§1189.4. Medical assistance programs; rural hospital reimbursement
A. The department shall adopt rules and regulations in accordance with the
Administrative Procedure Act that provide the following:
(1)Allow a rural hospital to certify as a contributing public agency, public funds as
representing expenditures eligible for federal financial participation in the Medicaid program
to the extent authorized by federal law. The expenditure of such funds shall be in accordance
with rules promulgated by the department.
(2)(a) Maximize funding for services rendered by rural hospitals to the extent
allowed by federal law and in amounts that may be appropriated by the legislature relative
to the use of Medicaid disproportionate share reimbursement and Medicaid reimbursement.
To the extent that inter
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§1189.4. Medical assistance programs; rural hospital reimbursement
A. The department shall adopt rules and regulations in accordance with the
Administrative Procedure Act that provide the following:
(1) Allow a rural hospital to certify as a contributing public agency, public funds as
representing expenditures eligible for federal financial participation in the Medicaid program
to the extent authorized by federal law. The expenditure of such funds shall be in accordance
with rules promulgated by the department.
(2)(a) Maximize funding for services rendered by rural hospitals to the extent
allowed by federal law and in amounts that may be appropriated by the legislature relative
to the use of Medicaid disproportionate share reimbursement and Medicaid reimbursement.
To the extent that intergovernmental transfers and the certification of eligible expenditures
are available for recognition of state match for such Medicaid disproportionate share
payments and Medicaid reimbursement, the department shall maximize the use of such
amounts for the benefit of rural hospitals to increase access to health care for Medicaid and
LaCHIP beneficiaries as well as indigent individuals.
(b) Notwithstanding any law to the contrary, by September 1, 2007, the department
shall file a state plan amendment with CMS amending the Medicaid state plan provisions
governing Medicaid hospital reimbursement to provide that a rural hospital, as defined in
R.S. 40:1189.3, shall be reimbursed at a rate which equals or approximates one hundred ten
percent, or, if a reduction is required by CMS, the maximum amount acceptable to CMS, but
in no event less than one hundred percent, of the appropriate reasonable cost of providing
hospital inpatient and outpatient services, including but not limited to services provided in
a rural health clinic licensed as part of a rural hospital. The new rural hospital payment
methodology shall utilize prospective rates approximating costs at the time of service for
inpatient acute and psychiatric services. To ensure that rural hospital outpatient services,
including those currently reimbursed on a cost basis and those currently reimbursed on a fee
schedule are reimbursed in the aggregate at one hundred ten percent of the reasonable costs
or such lesser amounts as approved by CMS, but in no event less than one hundred percent
of their reasonable costs, the department shall pay an interim rate for cost-based outpatient
services at one hundred ten percent of reasonable cost during the year and for fee-based
services paid on a claim-by-claim basis, and the department shall make quarterly estimates
of a supplemental payment required to bring the hospital's reimbursement for such services
up to one hundred percent of reasonable costs and immediately remit such payments to the
hospital and at final settlement pay such amounts as necessary to ensure that all outpatient
services in the aggregate (cost based and fee schedule) are paid at one hundred ten percent
of reasonable costs.
(c) On an expedited basis, the department shall take all steps necessary and available
to obtain CMS approval for the state plan amendment and shall, immediately upon
notification of such approval, promulgate an emergency rule to implement the state plan
amendment.
(d) Once the outpatient cost-based reimbursement payment methodology is
implemented, the department shall set and monitor interim payment rates to minimize the
amount of annual cost settlements.
(e) For cost reporting periods ending after July 1, 2008, the department shall pay
seventy-five percent of interim rural hospital outpatient cost report settlement amounts due
and one hundred percent of final rural hospital outpatient cost report settlement amounts due
within fourteen days of receipt by the department of such reports from the Medicaid audit
contractor.
(f) The new rural hospital payment methodology shall be effective for services
provided on or after July 1, 2008, or as soon thereafter as may be permitted by federal law.
(3)(a) With respect to reimbursement for services furnished in another state, the
department shall insure that reimbursement for such services shall be the lesser of the
payment for such services by the state wherein such hospital is located or the department's
payment made to like in-state providers. The department shall provide coverage for such
services to the same extent that it would pay for services furnished within the boundaries of
this state, only if any of the following conditions is met:
(i) Medical services are needed because of a medical emergency.
(ii) Medical services are needed and the recipient's health would be endangered if
he were required to travel to his state or residence.
(iii) The state determines, on the basis of medical advice, that the needed medical
services are necessary supplementary resources, and more readily available in the other state.
(iv) It is general practice for recipients in a particular locality to use medical
resources in another state.
(b) In the event federal requirements for the state plan for medical assistance permit
the department to impose further restrictions on payment for and coverage of medical
services to Louisiana Medicaid patients rendered by out-of-state providers, the department
shall promulgate regulations restricting payment for and coverage of such services to the
fullest extent permitted by law. Such restrictions shall include lowering the rate of
reimbursement provided for services rendered to out-of-state hospitals to the payment for
such services by the state wherein such hospital is located, the department's payment made
to like in-state providers, or the average rate paid to Louisiana rural hospitals located in the
state, whichever is the least.
(c) The secretary of the department may negotiate a higher rate of reimbursement to
an out-of-state hospital in the event that a Louisiana Medicaid recipient requires services that
cannot be provided by any Louisiana hospital or provider and when these services can only
be provided by an out-of-state provider.
(4)(a) Effective for services provided on or after July 1, 2010, or as soon thereafter
as may be permitted by federal law, the department shall develop and implement, by
emergency rule, a payment methodology which optimizes Medicaid inpatient and outpatient
payments to rural hospitals. Payments shall be developed utilizing available Medicare upper
payment limits for inpatient and outpatient services in accordance with state and federal law.
Calculated payments shall be distributed to qualifying rural hospitals no less than quarterly,
or as authorized by federal law.
(b) After federal funds are optimized, the remaining appropriated funds for rural
hospitals may be utilized to develop a state-only funded program to provide direct funds to
qualifying rural hospitals to support access to services that would not be available otherwise.
In the event the amount appropriated for such state-only funded program is insufficient in any
state fiscal year to meet the total payments required by all rural hospitals to recover payment
reductions, the payments to qualifying rural hospitals under this state-only funded program
may be reduced proportionately.
(c) The department shall review Medicaid and uninsured cost information, payment
information, patient charges, and hospital financial statements to the extent required by state
or federal law to determine the optimal combination of payments.
(d) Rural hospitals that do not provide the minimum set of documentation required
in Subparagraph (4)(c) of this Section to determine the optimal combination of payments
shall not be eligible for additional payments.
(e) The department is hereby authorized to publish and promulgate rules, in
accordance with the Administrative Procedure Act, to implement the provisions of this
Paragraph.
B. The rules and regulations promulgated pursuant to Subsection A of this Section
shall be promulgated no later than one hundred twenty days after August 15, 1997. No later
than one hundred twenty days after August 15, 1997, the department shall also submit to the
secretary of the United States Department of Health and Human Services those amendments
to the state plan for medical assistance necessary to conform the state plan for medical
assistance with the provisions of Subsection A of this Section.