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Delaware General AssemblyDelaware RegulationsMonthly Register of RegulationsFebruary 2014

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In compliance with the State's Administrative Procedures Act (APA - Title 29, Chapter 101 of the Delaware Code) with 42 CFR §447.205, and under the authority of Title 31 of the Delaware Code, Chapter 5, Section 512, Delaware Health and Social Services (DHSS) / Division of Medicaid and Medical Assistance (DMMA) is amending the Title XIX Medicaid State Plan regarding inpatient hospital services, specifically, Medicaid Inpatient Hospital Outlier Payments.
42 CFR §447.205, Public Notice of Changes in Statewide Methods and Standards for Setting Payment Rates
42 CFR §447, Subpart C - Payment for Inpatient Hospital and Long-Term Care Facility Services
NOTE: Previous notice to the public, published in the December 24, 2013 issue of the News Journal and the December 25, 2013 issue of the Delaware State News, originally posted the effective date as January 1, 2014. Please note that the effective date for the proposed change in reimbursement methodology is now March 1, 2014.
Outliers - Effective for dates of services on and after March 1, 2014, High high cost outliers will be identified when the cost of the discharge exceeds the threshold of four five (5) times the hospital operating rate per discharge. Outlier cases will be reimbursed at the discharge rate plus 70 sixty-five (65) percent of the difference between the outlier threshold and the total cost of the case. Costs of the case will be determined by applying the hospital-specific cost to charge ratio to the allowed charges reported on the claim for discharge.
Effective for dates of service on and after January 1, 2006, any provider with a high cost client case (outlier) will receive an interim payment; that is, a payment prior to the discharge of that patient when the charge amount reaches the designated level. An interim payment will be made for that inpatient stay when the client's charges have reached twenty-five (25) times the general discharge rate of that facility, or when the client's stay is greater than sixty (60) days. Additional interim payments will be made when either of the outlier conditions for an interim payment is met again. The interim payment amount is based on the current reimbursement methodology used to pay outliers. Upon the discharge of the client, the facility will receive the balance of the payment that would have been paid if the case were paid in full at the time of discharge.
Last Updated: December 31 1969 19:00:00.
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