February 3, 2023

Top Questions from the Disproportionate Share and Medicaid Eligibility Reviews (DSH) 101 Webinar

Looking for more information about the Disproportionate Share and Medicaid Eligibility Reviews? BESLER’s Director of Reimbursement Christina Brown answers your questions from the recent webinar.

To watch Christina’s Disproportionate Share and Medicaid Eligibility Reviews (DSH) 101 Webinar, click HERE.

What is the definition of the State Eligibility Code?

You would enter the State Program number.
Are patients that qualify for SSI and have Medicare Part A commercial plans included in the 15% DSH calculation?

The SSI percent that is calculated includes Medicare Part A eligible patients, so technically, it is part of the 15% calculation.
What is a patient population code – the hospital ID #?

Per the T18 Instructions: Enter a unique patient population code to identify a restricted or unrestricted Medicaid eligible day. For restricted eligibility, use code R1 for pregnancy/labor and delivery services; use code R2 for emergency services; or use a code R3 through R9 for user-defined restricted Medicaid eligibility and provide the definition for the code in column 18. For unrestricted Medicaid eligibility, use code U1 for general or use a code U2 through U9 for user-defined unrestricted Medicaid eligibility and provide the definition for the code in column 18.
Where do you find the codes that you referred to for patient population code?

In the Transmittal 18 instructions (Page 60) Here.
If a critical hospital is ineligible to receive DSH, is there a reason why they would still have to go through a DSH audit?

Critical Access Hospitals are not eligible for DSH so there would be nothing to audit for DSH. You may be thinking of 340B qualifications.
How much of your payor mix has to be of Medicaid to be eligible for DSH?
When combined with the SSI percentage, the two must be greater than 15%.
Is there any way to know which patients are receiving SSI? We would like to be able to project SSI days without relying on CMS for that figure.

CMS does not share the exact calculations of the SSI percent. This is something that has been an appeal issue in the past.
Where do the SSI days get identified?

CMS calculates the specific SSI percent that can be obtained from the MAC. This will go on line 30 of E Part A.
Regarding Transmittal 18, does every single patient need to be listed that was seen for the year?

You start with the total patient population, but the only population that gets reported on Exhibit 3A are the patients with Medicaid Eligible Days.
Is any of the information auto populated?

Not on the exhibit. Some of the forms in the cost report are auto populated based on entries in other areas of the cost report, but the exhibit with the detail is not.
SSI patients can be identified by their age since they would otherwise not have Medicare.

The exact factors and calculations for SSI has long been an appeal area, as the information used is not readily available and has been mostly concealed.
No mention of 1115 days that are now deemed eligible in states like TX, TN, KS or TN?

Yes, there is. As per the instructions for In State and Out of State Eligible days: “A Medicaid eligible unpaid day is an in-state/out-of-state day of inpatient care furnished to a patient eligible for inpatient benefits under an approved State Medicaid plan or eligible for inpatient benefits, or regarded as such, under a waiver authorized under section 1115(a)(2) of the Act on that day and for which the hospital has not received payment from Medicaid.”
There’s no way to estimate that officially since we don’t know who is getting SSI coverages. CMS hides the overall source of the information.
This is true.
Would you please clarify the “Days prior to eligibility approval” for under paid days statement on Page 18 of the slide package?

In the Transmittal 18 for S-2 Line 24 Columns 2 & 4, eligible days for Medicaid which a provider has not received payment are stated as: Reasons for non-payment could be related to the provider not billing timely, days that are beyond the number of days for which a State will pay, days that are utilized by a Medicaid beneficiary prior to an admission approval but for which a valid enrollment is determined within the prescribed period, and days for which payment is made by a third party.
Can a link be sent for the Transmittal 18 exhibits that we are going over now?

R18P240i | CMS
Does CMS now include the Alina decision in their calculation?

CMS has not shared the exact calculation.
Can you please explain Labor & Delivery days?

The amount reported on S-3, Part I, Column 7, Line 32. For Exhibit 3A column 11, per the instructions: L&D days are defined as days during which a maternity patient is in the labor/delivery room ancillary area at midnight at the time of census taking; the maternity patient is not included in the census count of the inpatient routine care area because the patient has not occupied an inpatient routine bed at some time before admission (see CMS Pub. 15-1, chapter 22, §2205.2). The days reported in this column must equal the number of days reported on Worksheet S-2, Part I, line 24, column 6.