42 C.F.R. 42 CFR--PART 412
Title 42 - Public Health
Effective Date(s): October 1, 2006 28. Section 412.525 is amended by— a. Revising paragraph (a)(3). b. Revising paragraph (a)(4)(ii). c. Revising paragraph (a)(4)(iii). d. Adding a new paragraph (a)(4)(iv). e. Adding a new paragraph (d)(3). f. Adding a new paragraph (d)(4). The revisions and additions read as follows: (a) * * * (3) The additional payment equals 80 percent of the difference between the estimated cost of the patient's care (determined by multiplying the hospital-specific cost-to-charge ratio by the Medicare allowable covered charge) and the sum of the adjusted LTCH PPS Federal prospective payment and the fixed-loss amount. (4) * * * (ii) For discharges occurring on or after August 8, 2003, and before October 1, 2006, high-cost outlier payments are subject to the provisions of §412.84(i)(1), (i)(3), and (i)(4) and (m) for adjustments of cost-to-charge ratios. (iii) For discharges occurring on or after October 1, 2003, and before October 1, 2006, high-cost outlier payments are subject to the provisions of §412.84(i)(2) for adjustments to cost-to-charge ratios. (iv) For discharges occurring on or after October 1, 2006, high-cost outlier payments are subject to the following provisions: (A) CMS may specify an alternative to the cost-to-charge ratio otherwise applicable under paragraph (a)(4)(iv)(B) of this section. A hospital may also request that its fiscal intermediary use a different (higher or lower) cost-to-charge ratio based on substantial evidence presented by the hospital. A request must be approved by the CMS Regional Office. (B) The cost-to-charge ratio applied at the time a claim is processed is based on either the most recent settled cost report or the most recent tentatively settled cost report, whichever is from the latest cost reporting period. (C) The fiscal intermediary may use a statewide average cost-to-charge ratio, which CMS establishes annually, if it is unable to determine an accurate cost-to-charge ratio for a hospital in one of the following circumstances: (1) A new hospital that has not yet submitted its first Medicare cost report. (For this purpose, a new hospital is defined as an entity that has not accepted assignment of an existing hospital's provider agreement in accordance with §489.18 of this chapter.) (2) A hospital whose cost-to-charge ratio is in excess of 3 standard deviations above the corresponding national geometric mean cost-to-charge ratio. CMS establishes and publishes this mean annually. (3) Any other hospital for which data to calculate a cost-to-charge ratio are not available. (D) Any reconciliation of outlier payments is based on the cost-to-charge ratio calculated based on a ratio of costs to charges computed from the relevant cost report and charge data determined at the time the cost report coinciding with the discharge is settled. (E) At the time of any reconciliation under paragraph (a)(4)(iv)(D) of this section, outlier payments may be adjusted to account for the time value of any underpayments or overpayments. Any adjustment is based upon a widely available index to be established in advance by the Secretary, and is applied from the midpoint of the cost reporting period to the date of reconciliation. * * * * * (d) * * * (3) Patients who are transferred to onsite providers and readmitted to a long-term care hospital, as provided for in §412.532. (4) Long-term care hospitals-within-hospitals and satellites of long-term care hospitals as provided in §412.534.
Amendment from August 18, 2006
42 CFR--PART 412
Amendment(s) published August 18, 2006, in 71 FR 48140
§ 412.525 Adjustments to the Federal prospective payment.
