CHAPTER 15. PAYMENT TO HOSPITALS; GENERAL
IC 12-15-15
Chapter 15. Payment to Hospitals; General
IC 12-15-15-1
Services at hospitals licensed under IC 16-21; rates establishedunder rules
Sec. 1. Payment of a service provided in a hospital licensed underIC 16-21 shall be determined in accordance with a payment rate forthe service that is established under rules adopted under IC 4-22-2 bythe secretary in conjunction with the office.
As added by P.L.2-1992, SEC.9. Amended by P.L.27-1992, SEC.11;P.L.2-1993, SEC.93.
IC 12-15-15-1.1
Reimbursement to hospitals for inpatient hospital services;intergovernmental transfers; calculating Medicaid shortfall
Sec. 1.1. (a) This section applies to a hospital that is:
(1) licensed under IC 16-21; and
(2) established and operated under IC 16-22-2, IC 16-22-8, orIC 16-23.
(b) For a state fiscal year ending after June 30, 2003, in additionto reimbursement received under section 1 of this chapter, a hospitalis entitled to reimbursement in an amount calculated as follows:
STEP ONE: The office shall identify the aggregate inpatienthospital services, reimbursable under this article and under thestate Medicaid plan, that were provided during the state fiscalyear by hospitals established and operated under IC 16-22-2,IC 16-22-8, or IC 16-23.
STEP TWO: For the aggregate inpatient hospital servicesidentified under STEP ONE, the office shall calculate theaggregate payments made under this article and under the stateMedicaid plan to hospitals established and operated underIC 16-22-2, IC 16-22-8, or IC 16-23, excluding payments underIC 12-15-16, IC 12-15-17, and IC 12-15-19.
STEP THREE: The office shall calculate a reasonable estimateof the amount that would have been paid in the aggregate by theoffice for the inpatient hospital services described in STEPONE under Medicare payment principles.
STEP FOUR: Subtract the amount calculated under STEP TWOfrom the amount calculated under STEP THREE.
STEP FIVE: Subject to subsection (g), from the amountcalculated under STEP FOUR, allocate to a hospital establishedand operated under IC 16-22-8 an amount not to exceed onehundred percent (100%) of the difference between:
(A) the total cost for the hospital's provision of inpatientservices covered under this article for the hospital's fiscalyear ending during the state fiscal year; and
(B) the total payment to the hospital for its provision ofinpatient services covered under this article for the hospital'sfiscal year ending during the state fiscal year, excluding
payments under IC 12-15-16, IC 12-15-17, and IC 12-15-19.
STEP SIX: Subtract the amount calculated under STEP FIVEfrom the amount calculated under STEP FOUR.
STEP SEVEN: Distribute an amount equal to the amountcalculated under STEP SIX to the eligible hospitals establishedand operated under IC 16-22-2 or IC 16-23 described insubsection (c) in an amount not to exceed each hospital'sMedicaid shortfall as defined in subsection (f).
(c) Subject to subsection (e), reimbursement for a state fiscal yearunder this section consists of payments made after the close of eachstate fiscal year. A hospital is not eligible for a payment described inthis subsection unless an intergovernmental transfer or certificationof expenditures is made under subsection (d).
(d) Subject to subsection (e):
(1) an intergovernmental transfer may be made by or on behalfof the hospital; or
(2) a certification of expenditures as eligible for federalfinancial participation may be made;
after the close of each state fiscal year. An intergovernmentaltransfer under this subsection must be made to the Medicaid indigentcare trust fund in an amount equal to a percentage, as determined bythe office, of the amount to be distributed to the hospital under thissection. The office shall use the intergovernmental transfer to fundpayments made under this section.
(e) A hospital that makes a certification of expenditures or makesor has an intergovernmental transfer made on the hospital's behalfunder this section may appeal under IC 4-21.5 the amountdetermined by the office to be paid the hospital under subsection (b).The periods described in subsections (c) and (d) for the hospital oranother entity to make an intergovernmental transfer or certificationof expenditures are tolled pending the administrative appeal and anyjudicial review initiated by the hospital under IC 4-21.5. Thedistribution to other hospitals under subsection (b) may not bedelayed due to an administrative appeal or judicial review institutedby a hospital under this subsection. If necessary, the office may makea partial distribution to the other eligible hospitals under subsection(b) pending the completion of a hospital's administrative appeal orjudicial review, at which time the remaining portion of the paymentsdue to the eligible hospitals shall be made. A partial distribution maybe based upon estimates and trends calculated by the office.
(f) For purposes of this section:
(1) the Medicaid shortfall of a hospital established and operatedunder IC 16-22-2 or IC 16-23 is calculated as follows:
STEP ONE: The office shall identify the inpatient hospitalservices, reimbursable under this article and under the stateMedicaid plan, that were provided during the state fiscalyear by the hospital.
STEP TWO: For the inpatient hospital services identifiedunder STEP ONE, the office shall calculate the paymentsmade under this article and under the state Medicaid plan to
the hospital, excluding payments under IC 12-15-16,IC 12-15-17, and IC 12-15-19.
STEP THREE: The office shall calculate a reasonableestimate of the amount that would have been paid by theoffice for the inpatient hospital services described in STEPONE under Medicare payment principles; and
(2) a hospital's Medicaid shortfall is equal to the amount bywhich the amount calculated in STEP THREE of subdivision(1) is greater than the amount calculated in STEP TWO ofsubdivision (1).
(g) The actual distribution of the amount calculated under STEPFIVE of subsection (b) to a hospital established and operated underIC 16-22-8 shall be made under the terms and conditions providedfor the hospital in the state plan for medical assistance. Payment toa hospital under STEP FIVE of subsection (b) is not a conditionprecedent to the tender of payments to hospitals under STEP SEVENof subsection (b).
As added by P.L.126-1998, SEC.4. Amended by P.L.113-2000,SEC.2; P.L.283-2001, SEC.19; P.L.66-2002, SEC.5; P.L.120-2002,SEC.13; P.L.1-2003, SEC.56; P.L.255-2003, SEC.16; P.L.212-2007,SEC.1; P.L.218-2007, SEC.11.
IC 12-15-15-1.3
Reimbursement to hospitals for outpatient hospital services;intergovernmental transfers; calculating Medicaid shortfall
Sec. 1.3. (a) This section applies to a hospital that is:
(1) licensed under IC 16-21; and
(2) established and operated under IC 16-22-2, IC 16-22-8, orIC 16-23.
(b) For a state fiscal year ending after June 30, 2003, in additionto reimbursement received under section 1 of this chapter, a hospitalis entitled to reimbursement in an amount calculated as follows:
STEP ONE: The office shall identify the aggregate outpatienthospital services, reimbursable under this article and under thestate Medicaid plan, that were provided during the state fiscalyear by hospitals established and operated under IC 16-22-2,IC 16-22-8, or IC 16-23.
STEP TWO: For the aggregate outpatient hospital servicesidentified under STEP ONE, the office shall calculate theaggregate payments made under this article and under the stateMedicaid plan to hospitals established and operated underIC 16-22-2, IC 16-22-8, or IC 16-23, excluding payments underIC 12-15-16, IC 12-15-17, and IC 12-15-19.
STEP THREE: The office shall calculate a reasonable estimateof the amount that would have been paid in the aggregate by theoffice under Medicare payment principles for the outpatienthospital services described in STEP ONE.
STEP FOUR: Subtract the amount calculated under STEP TWOfrom the amount calculated under STEP THREE.
STEP FIVE: Subject to subsection (g), from the amount
calculated under STEP FOUR, allocate to a hospital establishedand operated under IC 16-22-8 an amount not to exceed onehundred percent (100%) of the difference between:
(A) the total cost for the hospital's provision of outpatientservices covered under this article for the hospital's fiscalyear ending during the state fiscal year; and
(B) the total payment to the hospital for its provision ofoutpatient services covered under this article for thehospital's fiscal year ending during the state fiscal year,excluding payments under IC 12-15-16, IC 12-15-17, andIC 12-15-19.
STEP SIX: Subtract the amount calculated under STEP FIVEfrom the amount calculated under STEP FOUR.
STEP SEVEN: Distribute an amount equal to the amountcalculated under STEP SIX to the eligible hospitals establishedand operated under IC 16-22-2 or IC 16-23 described insubsection (c) in an amount not to exceed each hospital'sMedicaid shortfall as defined in subsection (f).
(c) A hospital is not eligible for a payment described in thissection unless:
(1) an intergovernmental transfer is made by the hospital or onbehalf of the hospital; or
(2) the hospital or another entity certifies the hospital'sexpenditures as eligible for federal financial participation.
(d) Subject to subsection (e):
(1) an intergovernmental transfer may be made by or on behalfof the hospital; or
(2) a certification of expenditures as eligible for federalfinancial participation may be made;
after the close of each state fiscal year. An intergovernmentaltransfer under this subsection must be made to the Medicaid indigentcare trust fund in an amount equal to a percentage, as determined bythe office, of the amount to be distributed to the hospital undersubsection (b). The office shall use the intergovernmental transfer tofund payments made under this section.
(e) A hospital that makes a certification of expenditures or makesor has an intergovernmental transfer made on the hospital's behalfunder this section may appeal under IC 4-21.5 the amountdetermined by the office to be paid by the hospital under subsection(b). The periods described in subsections (c) and (d) for the hospitalor other entity to make an intergovernmental transfer or certificationof expenditures are tolled pending the administrative appeal and anyjudicial review initiated by the hospital under IC 4-21.5. Thedistribution to other hospitals under subsection (b) may not bedelayed due to an administrative appeal or judicial review institutedby a hospital under this subsection. If necessary, the office may makea partial distribution to the other eligible hospitals under subsection(b) pending the completion of a hospital's administrative appeal orjudicial review, at which time the remaining portion of the paymentsdue to the eligible hospitals must be made. A partial distribution may
be calculated by the office based upon estimates and trends.
(f) For purposes of this section:
(1) the Medicaid shortfall of a hospital established and operatedunder IC 16-22-2 or IC 16-23 is calculated as follows:
STEP ONE: The office shall identify the outpatient hospitalservices, reimbursable under this article and under the stateMedicaid plan, that were provided during the state fiscalyear by the hospital.
STEP TWO: For the outpatient hospital services identifiedunder STEP ONE, the office shall calculate the paymentsmade under this article and under the state Medicaid plan tothe hospital, excluding payments under IC 12-15-16,IC 12-15-17, and IC 12-15-19.
STEP THREE: The office shall calculate a reasonableestimate of the amount that would have been paid by theoffice for the outpatient hospital services described in STEPONE under Medicare payment principles; and
(2) a hospital's Medicaid shortfall is equal to the amount bywhich the amount calculated in STEP THREE of subdivision(1) is greater than the amount calculated in STEP TWO ofsubdivision (1).
(g) The actual distribution of the amount calculated under STEPFIVE of subsection (b) to a hospital established and operated underIC 16-22-8 shall be made under the terms and conditions providedfor the hospital in the state plan for medical assistance. Payment toa hospital under STEP FIVE of subsection (b) is not a conditionprecedent to the tender of payments to hospitals under STEP SEVENof subsection (b).
As added by P.L.120-2002, SEC.14. Amended by P.L.255-2003,SEC.17; P.L.212-2007, SEC.2; P.L.218-2007, SEC.12.
IC 12-15-15-1.5
Additional reimbursements to certain hospitals; appeal of amountof distribution
Sec. 1.5. (a) This section applies to a hospital that:
(1) is licensed under IC 16-21;
(2) is not a unit of state or local government; and
(3) is not owned or operated by a unit of state or localgovernment.
(b) For a state fiscal year ending after June 30, 2003, and beforeJuly 1, 2007, in addition to reimbursement received under section 1of this chapter, a hospital eligible under this section is entitled toreimbursement in an amount calculated as follows:
STEP ONE: The office shall identify the total inpatient hospitalservices and the total outpatient hospital services, reimbursableunder this article and under the state Medicaid plan, that wereprovided during the state fiscal year by the hospitals describedin subsection (a).
STEP TWO: For the total inpatient hospital services and thetotal outpatient hospital services identified under STEP ONE,
the office shall calculate the aggregate payments made underthis article and under the state Medicaid plan to hospitalsdescribed in subsection (a), excluding payments underIC 12-15-16, IC 12-15-17, and IC 12-15-19.
STEP THREE: The office shall calculate a reasonable estimateof the amount that would have been paid in the aggregate by theoffice for the inpatient hospital services and the outpatienthospital services identified in STEP ONE under Medicarepayment principles.
STEP FOUR: Subtract the amount calculated under STEP TWOfrom the amount calculated under STEP THREE.
STEP FIVE: Distribute an amount equal to the amountcalculated under STEP FOUR to the eligible hospitals describedin subsection (a) as follows:
(A) Subject to the availability of funds underIC 12-15-20-2(8)(D) to serve as the nonfederal share of suchpayment, the first ten million dollars ($10,000,000) of theamount calculated under STEP FOUR for a state fiscal yearshall be paid to a hospital described in subsection (a) thathas more than sixty thousand (60,000) Medicaid inpatientdays.
(B) Following the payment to the hospital under clause (A)and subject to the availability of funds underIC 12-15-20-2(8)(D) to serve as the nonfederal share of suchpayments, the remaining amount calculated under STEPFOUR for a state fiscal year shall be paid to all hospitalsdescribed in subsection (a). The payments shall be made ona pro rata basis based on the hospitals' Medicaid inpatientdays or other payment methodology approved by the Centersfor Medicare and Medicaid Services. For purposes of thisclause, a hospital's Medicaid inpatient days are the hospital'sin-state and paid Medicaid fee for service and managed caredays for the state fiscal year for which services are identifiedunder STEP ONE, as determined by the office.
(C) Subject to IC 12-15-20.7, in the event the entirety of theamount calculated under STEP FOUR is not distributedfollowing the payments made under clauses (A) and (B), theremaining amount may be paid to hospitals described insubsection (a) that are eligible under this clause. A hospitalis eligible for a payment under this clause only if thenonfederal share of the hospital's payment is provided by oron behalf of the hospital. The remaining amount shall bepaid to those eligible hospitals:
(i) on a pro rata basis in relation to all hospitals eligibleunder this clause based on the hospitals' Medicaidinpatient days; or
(ii) other payment methodology determined by the officeand approved by the Centers for Medicare and MedicaidServices.
(c) As used in this subsection, "Medicaid supplemental payments"
means Medicaid payments for hospitals that are in addition toMedicaid fee-for-service payments, Medicaid risk-based managedcare payments, and Medicaid disproportionate share payments, andthat are included in the Medicaid state plan, including Medicaidsafety-net payments, and payments made under this section andsections 1.1, 1.3, 9, and 9.5 of this chapter. For a state fiscal yearending after June 30, 2007, in addition to the reimbursement receivedunder section 1 of this chapter, a hospital eligible under this sectionis entitled to reimbursement in an amount calculated as follows:
STEP ONE: The office shall identify the total inpatient hospitalservices and the total outpatient hospital services reimbursableunder this article and under the state Medicaid plan that wereprovided during the state fiscal year for all hospitals describedin subsection (a).
STEP TWO: For the total inpatient hospital services and thetotal outpatient hospital services identified in STEP ONE, theoffice shall calculate the total payments made under this articleand under the state Medicaid plan to all hospitals described insubsection (a). A calculation under this STEP excludes apayment made under the following:
(A) IC 12-15-16.
(B) IC 12-15-17.
(C) IC 12-15-19.
STEP THREE: The office shall calculate, under Medicarepayment principles, a reasonable estimate of the total amountthat would have been paid by the office for the inpatienthospital services and the outpatient hospital services identifiedin STEP ONE.
STEP FOUR: Subtract the amount calculated under STEP TWOfrom the amount calculated under STEP THREE.
STEP FIVE: Distribute an amount equal to the amountcalculated under STEP FOUR to the eligible hospitals describedin subsection (a) as follows:
(A) As used in this clause, "Medicaid inpatient days" are thehospital's in-state paid Medicaid fee for service andrisk-based managed care days for the state fiscal year forwhich services are identified under STEP ONE, asdetermined by the office. Subject to the availability of fundstransferred to the Medicaid indigent care trust fund underSTEP FOUR of IC 12-16-7.5-4.5(c) and remaining in theMedicaid indigent care trust fund under IC 12-15-20-2(8)(G)to serve as the nonfederal share of the payments, the amountcalculated under STEP FOUR for a state fiscal year shall bepaid to all hospitals described in subsection (a). Thepayments shall be made on a pro rata basis, based on thehospitals' Medicaid inpatient days or in accordance withanother payment methodology determined by the office andapproved by the Centers for Medicare and MedicaidServices.
(B) Subject to IC 12-15-20.7, if the entire amount calculated
under STEP FOUR is not distributed following the paymentsmade under clause (A), the remaining amount shall be paidas described in clauses (C) and (D) to a hospital that isdescribed in subsection (a) and that is described as eligibleunder this clause. A hospital is eligible for a payment underclause (C) only if the hospital:
(i) has less than sixty thousand (60,000) Medicaidinpatient days annually;
(ii) was eligible for Medicaid disproportionate sharehospital payments in the state fiscal year ending June 30,1998, or the hospital met the office's Medicaiddisproportionate share payment criteria based upon statefiscal year 1998 data and received a Medicaiddisproportionate share payment for the state fiscal yearending June 30, 2001; and
(iii) received a Medicaid disproportionate share paymentunder IC 12-15-19-2.1 for state fiscal years 2001, 2002,2003, and 2004.
The payment amount under clause (C) for an eligiblehospital is subject to the availability of the nonfederal shareof the hospital's payment being provided by the hospital oron behalf of the hospital.
(C) For state fiscal years ending after June 30, 2007, butbefore July 1, 2009, payments to eligible hospitals describedin clause (B) shall be made as follows:
(i) The payment to an eligible hospital that merged two (2)hospitals under a single Medicaid provider numbereffective January 1, 2004, shall equal one hundred percent(100%) of the hospital's hospital-specific limit for the statefiscal year ending June 30, 2005, when the payment iscombined with any Medicaid disproportionate sharepayment made under IC 12-15-19-2.1, Medicaid, and otherMedicaid supplemental payments, paid or to be paid to thehospital for a state fiscal year.
(ii) The payment to an eligible hospital described in clause(B) other than a hospital described in item (i) shall equalone hundred percent (100%) of the hospital's hospitalspecific limit for the state fiscal year ending June 30,2004, when the payment is combined with any Medicaiddisproportionate share payment made underIC 12-15-19-2.1, Medicaid, and other Medicaidsupplemental payments, paid or to be paid to the hospitalfor a state fiscal year.
(D) For state fiscal years beginning after June 30, 2009,payments to an eligible hospital described in clause (B) shallbe made in a manner determined by the office.
(E) Subject to IC 12-15-20.7, if the entire amount calculatedunder STEP FOUR is not distributed following the paymentsmade under clause (A) and clauses (C) or (D), the remainingamount may be paid as described in clause (F) to a hospital
described in subsection (a) that is described as eligible underthis clause. A hospital is eligible for a payment for a statefiscal year under clause (F) if the hospital:
(i) is eligible to receive Medicaid disproportionate sharepayments for the state fiscal year for which the Medicaiddisproportionate share payment is attributable underIC 12-15-19-2.1, for a state fiscal year ending after June30, 2007; and
(ii) does not receive a payment under clauses (C) or (D)for the state fiscal year.
A payment to a hospital under this clause is subject to theavailability of nonfederal matching funds.
(F) Payments to eligible hospitals described in clause (E)shall be made:
(i) to best use federal matching funds available forhospitals that are eligible for Medicaid disproportionateshare payments under IC 12-15-19-2.1; and
(ii) by using a methodology that allocates availablefunding under this clause, Medicaid supplementalpayments, and payments under IC 12-15-19-2.1, in amanner in which all hospitals eligible under clause (E)receive payments in a manner that takes into account thesituation of eligible hospitals that have historicallyqualified for Medicaid disproportionate share paymentsand ensures that payments for eligible hospitals areequitable.
(G) If the Centers for Medicare and Medicaid Services doesnot approve the payment methodologies in clauses (A)through (F), the office may implement alternative paymentmethodologies that are eligible for federal financialparticipation to implement a program consistent with thepayments for hospitals described in clauses (A) through (F).
(d) A hospital described in subsection (a) may appeal underIC 4-21.5 the amount determined by the office to be paid to thehospital under STEP FIVE of subsections (b) or (c). The distributionto other hospitals under STEP FIVE of subsection (b) or (c) may notbe delayed due to an administrative appeal or judicial reviewinstituted by a hospital under this subsection. If necessary, the officemay make a partial distribution to the other eligible hospitals underSTEP FIVE of subsection (b) or (c) pending the completion of ahospital's administrative appeal or judicial review, at which time theremaining portion of the payments due to the eligible hospitals shallbe made. A partial distribution may be based on estimates and trendscalculated by the office.
As added by P.L.255-2003, SEC.18. Amended by P.L.212-2007,SEC.3; P.L.218-2007, SEC.13; P.L.3-2008, SEC.92.
IC 12-15-15-1.6
Alternative payment methodology for payments to hospitals
Sec. 1.6. (a) This section applies only if the office determines,
based on information received from the federal Centers for Medicareand Medicaid Services, that payments made under section 1.5(b)STEP FIVE (A), (B), or (C) of this chapter will not be approved forfederal financial participation.
(b) If the office determines that payments made under section1.5(b) STEP FIVE (A) of this chapter will not be approved forfederal financial participation, the office may make alternativepayments to payments under section 1.5(b) STEP FIVE (A) of thischapter if:
(1) the payments for a state fiscal year are made only to ahospital that would have been eligible for a payment for thatstate fiscal year under section 1.5(b) STEP FIVE (A) of thischapter; and
(2) the payments for a state fiscal year to each hospital are anamount that is as equal as possible to the amount each hospitalwould have received under section 1.5(b) STEP FIVE (A) ofthis chapter for that state fiscal year.
(c) If the office determines that payments made under section1.5(b) STEP FIVE (B) of this chapter will not be approved forfederal financial participation, the office may make alternativepayments to payments under section 1.5(b) STEP FIVE (B) of thischapter if:
(1) the payments for a state fiscal year are made only to ahospital that would have been eligible for a payment for thatstate fiscal year under section 1.5(b) STEP FIVE (B) of thischapter; and
(2) the payments for a state fiscal year to each hospital are anamount that is as equal as possible to the amount each hospitalwould have received under section 1.5(b) STEP FIVE (B) ofthis chapter for that state fiscal year.
(d) If the office determines that payments made under section1.5(b) STEP FIVE (C) of this chapter will not be approved forfederal financial participation, the office may make alternativepayments to payments under section 1.5(b) STEP FIVE (C) of thischapter if:
(1) the payments for a state fiscal year are made only to ahospital that would have been eligible for a payment for thatstate fiscal year under section 1.5(b) STEP FIVE (C) of thischapter; and
(2) the payments for a state fiscal year to each hospital are anamount that is as equal as possible to the amount each hospitalwould have received under section 1.5(b) STEP FIVE (C) ofthis chapter for that state fiscal year.
(e) If the office determines, based on information received fromthe federal Centers for Medicare and Medicaid Services, thatpayments made under subsection (b), (c), or (d) will not be approvedfor federal financial participation, the office shall use the funds thatwould have served as the nonfederal share of these payments for astate fiscal year to serve as the nonfederal share of a paymentprogram for hospitals to be established by the office. The payment
program must distribute payments to hospitals for a state fiscal yearbased upon a methodology determined by the office to be equitableunder the circumstances.
As added by P.L.78-2004, SEC.4.
IC 12-15-15-2
Rates adopted for hospital licensed under IC 16-21; prospective orretrospective application
Sec. 2. The rates adopted under this chapter for a hospital licensedunder IC 16-21 may be the following:
(1) Prospective.
(2) Retroactive.
(3) A combination of prospective and retroactive.
As added by P.L.2-1992, SEC.9. Amended by P.L.2-1993, SEC.94.
IC 12-15-15-2.5
Payment for physician services in emergency department
Sec. 2.5. (a) Payment for physician services provided in theemergency department of a hospital licensed under IC 16-21 must beat a rate of one hundred percent (100%) of rates payable under theMedicaid fee structure.
(b) The payment under subsection (a) must be calculated using thesame methodology used for all other physicians participating in theMedicaid program.
(c) For services rendered and documented in an individual'smedical record, physicians must be reimbursed for federally requiredmedical screening exams that are necessary to determine thepresence of an emergency using the appropriate Current ProceduralTerminology (CPT) codes 99281, 99282, or 99283 described in theCurrent Procedural Terminology Manual published annually by theAmerican Medical Association, without authorization by theenrollee's primary medical provider.
(d) Payment for all other physician services provided in anemergency department of a hospital to enrollees in the Medicaidprimary care case management program must be at a rate of onehundred percent (100%) of the Medicaid fee structure rates, providedthe service is authorized, prospectively or retrospectively, by theenrollee's primary medical provider.
(e) This section does not apply to a person enrolled in theMedicaid risk-based managed care program.
As added by P.L.153-1995, SEC.10. Amended by P.L.119-1997,SEC.5; P.L.245-1999, SEC.1; P.L.223-2001, SEC.10.
IC 12-15-15-3
Services provided at hospitals operating under IC 16-24-1;prospective payment rate
Sec. 3. Payment of a service provided in a hospital operatingunder IC 16-24-1 shall be determined in accordance with aprospective payment rate for the service.
As added by P.L.2-1992, SEC.9. Amended by P.L.2-1993, SEC.95.
IC 12-15-15-4
Per diem rate for services provided in hospitals operating underIC 16-24-1
Sec. 4. The office shall establish a per diem rate for the serviceprovided in a hospital operating under IC 16-24-1 under rulesadopted under IC 4-22-2 by the secretary.
As added by P.L.2-1992, SEC.9. Amended by P.L.2-1993, SEC.96.
IC 12-15-15-4.5
Payment for HIV test; limitation
Sec. 4.5. Payment to a hospital for a test required underIC 16-41-6-4 must be in an amount equal to the hospital's actual costof performing the test and may not reduce or replace thereimbursement of other services that are provided to the patientunder the state Medicaid program. The total cost to the state may notbe more than twenty-four thousand dollars ($24,000) in a state fiscalyear.
As added by P.L.237-2003, SEC.2.
IC 12-15-15-5
Repealed
(Repealed by P.L.126-1998, SEC.22.)
IC 12-15-15-6
Fees in addition to infant delivery fees
Sec. 6. (a) In addition to a payment due to a hospital for thedelivery of a newborn infant, the office shall tender a payment to thehospital for the hospital's collection, handling, and delivery of aspecimen for testing under IC 16-41-17-2(a)(10).
(b) Payment to a hospital required under subsection (a) must bein an amount equal to the total of the following costs:
(1) The cost incurred by the hospital to collect, handle, anddeliver the specimen obtained for testing underIC 16-41-17-2(a)(10).
(2) Any fee assessed against the hospital for a laboratory'stesting of the specimen under IC 16-41-17-2(a)(10).
(3) Any newborn screening fee or other fee assessed against thehospital by the state department of health in connection with thetesting of the specimen under IC 16-41-17-2(a)(10).
As added by P.L.149-2001, SEC.2.
IC 12-15-15-7
Reserved
IC 12-15-15-8
Repealed
(Repealed by P.L.126-1998, SEC.21.)
IC 12-15-15-9
Attribution of payable claim to county; amount of payment onpayable claims; conditions on payments; funds available forpayments
Sec. 9. (a) For purposes of this section and IC 12-16-7.5-4.5, apayable claim is attributed to a county if the payable claim issubmitted to the division by a hospital licensed under IC 16-21-2 forpayment under IC 12-16-7.5 for care provided by the hospital to anindividual who qualifies for the hospital care for the indigentprogram under IC 12-16-3.5-1 or IC 12-16-3.5-2 and:
(1) who is a resident of the county;
(2) who is not a resident of the county and for whom the onsetof the medical condition that necessitated the care occurred inthe county; or
(3) whose residence cannot be determined by the division andfor whom the onset of the medical condition that necessitatedthe care occurred in the county.
(b) For each state fiscal year ending after June 30, 2003, andbefore July 1, 2007, a hospital licensed under IC 16-21-2 thatsubmits to the division during the state fiscal year a payable claimunder IC 12-16-7.5 is entitled to a payment under subsection (c).
(c) Except as provided in section 9.8 of this chapter and subjectto section 9.6 of this chapter, for a state fiscal year, the office shallpay to a hospital referred to in subsection (b) an amount equal to theamount, based on information obtained from the division and thecalculations and allocations made under IC 12-16-7.5-4.5, that theoffice determines for the hospital under STEP SIX of the followingSTEPS:
STEP ONE: Identify:
(A) each hospital that submitted to the division one (1) ormore payable claims under IC 12-16-7.5 during the statefiscal year; and
(B) the county to which each payable claim is attributed.
STEP TWO: For each county identified in STEP ONE, identify:
(A) each hospital that submitted to the division one (1) ormore payable claims under IC 12-16-7.5 attributed to thecounty during the state fiscal year; and
(B) the total amount of all hospital payable claims submittedto the division under IC 12-16-7.5 attributed to the countyduring the state fiscal year.
STEP THREE: For each county identified in STEP ONE,identify the amount of county funds transferred to the Medicaidindigent care trust fund under IC 12-16-7.5-4.5.
STEP FOUR: For each hospital identified in STEP ONE, withrespect to each county identified in STEP ONE, calculate thehospital's percentage share of the county's funds transferred tothe Medicaid indigent care trust fund under IC 12-16-7.5-4.5.Each hospital's percentage share is based on the total amount ofthe hospital's payable claims submitted to the division underIC 12-16-7.5 attributed to the county during the state fiscal year,
calculated as a percentage of the total amount of all hospitalpayable claims submitted to the division under IC 12-16-7.5attributed to the county during the state fiscal year.
STEP FIVE: Subject to subsection (j), for each hospitalidentified in STEP ONE, with respect to each county identifiedin STEP ONE, multiply the hospital's percentage sharecalculated under STEP FOUR by the amount of the county'sfunds transferred to the Medicaid indigent care trust fund underIC 12-16-7.5-4.5.
STEP SIX: Determine the sum of all amounts calculated underSTEP FIVE for each hospital identified in STEP ONE withrespect to each county identified in STEP ONE.
(d) For state fiscal years beginning after June 30, 2007, a hospitalthat received a payment determined under STEP SIX of subsection(c) for the state fiscal year ending June 30, 2007, shall be paid in anamount equal to the amount determined for the hospital under STEPSIX of subsection (c) for the state fiscal year ending June 30, 2007.
(e) A hospital's payment under subsection (c) or (d) is in the formof a Medicaid supplemental payment. The amount of a hospital'sMedicaid supplemental payment is subject to the availability offunding for the non-federal share of the payment under subsection(f). The office shall make the payments under subsection (c) and (d)before December 15 that next succeeds the end of the state fiscalyear.
(f) The non-federal share of a payment to a hospital undersubsection (c) or (d) is funded from the funds transferred to theMedicaid indigent care trust fund under IC 12-16-7.5-4.5.
(g) The amount of a county's transferred funds available to beused to fund the non-federal share of a payment to a hospital undersubsection (c) is an amount that bears the same proportion to the totalamount of funds of the county transferred to the Medicaid indigentcare trust fund under IC 12-16-7.5-4.5 that the total amount of thehospital's payable claims under IC 12-16-7.5 attributed to the countysubmitted to the division during the state fiscal year bears to the totalamount of all hospital payable claims under IC 12-16-7.5 attributedto the county submitted to the division during the state fiscal year.
(h) Any county's funds identified in subsection (g) that remainafter the non-federal share of a hospital's payment has been fundedare available to serve as the non-federal share of a payment to ahospital under section 9.5 of this chapter.
(i) For purposes of this section, "payable claim" has the meaningset forth in IC 12-16-7.5-2.5(b)(1).
(j) For purposes of subsection (c):
(1) the amount of a payable claim is an amount equal to theamount the hospital would have received under the state'sfee-for-service Medicaid reimbursement principles for thehospital care for which the payable claim is submitted underIC 12-16-7.5 if the individual receiving the hospital care hadbeen a Medicaid enrollee; and
(2) a payable hospital claim under IC 12-16-7.5 includes a
payable claim under IC 12-16-7.5 for the hospital's caresubmitted by an individual or entity other than the hospital, tothe extent permitted under the hospital care for the indigentprogram.
(k) The amount calculated under STEP FIVE of subsection (c) fora hospital with respect to a county may not exceed the total amountof the hospital's payable claims attributed to the county during thestate fiscal year.
As added by P.L.126-1998, SEC.5. Amended by P.L.113-2000,SEC.3; P.L.283-2001, SEC.20; P.L.1-2002, SEC.52; P.L.120-2002,SEC.15; P.L.1-2003, SEC.57; P.L.255-2003, SEC.19; P.L.78-2004,SEC.5; P.L.212-2007, SEC.4; P.L.218-2007, SEC.14.
IC 12-15-15-9.5
Attribution of payable claim to county; funds available forpayments; limitation on payments
Sec. 9.5. (a) For purposes of this section and IC 12-16-7.5-4.5, apayable claim is attributed to a county if the payable claim issubmitted to the division by a hospital licensed under IC 16-21-2 forpayment under IC 12-16-7.5 for care provided by the hospital to anindividual who qualifies for the hospital care for the indigentprogram under IC 12-16-3.5-1 or IC 12-16-3.5-2 and:
(1) who is a resident of the county;
(2) who is not a resident of the county and for whom the onsetof the medical condition that necessitated the care occurred inthe county; or
(3) whose residence cannot be determined by the division andfor whom the onset of the medical condition that necessitatedthe care occurred in the county.
(b) For each state fiscal year ending after June 30, 2003, butbefore July 1, 2007, a hospital licensed under IC 16-21-2:
(1) that submits to the division during the state fiscal year apayable claim under IC 12-16-7.5; and
(2) whose payment under section 9(c) of this chapter was lessthan the total amount of the hospital's payable claims underIC 12-16-7.5 submitted by the hospital to the division during thestate fiscal year;
is entitled to a payment under subsection (c).
(c) Subject to section 9.6 of this chapter, for a state fiscal year, theoffice shall pay to a hospital referred to in subsection (b) an amountequal to the amount, based on information obtained from the divisionand the calculations and allocations made under IC 12-16-7.5-4.5,that the office determines for the hospital under STEP EIGHT of thefollowing STEPS:
STEP ONE: Identify each county whose transfer of funds to theMedicaid indigent care trust fund under IC 12-16-7.5-4.5 for thestate fiscal year was less than the total amount of all hospitalpayable claims attributed to the county and submitted to thedivision during the state fiscal year.
STEP TWO: For each county identified in STEP ONE,
calculate the difference between the amount of funds of thecounty transferred to the Medicaid indigent care trust fundunder IC 12-16-7.5-4.5 and the total amount of all hospitalpayable claims attributed to the county and submitted to thedivision during the state fiscal year.
STEP THREE: Calculate the sum of the amounts calculated forthe counties under STEP TWO.
STEP FOUR: Identify each hospital whose payment undersection 9(c) of this chapter was less than the total amount of thehospital's payable claims under IC 12-16-7.5 submitted by thehospital to the division during the state fiscal year.
STEP FIVE: Calculate for each hospital identified in STEPFOUR the difference between the hospital's payment undersection 9(c) of this chapter and the total amount of the hospital'spayable claims under IC 12-16-7.5 submitted by the hospital tothe division during the state fiscal year.
STEP SIX: Calculate the sum of the amounts calculated foreach of the hospitals under STEP FIVE.
STEP SEVEN: For each hospital identified in STEP FOUR,calculate the hospital's percentage share of the amountcalculated under STEP SIX. Each hospital's percentage share isbased on the amount calculated for the hospital under STEPFIVE calculated as a percentage of the sum calculated underSTEP SIX.
STEP EIGHT: For each hospital identified in STEP FOUR,multiply the hospital's percentage share calculated under STEPSEVEN by the sum calculated under STEP THREE. Theamount calculated under this STEP for a hospital may notexceed the amount by which the hospital's total payable claimsunder IC 12-16-7.5 submitted during the state fiscal yearexceeded the amount of the hospital's payment under section9(c) of this chapter.
(d) For state fiscal years beginning after June 30, 2007, a hospitalthat received a payment determined under STEP EIGHT ofsubsection (c) for the state fiscal year ending June 30, 2007, shall bepaid an amount equal to the amount determined for the hospitalunder STEP EIGHT of subsection (c) for the state fiscal year endingJune 30, 2007.
(e) A hospital's payment under subsection (c) or (d) is in the formof a Medicaid supplemental payment. The amount of the hospital'sadd-on payment is subject to the availability of funding for thenonfederal share of the payment under subsection (f). The officeshall make the payments under subsection (c) or (d) before December15 that next succeeds the end of the state fiscal year.
(f) The nonfederal share of a payment to a hospital undersubsection (c) or (d) is derived from funds transferred to theMedicaid indigent care trust fund under IC 12-16-7.5-4.5 and notexpended under section 9 of this chapter.
(g) Except as provided in subsection (h), the office may not makea payment under this section until the payments due under section 9
of this chapter for the state fiscal year have been made.
(h) If a hospital appeals a decision by the office regarding thehospital's payment under section 9 of this chapter, the office maymake payments under this section before all payments due undersection 9 of this chapter are made if:
(1) a delay in one (1) or more payments under section 9 of thischapter resulted from the appeal; and
(2) the office determines that making payments under thissection while the appeal is pending will not unreasonably affectthe interests of hospitals eligible for a payment under thissection.
(i) Any funds transferred to the Medicaid indigent care trust fundunder IC 12-16-7.5-4.5 remaining after payments are made under thissection shall be used as provided in IC 12-15-20-2(8).
(j) For purposes of subsection (c):
(1) "payable claim" has the meaning set forth inIC 12-16-7.5-2.5(b);
(2) the amount of a payable claim is an amount equal to theamount the hospital would have received under the state'sfee-for-service Medicaid reimbursement principles for thehospital care for which the payable claim is submitted underIC 12-16-7.5 if the individual receiving the hospital care hadbeen a Medicaid enrollee; and
(3) a payable hospital claim under IC 12-16-7.5 includes apayable claim under IC 12-16-7.5 for the hospital's caresubmitted by an individual or entity other than the hospital, tothe extent permitted under the hospital care for the indigentprogram.
As added by P.L.255-2003, SEC.20. Amended by P.L.78-2004,SEC.6; P.L.212-2007, SEC.5; P.L.218-2007, SEC.15; P.L.3-2008,SEC.93.
IC 12-15-15-9.6
Limitation on total amount of payments
Sec. 9.6. For state fiscal years beginning after June 30, 2007, thetotal amount of payments to hospitals under sections 9 and 9.5 of thischapter may not exceed the amount paid to hospitals under sections9 and 9.5 of this chapter for the state fiscal year ending June 30,2007.
As added by P.L.255-2003, SEC.21. Amended by P.L.212-2007,SEC.6; P.L.218-2007, SEC.16.
IC 12-15-15-9.8
Repealed
(Repealed by P.L.212-2007, SEC.31; P.L.218-2007, SEC.52.)
IC 12-15-15-10
Payments to providers under Medicaid disproportionate shareprovider program
Sec. 10. (a) This section applies to a hospital that: (1) is licensed under IC 16-21; and
(2) qualifies as a provider under IC 12-15-16, IC 12-15-17, orIC 12-15-19 of the Medicaid disproportionate share providerprogram.
(b) The office may, after consulting with affected providers, doone (1) or more of the following:
(1) Establish a nominal charge hospital payment program.
(2) Establish any other permissible payment program.
(c) A program expanded or established under this section issubject to the availability of:
(1) intergovernmental transfers;
(2) funds certified as being eligible for federal financialparticipation; or
(3) other permissible sources of non-federal share dollars.
(d) The office may not implement a program under this sectionuntil the federal Centers for Medicare and Medicaid Servicesapproves the provisions regarding the program in the amended stateplan for medical assistance.
(e) The office may determine not to continue to implement aprogram established under this section if federal financialparticipation is not available.
As added by P.L.113-2000, SEC.4. Amended by P.L.66-2002, SEC.6;P.L.212-2007, SEC.7; P.L.218-2007, SEC.17.
IC 12-15-15-11
Nominal charge hospitals
Sec. 11. Hospitals licensed under IC 16-21 that are establishedand operated under IC 16-22, IC 16-22-8, or IC 16-23 are nominalcharge hospitals for purposes of the Medicaid program.
As added by P.L.283-2001, SEC.21.