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Hospital Financial Assistance Policy

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Hospital Financial Assistance Policy Powered By Docstoc
					        WORKSHEET TO DETERMINE ELIGIBILITY FOR RATE ADJUSTMENT PAYMENTS
      FOR HOSPITALS SERVING DISPROPORTIONATE SHARE OF LOW INCOME PATIENTS
           FOR THE RATE YEAR OCTOBER 1, 2010 THROUGH SEPTEMBER 30, 2011

                                             INSTRUCTIONS

 1. Do not alter the form in any way. Form headings and printing are preformatted at 80% of normal size,
    which should require 2 full pages.
 2. Submit the completed worksheet and backup to DMA by close of business August 2, 2010.
     Email the completed electronic Excel version of the worksheet to Mary Sanford at:
             Mary.Sanford@dhhs.nc.gov
     Mail a signed and dated hard copy of your completed worksheet and backup documentation to:
             Mary Sanford, Finance Management
             2501 Mail Service Center, Raleigh, North Carolina 27699-2501

    Overnight mailings should be directed to Mary Sanford at:
           DMA, Kirby Building, 1985 Umstead Drive, Raleigh, NC 27603
 3. Complete the non-shaded (white) fields only.
 4. Use the days, cost, and financial information from your hospital's 2009 fiscal year to complete the
    worksheet.
 5. All hospitals that received Medicaid inpatient payments for services during this period must complete
    Section 1, regardless of eligibility for rate adjustment.
 6. In order for a hospital to receive any type of DSH payment, each hospital is required to complete
    Sections 1 and 4. To be determined eligible to receive the 2.5% Rate Adjustment, each hospital is
    required to complete Sections 2 and 3 also (i.e., complete all sections).
 7. Include all Medicaid eligibles, including HMO, out-of-state and zero-paid Medicaid claims in your
    calculations. Exclude all SNF, NF, HHA, RHC and/or clinics not included in hospital financial reporting.

 8. Percentage calculations and some field population will occur automatically as data is entered. Field
    references and calculations are on the form itself, to the left of each input or calculation field.

 9. A definition of terms is included in this notebook for your reference. See tab labelled
    "2. Definition of Terms".
10. Use the comments space for notes and qualifying comments.
11. Submit a copy of the Worksheet S-3, Part I, from your hospital's 2009 Medicaid cost report.
12. Submit back-up documentation for all data reported. Examples of documentation include pages and/or
    sections from audited financial reports that support the revenues, charges, bad debts and charity care
    reported. DO NOT SEND HIPAA PROTECTED PATIENT INFORMATION LISTINGS.

13. If you need further assistance, contact Mary Sanford at Mary.Sanford@dhhs.nc.gov or (919) 855-4192.
Definition of Terms                     NOTE: ALL DEFINITIONS BELOW EXCLUDE SNF, NF, HHA AND
                                        CLINICS NOT ON HOSPITAL FINANCIALS.

1.1   Medicaid Inpatient Days           Includes all Medicaid eligible days (including paid and zero-paid
                                        acute, psychiatric and rehabilitation days; nursery, HMO, out of
                                        state, etc.)
1.2   Total Inpatient Days              Includes all acute, psychiatric and rehabilitation days
1.3   Medicaid Inpatient Utilization    Formula dividing Medicaid Inpatient Days (1.1 above) by Total
                                        Inpatient Days (1.2 above)
1.4   Minimum required Medicaid         At least one standard deviation above the mean Medicaid inpatient
      inpatient utilization             utilization rate for all hospitals that receive Medicaid payments in
                                        the state. This is why all hospitals receiving Medicaid are required
                                        to submit completed worksheets.
2.1   Medicaid Net Revenue              Gross Medicaid acute care, psychiatric and rehabilitation patient
                                        revenues less contractual adjustments, policy adjustments and
                                        charity care provided. Includes inpatient and outpatient.

2.2   Subsidies Received from State &   Dollars received from State and Local governmental sources for
      Local Government for Patient      inpatient and outpatient care services rendered to uninsured
      Care                              (excluding Medicaid & Medicare).
2.3   Total Low Income Net Charges      Formula summing Medicaid Net Revenue for Acute Care Services
                                        (2.1 above) and Subsidies Received from State & Local
                                        Government for Patient Care (2.2 above).
2.4   Total Net Charges                 Gross acute care, psychiatric and rehabilitation total hospital
                                        patient revenues less contractual adjustments, policy adjustments
                                        and charity care provided. Includes inpatient and outpatient
                                        (excluding SNF, NF, HHA and clinics not on hospital financials).

2.5  Low Income Payment Percentage Formula dividing Total Low Income Net Charges (2.3 above) by
                                    Total Net Charges (2.4 above)
2.6 Gross Inpatient Charges for     Gross acute care, psychiatric and rehabilitation inpatient charges
     Charity Care                   determined to be uncollectible and written off without further
                                    collection efforts, in accordance with the hospital's established
                                    charity care policy.
2.7 Subsidies Received from State & Dollars received from State and Local governmental agencies for
     Local Government for Inpatient inpatient care services rendered (excluding Medicaid & Medicare).
     Care
2.8 Total Inpatient Charity Care    Formula summing Gross Inpatient Charges for Charity Care (2.6
                                    above) and Subsidies Received from State & Local Government for
                                    Inpatient Care (2.7 above)
2.9 Total Hospital Gross Inpatient  Gross acute care, psychiatric and rehabilitation inpatient charges
     Charges                        for entire hospital (excluding SNF, NF, HHA and clinics not on
                                    hospital financials).
2.10 Charity Care Charge Percentage Formula dividing Total Inpatient Charity Care (2.8 above) by Total
                                    Hospital Gross Inpatient Charges (2.9 above)
2.11 Low Income Utilization Rate    Formula summing Charity Care Charge Percentage (2.10 above and
                                    Low Income Payment Percentage (2.5 above)




                                                  Page 2 of 5
Definition of Terms                  NOTE: ALL DEFINITIONS BELOW EXCLUDE SNF, NF, HHA AND
                                     CLINICS NOT ON HOSPITAL FINANCIALS.

3.1   Medicaid Gross Revenue         Gross Medicaid acute care, psychiatric and rehabilitation charges
                                     for inpatient and outpatient services (excluding SNF, NF, HHA and
                                     clinics not on hospital financials).
3.2   Bad Debt Allowance Net of      Gross acute care, psychiatric and rehabilitation charges, both
      Recoveries                     inpatient and outpatient, determined to be uncollectible in
                                     accordance with the hospital's established Bad Debt Allowance
                                     policy net of any recoveries.
3.3   Total Charity Care             Gross acute care, psychiatric and rehabilitation charges, both
                                     inpatient and outpatient, determined to be uncollectible and written
                                     off without further collection efforts, in accordance with the
                                     hospital's established charity care policy.
3.4   Total Indigent Care            Formula summing Medicaid Gross Revenue (3.1 above), Bad Debt
                                     Allowance Net of Recoveries (3.2 above) and Total Charity Care
                                     (3.3 above)
3.5   Total Hospital Gross Revenue   Gross acute care, psychiatric and rehabilitation inpatient and
                                     outpatient charges for entire hospital, excluding SNF, NF, HHA and
                                     clinics not on hospital financials.
3.6   Indigent Care Proportion       Formula dividing Total Indigent Care (3.4 above) by Total Hospital
                                     Gross Revenue (3.5 above)




                                               Page 3 of 5
                             WORKSHEET TO DETERMINE ELIGIBILITY FOR RATE ADJUSTMENT
                       FOR HOSPITALS SERVING DISPROPORTIONATE SHARE OF LOW INCOME PATIENTS
                                    OCTOBER 1, 2010, THROUGH SEPTEMBER 30, 2011


PROVIDER NUMBER (Medicaid 7 digits):
PROVIDER NAME:
DATA FROM HOSPITAL FISCAL YR ENDING:

IMPORTANT: Do not complete this form until you have read the instructions on tab 1. of this Excel notebook (see
tab below labelled "1. INSTRUCTIONS FOR COMPLETING"). Please contact Mary Sanford at (919) 855-4192 if you
have questions. PLEASE DO NOT ALTER THIS FORM.

EXCLUDE SNF, NF, HHA and clinics that are not included in hospital financials.



Section 1                  COMPUTATION OF MEDICAID INPATIENT UTILIZATION RATE
                           1.1  Medicaid Inpatient Days                      A
              Inpatient




                           1.2  Total Inpatient Days                         B
                           1.3    Medicaid Inpatient Utilization                            C=A/B                 0.0000%
                           1.4    Minimum Required                                           D           to be established



Section 2                  COMPUTATION OF LOW INCOME UTILIZATION RATE
                           2.1  Medicaid Net Revenue for Acute Care Services (include
                                beneficiary cost sharing)                                     E
 Inpatient &




                           2.2  Subsidies Received from State & Local
 Outpatient




                                Government for Patient Care                                   F
    Net




                           2.3  Total Low Income Net Charges                                G=E+F    $                   -
                           2.4  Total Hospital Net Charges                                    H
                           2.5  Low Income Payment Percentage                               I=G/H                 0.0000%
                           2.6  Gross Inpatient Charges for Charity Care (net of out-of-
                                pocket patient payments)                                      J
                           2.7  Subsidies Received from State & Local
        Inpatient
          Gross




                                Government for Inpatient Care                                 K
                           2.8  Total Inpatient Charity Care                                L=J-K    $                   -
                           2.9  Total Hospital Gross Inpatient Charges                        M
                           2.10 Charity Care Charge Percentage                              N=L/M                 0.0000%
                           2.11 Low Income Utilization Rate                                 O=I+N                 0.0000%
                           2.12 Must Exceed                                                   P                      25%



Section 3                  COMPUTATION OF INDIGENT CARE PROPORTION
                           3.1  Medicaid Gross Revenue for Acute Care Services
                                (include beneficiary cost sharing)                           Q
  Inpatient & Outpatient




                           3.2    Bad Debt Allowance for Acute Care Services Net of
                                  Recoveries                                                  R
          Gross




                           3.3    Total Charity Care Written Off                              S
                           3.4    Total Acute Care Indigent Care                           T=Q+R+S   $                   -
                           3.5    Total Hospital Gross Acute Care Revenue                     U
                           3.6    Indigent Care Proportion                                  V=T/U                 0.0000%
                           3.7    Must Exceed                                                W                       20%




 ac67a405-d91d-42f2-9c24-a0aa10cbdbb0.xls                               Page 4 of 5                        Version: 6/2009
            WORKSHEET TO DETERMINE ELIGIBILITY FOR RATE ADJUSTMENT
      FOR HOSPITALS SERVING DISPROPORTIONATE SHARE OF LOW INCOME PATIENTS
                   OCTOBER 1, 2010, THROUGH SEPTEMBER 30, 2011



Section 4   OBSTETRICAL CARE STATEMENT
            Enter "yes" in the space provided to the right of the applicable line below and sign the statement. If you enter "yes" in
            one of the first two boxes, enter the names of two obstetricians or other physicians who have agreed to provide
            obstetric services to individuals eligible for Medicaid in the space provided below (following your email address).


       4.1 I certify that the hospital indicated below has at least two (2) obstetricians who have
           staff privileges at the hospital and have agreed to provide obstetric services to individuals
           eligible for Medicaid.

                                                   OR
       4.2 I certify that the hospital indicated below is located in a rural area and has at least two
           (2) qualified physicians with staff privileges who have agreed to provide non-emergency
           obstetric services to individuals eligible for Medicaid.

                                                   OR
       4.3 I certify that the hospital indicated below did not offer non-emergency obstetric services
           to the general population as of December 21, 1987, or that the inpatients of the hospital
           are predominantly individuals under 18 years of age.




                                                        SIGNATURE OF CHIEF EXECUTIVE OFFICER

                                                                                                      -
                                                        HOSPITAL NAME

            NAME OF PREPARER                                                                               DATE
                                                                 (PRINT)


                                EMAIL ADDRESS                                                PHONE NUMBER


                               Physician Names*                                                             (1)

                                                                                                            (2)



                                       Comments




                     * If the answer to either statement 1 or 2 is yes, then enter the names of at least two (2) obstetricians or other
                     physicians that fulfill the requirement.



 ac67a405-d91d-42f2-9c24-a0aa10cbdbb0.xls                        Page 5 of 5                                          Version: 6/2009

				
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