CHAPTER 16. DISPROPORTIONATE SHARE PROVIDERS; ELIGIBILITY
IC 12-15-16
Chapter 16. Disproportionate Share Providers; Eligibility
IC 12-15-16-1
Disproportionate share provider status
Sec. 1. (a) A provider that is an acute care hospital licensed underIC 16-21, a state mental health institution under IC 12-24-1-3, or aprivate psychiatric institution licensed under IC 12-25 is adisproportionate share provider if the provider meets either of thefollowing conditions:
(1) The provider's Medicaid inpatient utilization rate is at leastone (1) standard deviation above the mean Medicaid inpatientutilization rate for providers receiving Medicaid payments inIndiana. However, the Medicaid inpatient utilization rate ofproviders whose low income utilization rate exceedstwenty-five percent (25%) must be excluded in calculating thestatewide mean Medicaid inpatient utilization rate.
(2) The provider's low income utilization rate exceedstwenty-five percent (25%).
(b) An acute care hospital licensed under 16-21 is a municipaldisproportionate share provider if the hospital:
(1) has a Medicaid utilization rate greater than one percent(1%); and
(2) is established and operated under IC 16-22-2 or IC 16-23.
(c) A community mental health center:
(1) that is identified in IC 12-29-2-1;
(2) for which a county provides funds under:
(A) IC 12-29-1-7(b) before January 1, 2004; or
(B) IC 12-29-2-20(d) after December 31, 2003;
or from other county sources; and
(3) that provides inpatient services to Medicaid patients;
is a community mental health center disproportionate share providerif the community mental health center's Medicaid inpatientutilization rate is greater than one percent (1%).
(d) A disproportionate share provider under IC 12-15-17 musthave at least two (2) obstetricians who have staff privileges and whohave agreed to provide obstetric services under the Medicaidprogram. For a hospital located in a rural area (as defined in Section1886 of the Social Security Act), an obstetrician includes a physicianwith staff privileges at the hospital who has agreed to performnonemergency obstetric procedures. However, this obstetric servicerequirement does not apply to a provider whose inpatients arepredominantly individuals less than eighteen (18) years of age or thatdid not offer nonemergency obstetric services as of December 21,1987.
(e) The determination of a provider's status as a disproportionateshare provider under this section shall be based on utilization andrevenue data from the most recent year for which an audited costreport from the provider is on file with the office.
As added by P.L.2-1992, SEC.9. Amended by P.L.27-1992, SEC.12;
P.L.277-1993(ss), SEC.71; P.L.126-1998, SEC.6; P.L.113-2000,SEC.5; P.L.78-2004, SEC.8; P.L.123-2008, SEC.1.
IC 12-15-16-2
Inpatient utilization rate
Sec. 2. (a) For purposes of disproportionate share eligibility, aprovider's Medicaid inpatient utilization rate is a fraction (expressedas a percentage) where:
(1) the numerator is the provider's total number of Medicaidinpatient days in the most recent year for which an audited costreport is on file with the office; and
(2) the denominator is the total number of the provider'sinpatient days in the most recent year for which an audited costreport is on file with the office.
(b) For purposes of this section, "Medicaid inpatient days"includes all acute care days attributable to individuals eligible forMedicaid benefits under a state plan approved under 42 U.S.C. 1396aon the days of service:
(1) whether attributable to individuals eligible for Medicaid inIndiana or any other state;
(2) even if the office did not make payment for any services,including inpatient days that are determined to be medicallynecessary but for which payment is denied by the office forother reasons; and
(3) including days attributable to Medicaid beneficiariesreceiving services through a managed care organization orhealth maintenance organization.
However, a day is not a Medicaid inpatient day for purposes of thissection if the patient was entitled to both Medicare Part A (as definedin 42 U.S.C. 1395c) and Medicaid on that day.
As added by P.L.2-1992, SEC.9. Amended by P.L.277-1993(ss),SEC.72; P.L.156-1995, SEC.2; P.L.126-1998, SEC.7; P.L.113-2000,SEC.6; P.L.283-2001, SEC.22.
IC 12-15-16-3
Low income utilization rate; contractual allowances and discounts
Sec. 3. (a) For purposes of disproportionate share eligibility, aprovider's low income utilization rate is the sum of the following,based on the most recent year for which an audited cost report is onfile with the office:
(1) A fraction (expressed as a percentage) for which:
(A) the numerator is the sum of:
(i) the total Medicaid patient revenues paid to theprovider; plus
(ii) the amount of the cash subsidies received directly fromstate and local governments, including payments madeunder the hospital care for the indigent program (IC12-16-2) (before its repeal) and IC 12-16-2.5; and
(B) the denominator is the total amount of the provider'spatient revenues paid to the provider, including cash
subsidies; and
(2) A fraction (expressed as a percentage) for which:
(A) the numerator is the total amount of the provider'scharges for inpatient services that are attributable to careprovided to individuals who have no source of payment; and
(B) the denominator is the total amount of charges forinpatient services.
(b) The numerator in subsection (a)(1)(A) does not includecontractual allowances and discounts other than for indigent patientsnot eligible for Medicaid.
As added by P.L.2-1992, SEC.9. Amended by P.L.277-1993(ss),SEC.73; P.L.113-2000, SEC.7; P.L.283-2001, SEC.23;P.L.120-2002, SEC.16.
IC 12-15-16-4
Repealed
(Repealed by P.L.156-1995, SEC.9.)
IC 12-15-16-5
Implementation; federal Health Care Financing Administrationapproval; percentage reduction of payments to Medicaid indigentcare trust fund
Sec. 5. (a) The office may not implement this chapter,IC 12-15-17, IC 12-15-18, IC 12-15-19, or IC 12-15-20 until thefederal Centers for Medicare and Medicaid Services has issued itsapproval of the amended state plan for medical assistance.
(b) The office may determine not to continue to implement thischapter, IC 12-15-17, IC 12-15-18, IC 12-15-19, and IC 12-15-20 iffederal financial participation is not available.
(c) If federal financial participation is approved for less than allof the amounts paid into the Medicaid indigent care trust fund withrespect to a fiscal year, the office may reduce payments attributableto that fiscal year under IC 12-15-19-1 by a percentage sufficient tocompensate for the aggregate reduction in federal financialparticipation. If additional federal financial participation issubsequently approved with respect to payments into the Medicaidindigent care trust fund for the same fiscal year, the office shalldistribute such amounts using the percentage that was used tocompensate for the prior reduction in federal financial participation.
As added by P.L.2-1992, SEC.9. Amended by P.L.277-1993(ss),SEC.74; P.L.156-1995, SEC.3; P.L.126-1998, SEC.8; P.L.66-2002,SEC.7.
IC 12-15-16-6
Basic disproportionate payments to hospitals; amount
Sec. 6. (a) As used in this section, "low income utilization rate"refers to the low income utilization rate described in section 3 of thischapter.
(b) Hospitals that qualify for basic disproportionate share undersection 1(a) of this chapter shall receive disproportionate share
payments as follows:
(1) For the state fiscal year ending June 30, 1999, a pool notexceeding twenty-one million dollars ($21,000,000) shall bedistributed to all hospitals licensed under IC 16-21 that qualifyunder section 1(a)(1) of this chapter. The funds in the pool mustbe distributed to qualifying hospitals in proportion to eachhospital's Medicaid day utilization rate and Medicaiddischarges, as determined based on data from the most recentaudited cost report on file with the office. Any funds remainingin the pool referred to in this subdivision following distributionto all qualifying hospitals shall be transferred to the pooldistributed under subdivision (3).
(2) Hospitals licensed under IC 16-21 that qualify under bothsection 1(a)(1) and 1(a)(2) of this chapter shall receive adisproportionate share payment in accordance with subdivision(1).
(3) For the state fiscal year ending June 30, 1999, a pool notexceeding five million dollars ($5,000,000), subject toadjustment by the transfer of any funds remaining in the poolreferred to in subdivision (1), following distribution to allqualifying hospitals, shall be distributed to all hospitals licensedunder IC 16-21 that:
(A) qualify under section 1(a)(1) or 1(a)(2) of this chapter;and
(B) have at least twenty-five thousand (25,000) Medicaidinpatient days per year, based on data from each hospital'sMedicaid cost report for the fiscal year ended during statefiscal year 1996.
The funds in the pool must be distributed to qualifying hospitals inproportion to each hospital's Medicaid day utilization rate and totalMedicaid patient days, as determined based on data from the mostrecent audited cost report on file with the office. Payments under thissubdivision are in place of the payments made under subdivisions (1)and (2).
(c) Other institutions that qualify as disproportionate shareproviders under section 1 of this chapter, in each state fiscal year,shall receive disproportionate share payments as follows:
(1) For each of the state fiscal years ending after June 30, 1995,a pool not exceeding two million dollars ($2,000,000) shall bedistributed to all private psychiatric institutions licensed underIC 12-25 that qualify under section 1(a)(1) or 1(a)(2) of thischapter. The funds in the pool must be distributed to thequalifying institutions in proportion to each institution'sMedicaid day utilization rate as determined based on data fromthe most recent audited cost report on file with the office.
(2) A pool not exceeding one hundred ninety-one milliondollars ($191,000,000) for all state fiscal years ending afterJune 30, 1995, shall be distributed to all state mental healthinstitutions under IC 12-24-1-3 that qualify under either section1(a)(1) or 1(a)(2) of this chapter. The funds in the pool must be
distributed to each qualifying institution in proportion to eachinstitution's low income utilization rate, as determined based onthe most recent data on file with the office.
(d) Disproportionate share payments described in this sectionshall be made on an interim basis throughout the year, as provided bythe office.
As added by P.L.277-1993(ss), SEC.75. Amended by P.L.156-1995,SEC.4; P.L.24-1997, SEC.49; P.L.126-1998, SEC.9; P.L.113-2000,SEC.8.