June 18, 2009 Page 1
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1 Base Year Current LOC base rates calculated using: Wyoming Medicaid inpatient hospital claims data from July 1, 1994 through December 31, 1996 Most recently audited Medicare cost report with provider fiscal year end on or before August 31, 1994 through December 31, 1996 Rebased LOC base rates calculated using: Wyoming Medicaid inpatient hospital claims data paid in State Fiscal Years (SFYs) 2006 and 2007 Participating provider Medicare cost report data from provider fiscal years 2005 and 2006 Base Rates Hospital specific and statewide per discharge rates Per diem rates (rehabilitation levels of care) and per discharge rates (all other levels of care): Hospital specific Peer Groups Hospital specific and statewide Teaching hospitals Peer group aggregate (participating providers without hospital specific rates) Statewide aggregate (non participating providers) Critical Access Hospitals Hospitals with 90 staffed beds or less Hospitals with more than 90 staffed beds Hospitals that provide psychiatric services June 18, 2009 Page 1
2 Ceiling Rates The ceiling rate for hospital specific LOCs equals: 150% of the LOC median cost per discharge for participating children s hospitals 110% of the LOC median cost per discharge for all other participating providers The ceiling rate for statewide LOCs equals the statewide mean cost per discharge for each LOC. The per discharge ceiling rate for each LOC and peer group equals: 150% of the peer group median cost per discharge for NICU Level III discharges for all other levels of care (excludes rehab per diems) Participating Providers In state hospitals In state hospitals that submitted a claim in the base period Out of state hospitals with payments greater than or equal to $250,000 for claims paid from July 1, 1994 through December 31, Rehabilitation and psychiatric facilities that received payment for claims during the period from July 1, 1994 through December 31, Out of state hospitals with Medicaid payments (inflated to SFY 2009) greater than or equal to $400,000 for claims paid in SFYs 2006 and Rehabilitation and psychiatric facilities that are active Wyoming Medicaid providers and received Medicaid payments for claims during SFYs 2006 or June 18, 2009 Page 2
3 Capital Payment Rate (Participating Providers only) Direct Medical Education Payment Rates (Participating Providers only) $ per discharge (Statewide median capital cost per discharge) *Implemented using a three year phase in approach. Hospital specific per discharge rate [LOC base rate X (Medical education costs/operating costs)] $ per discharge (Statewide median capital cost per discharge*) $73.12 per diem (Statewide median capital cost per discharge divided by the average length of stay across all inpatient hospital claims*) Capital per diem payments are made for transfer claims and rehabilitation claims, and the total capital payment cannot exceed the capital per discharge rate of $ Capital payments are not made for one day stays. *Note: The calculation of the capital payment rate excludes one day stays. No medical education payment Medical education costs are considered nonallowable and were not included in the rate development or budget impact analysis. June 18, 2009 Page 3
4 Transfer Rate/One day stay Payment Rates Hospital specific and statewide LOC per diem rate [LOC base rate/geometric mean length of stay] *Note: Transfers for participating hospitals receive a capital payment when the transfer payment equals the LOC payment, but one day stays do not receive capital payments. Hospital specific per diem rates Peer group per diem rates (participating providers) Statewide LOC per diem rates (non participating providers) [LOC base rate/geometric mean length of stay] *Note: Transfer cases are paid a per diem rate not to exceed the LOC payment. Transfers for participating hospitals receive a capital per diem payment not to exceed the capital per discharge payment, but one day stays do not receive capital payments. Incentive Payments If a claim is paid through a level of care capped by the statewide ceiling using the hospital s mean cost per discharge and the hospital s mean cost per discharge is less than the statewide cost per discharge, the claim is eligible for an incentive payment. The incentive payment equals 25% of the difference between the statewide mean cost per discharge and the hospital specific mean cost per discharge for the LOC. Hospitals with an average cost per discharge that is below the ceiling receive an additional incentive payment to continue to hold down their costs. For all services except rehabilitation, the incentive payment equals 15% of the difference between 110% of the peer group median cost per discharge and the hospital specific average cost per discharge for the LOC. June 18, 2009 Page 4
5 Cost to Charge Ratios (Used to calculate allowable costs) Hospital specific and statewide for each LOC *Note: Hospital specific CCRs > 1.0 are capped at the statewide LOC CCR. Hospital specific CCRs Peer group CCRs (participating providers) Statewide LOC CCRs (non participating providers) *Note: Hospital specific CCRs > 1.0 are capped at the statewide LOC CCR. Outlier Policy Threshold: Children s Hospitals: Two times the level of care payment Threshold: Two times the level of care payment Payment: 75% of the difference between allowable costs and the outlier threshold. All Other Hospitals: Three times the level of care payment Payment: 75% of the difference between allowable costs and the outlier threshold. Specialty Services Transplants Contracted Per Discharge Rate Contracted Per Discharge Rate Extended Psychiatric (Discontinued) Contracted Per Diem Rate N/A (Combined with psychiatric LOC services) June 18, 2009 Page 5
6 LOC Rates Rehabilitation with and without ventilator (Updated LOC) Specialty Rehabilitation (LOC 15) pays a contracted per diem rate Rehabilitation LOC (LOC 25) pays the lower of: Hospital specific median cost per discharge 150% of the median cost per discharge for children s hospitals 110% of the median cost per discharge for all other participating providers Hospital average cost per diem for non ventilator services Add on of $143 per day when ventilator ICD 9 procedure code is present on the claim *Note: Includes specialty rehabilitation services and LOC rehabilitation services. Maternity/Surgical Hospital specific average cost per discharge Statewide average cost per discharge Maternity/Medical Hospital specific mean cost per discharge Statewide mean cost per discharge June 18, 2009 Page 6
7 NICU (New LOC) Level I & II NICU Hospitals Level III NICU Hospitals ICU/CCU/Burn N/A For participating children s hospitals, the lower of: 150% of the peer group median cost per discharge For all other providers, the lower of: Hospital specific median cost per discharge 150% of the median cost per discharge for children s hospitals 110% of the median cost per discharge for all other participating providers Surgery Hospital specific median cost per discharge 150% of the median cost per discharge for children s hospitals 110% of the median cost per discharge for all other participating providers June 18, 2009 Page 7
8 Psychiatric (Updated LOC) Newborn Nursery (Updated LOC) Hospital specific median cost per discharge 150% of the median cost per discharge for children s hospitals 110% of the median cost per discharge for all other participating providers Rates for the Normal Newborn and Newborn Readmissions LOCs based on the lower of: Hospital specific mean cost per discharge Statewide mean cost per discharge *Note: Includes extended psychiatric services and LOC psychiatric services. Routine Hospital specific mean cost per discharge Statewide mean cost per discharge June 18, 2009 Page 8
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