

processing, the originating facility must request an

adjustment to the precertification date span and adjust

any previously paid claim for the initial hospitalization;

and combine and resubmit as a single claim for both date

spans. The dates of service spent in the alternate facility

are reflected as leave of absence days.