CHAPTER 33

REIMBURSEMENT OF OUTPATIENT HOSPITAL SERVICES

 

Section 1.                Authority. This Chapter is promulgated by the Wyoming Department of Health pursuant to the Wyoming Medical Assistance and Services Act at Wyoming Statutes 42-4-101 through -121.

Section 2.                Purpose and Applicability.

(a)              This Chapter has been adopted to establish the scope of Medicaid reimbursement of outpatient hospital services furnished to individuals admitted on or after its effective date.

 

(b)              The requirements of XVIII and XIX of the Social Security Act, 42 C.F.R. Ch. IV, Subch. B, Pt. 413 and 419, 42 C.F.R. Ch. IV, Subch. C, Pt. 447, and the Medicaid State Plan also apply to Medicaid and are incorporated by this reference.

 

Section 3.                Definitions. Except as otherwise specified in Chapter 1, or as defined herein, the terminology used in this rule is the standard terminology and has the standard meaning used in health care, Medicaid and Medicare.

 

(a)              "Chapter" used herein refers to the specified Chapter in the Wyoming Department of Health, Medicaid Rules.

 

Section 4.                Provider Participation. 

 

(a)              Payments only to providers. No provider that furnishes outpatient hospital services to a client shall receive Medicaid funds unless the provider is enrolled.

 

(b)              Compliance with Chapter 3. A provider that wishes to receive Medicaid reimbursement for outpatient hospital services furnished to a client shall meet the requirements of Chapter 3.

 

Section 5.                Medicaid Allowable Payment for Outpatient Hospital Services.

(a)       Generally.    Payment to facilities for outpatient hospital services shall be provided pursuant to 42 C.F.R. § 413.65.  State-developed fee schedule rates for services described in this section shall be the same for public and private providers.  The fee schedule and any periodic adjustments to the fee schedule shall be published at the Department's fiscal agent's website.  Medicaid allowable payments for outpatient hospital services shall be made according to one of the following fee schedules depending on the type of service:

(i)                   Medicaid Ambulatory Payment Classification (APC) fee schedule.  The APC fee schedule shall be based on services that are included and excluded in Medicare's outpatient prospective payment system pursuant to 42 C.F.R. §§ 419.21 and  419.22.

 

(A)            Services included under the APC fee schedule:

 

(I)                Significant outpatient procedures, e.g., a procedure or surgery provided to a patient that constitutes the primary reason for the visit to the hospital;

 

(II)              Ancillary Services;

 

(III)           Emergency Services;

 

(IV)           Observation;

 

(V)             Drugs;

 

(VI)           Laboratory services not included in Medicare's clinical laboratory fee schedule;

 

(VII)        Durable medical equipment, prosthetics and orthotics;

 

(VIII)     Radiology; and

 

(IX)           Vaccines and immunizations.

 

(B)             Ambulatory Payment Classification relative weights.  The Department shall use Medicare's APC relative weights.

 

(C)             Wyoming-specific Medicaid conversion factors.  The Department shall use a Wyoming-specific Medicaid conversion factor for each of the following three (3) hospital groups:  children's hospitals, critical access hospitals, and general acute care hospitals as follows:

 

(I)                For each group of hospitals, the Wyoming-specific Medicaid conversion factor shall be the result after dividing the estimated costs of APC-based services by the sum of the relative weights for the hospital group.

 

(1.)             For each hospital, the calculated estimated cost-to-charge ratios shall be determined by dividing state fiscal year (SFY) 2005 estimated Medicaid costs by SFY 2005 Medicaid billed charges (paid claims).

 

(2.)             The Department shall calculate estimated SFY 2005 Medicaid costs by multiplying SFY 2005 billed charges by hospital-specific outpatient hospital cost-to-charge ratios calculated from provider fiscal year end 2004 as-filed cost reports.

 

(II)              For each group of hospitals, the Department shall calculate the conversion factor percentage of Medicare's final calendar year (CY) 2006 conversion factor as published in the Federal Register Vol. 70, No. 217 (November 10, 2005).  The Department divided the Wyoming-specific Medicaid conversion factor by Medicare's final CY 2006 conversion factor as follows:

 

(1.)             The Wyoming-specific Medicaid conversion factor for children's hospitals shall be one hundred seventy-one percent (171%) of Medicare's final CY 2006 conversion factor.

 

(2.)             The Wyoming-specific Medicaid conversion factor for critical access hospitals shall be one hundred ninety-six percent (196%) of Medicare's final CY 2006 conversion factor.

 

(3.)             The Wyoming-specific Medicaid conversion factor for general acute care hospitals shall be seventy-five percent (75%) of Medicare's final CY 2006 conversion factor.

 

(D)            Fee schedule payment calculation.  The fee schedule shall be established by multiplying the Wyoming-specific Medicaid conversion factor by the Medicare APC relative weight.

 

(E)             Discounting.  Payment amounts for certain multiple, bilateral or discontinued procedures, reimbursed using the Medicaid APC fee schedule, shall be discounted. The Department shall use the discount formulas that are included in Medicare's Integrated Outpatient Code Editor (I/OCE) with the exception of discount formula 8 (used for bilateral procedures).  For discount formula 8, the Department shall use one hundred fifty percent (150%) rather than Medicare's two hundred percent (200%).  Medicare outlines its discount formulas in the I/OCE Quarterly Transmittal, Appendix D, which is incorporated herein.

 

(F)              Medicaid physician fee schedule.  The Medicaid allowable payment shall be based on the reported procedure code and shall be the lesser of charges or the fee schedule amount.  The following outpatient hospital services shall be reimbursed using the physician fee schedule:

 

(I)                Physical, occupational, and speech therapy;

 

(II)              Radiology, including mammography screening and diagnostic mammography; and

 

(III)           Vaccines and immunization.

 

(G)            Medicaid durable medical equipment, prosthetics and orthotics fee schedule.  For those durable medical equipment, prosthetics and orthotics not included in the APC fee schedule, the Medicaid allowable payment shall be based on the reported procedure code and shall be the lesser of billed charges or the fee schedule amount. 

 

(H)            The Medicaid laboratory fee schedule.  For those laboratory services not included in the APC fee schedule, the Medicaid allowable payment shall be based on the reported procedure code and shall be the lesser of billed charges or the fee schedule amount.  The laboratory fee schedule is described in detail in State Plan Attachment 4.19 B, Policy and Methods of Establishing Payment Rate for Each Type of Care Provided, (3) Other Laboratory and X-ray Services.

 

(I)               Percent of charges.  The following services shall be reimbursed based on a percent of allowed charges.   These services include the following:

 

(I)                Transplants shall be reimbursed at fifty-five percent (55%) of billed charges, not to exceed the upper payment limits described in Section 1903(i) of the Social Security Act;

 

(II)              Corneal tissue shall be reimbursed using the hospital-specific Medicaid cost-to-charge ratio calculated annually for inpatient level of care participating providers and may not exceed one hundred percent (100%).  Non-participating hospitals shall be reimbursed using the average Medicaid cost-to-charge ratio for their provider type (children's hospital, critical access hospital and general acute care hospital);

 

(III)           Medical devices that are paid transitional pass-through payments under Medicare's outpatient prospective payment system pursuant to Social Security Act § 1833(t)(6) shall be reimbursed using the hospital-specific Medicaid cost-to-charge ratios used in Section 5(a)(i)(C)(I) of this Chapter;

 

(IV)           Dental shall be reimbursed using the hospital-specific Medicaid cost-to-charge ratios used in Section 5(a)(i)(C)(I) of this Chapter.

 

(ii)       Qualified Rate Adjustment payments.  The Department shall annually reimburse non-State government owned and operated hospitals that qualify for Qualified Rate Adjustment payments pursuant to State Plan Attachment 4.19B, Part 1, Addendum 1, by the end of the first quarter of each federal fiscal year.

 

(iii)     Private Hospital Supplemental payments.  The Department shall quarterly reimburse privately owned and operated hospitals that are providing services as of July 1 of each year and that qualify for a private hospital supplemental payment pursuant to State Plan Attachment 4.19B, Part 1, Addendum 2, by the end of each quarter.  For each year, the first private hospital supplemental payment shall be made by December 31.

 

(b)              Upper payment limits.  The Medicaid payments shall not exceed Medicare upper payment limits according to 42 C.F.R. § 447.321.  Reimbursement for laboratory services shall comply with federal upper limits for laboratory services pursuant to Section 1903(i) of the Social Security Act.

 

(c)              Medicaid reimbursement shall not be available for services that are not medically necessary.

 

(d)              Services that require prior authorization.  The Department may designate outpatient hospital services that require prior authorization.  In designating such services, the Department shall consider the cost of the service, the potential for over-utilization of the service, and the availability of lower cost alternatives.  The Department shall disseminate a current list of services that require prior authorization to providers through manuals and bulletins.  The failure to obtain prior authorization shall result in denial of Medicaid payment for the service.

 

(e)              Claims for outpatient and inpatient hospital services.  A claim seeking reimbursement for outpatient hospital services provided to a client within twenty-four (24) hours before the client received inpatient hospital services for the same or similar diagnosis shall be denied.

 

(f)               Updates.  The APC conversion factors and relative weights shall be reviewed annually.  Considerations for update include adequate provider participation, beneficiary access, and the reduction of inequities in the system.

 

Section 6.                Third Party Liability.  Third Party Liability is subject to the requirements of Chapter 35.

 

Section 7.                Payment of Claims.  Payment of claims shall be pursuant to Chapter 3.

Section 8.                Audits.   Audits shall be subject to the provisions of Chapter 16.

Section 9.                Recovery of Overpayments.   The Department shall recover overpayments pursuant to Chapter 16.

Section 10.           Reconsideration. A provider may request reconsideration of the decision to recover overpayments pursuant to Chapter 16.

Section 11.           Interpretation of Chapter.

 

(a)              The order in which the provisions of this Chapter appear is not to be construed to mean that any one provision is more or less important than any other provision.

 

(b)              The text of this Chapter shall control the titles of its various provisions.

Section 12.           Superseding Effect.  This Chapter supersedes all prior rules or policy statements issued by the Department, including manuals and bulletins, which are inconsistent with this Chapter.

Section 13.           Severability.   If any portion of these rules is found invalid or unenforceable, the remainder shall continue in effect.

 

Section 14.           Incorporation by Reference.

(a)              For any code, standard, rule, or regulation incorporated by reference in these rules:

(i)                The Department has determined that incorporation of the full text in these rules would be cumbersome or inefficient given the length or nature of the rules;

 

(ii)              The incorporation by reference does not include any later amendments or editions of the incorporated matter beyond the applicable date identified in subsection (b) of this section; and

 

(iii)           The incorporated code, standard, rule, or regulation is maintained at the Department and is available for public inspection and copying at cost at the same location.

 

(b)              Each rule or regulation incorporated by reference in these rules is further identified as follows:

 

(i)                Referenced in Section 5 of this Chapter is Title XIX of the Social Security Act, 42 CFR, Ch. IV, Subch. B, Part 413, Subpart E, incorporated as of the effective date of this Chapter and can be found at https://www.ecfr.gov.

 

(ii)              Referenced in Section 5 of this Chapter is Title XIX of the Social Security Act, 42 CFR, Chapter IV, Subch. B, Part 419, incorporated as of the effective date of this Chapter and can be found at https://www.ecfr.gov.

 

(iii)           Referenced in Section 5 of this Chapter is the Federal Register, Volume 70, No. 217, November 10, 2005, incorporated as of the effective date of this Chapter and can be found at https://www.gpo.gov/fdsys/pkg/FR-2005-11-10/content-detail.html.

 

(iv)            Referenced in Section 5 of this Chapter is the I/OCE Quarterly Transmittal, Appendix D, incorporated as of the effective date of this Chapter and can be found at https://www.cms.gov/Medicare/Coding/OutpatientCodeEdit/OCEQtrReleaseSpecs.html.

 

(v)              Referenced in Section 5 of this Chapter is the Wyoming Medicaid State Plan Attachment 4.19 B, incorporated as of the effective date of this Chapter and can be found at https://health.wyo.gov/healthcarefin/medicaid/spa/.

 

(vi)            Referenced in Section 5 of this Chapter is Section 1903(i) of the Social Security Act, incorporated as of the effective date of this Chapter and can be found at https://www.ssa.gov/OP_Home/ssact/title19/1903.htm.

 

(vii)         Referenced in Section 5 of this Chapter is Section 1833(t)(6) of the Social Security Act, incorporated as of the effective date of this Chapter and can be found at https://www.ssa.gov/OP_Home/ssact/title18/1833.htm.

 

(viii)       Referenced in Section 5 of this Chapter is Title XIX of the Social Security Act, 42 CFR, Chapter IV, Subch. C, Part 447, Subpart F, incorporated as of the effective date of this Chapter and can be found at https://www.ecfr.gov.