2014 Indiana Code TITLE 12. HUMAN SERVICES ARTICLE 15. MEDICAID CHAPTER 15. PAYMENT TO HOSPITALS; GENERAL
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IC 12-15-15
Chapter 15. Payment to Hospitals; General
IC 12-15-15-1
Services at hospitals licensed under IC 16-21; rates established
under rules
Sec. 1. Payment of a service provided in a hospital licensed under
IC 16-21 shall be determined in accordance with a payment rate for
the service that is established under rules adopted under IC 4-22-2 by
the secretary in conjunction with the office.
As added by P.L.2-1992, SEC.9. Amended by P.L.27-1992, SEC.11;
P.L.2-1993, SEC.93.
IC 12-15-15-1.1
Reimbursement to hospitals for inpatient hospital services;
intergovernmental transfers; calculating Medicaid shortfall
Sec. 1.1. (a) This section applies to a hospital that is:
(1) licensed under IC 16-21; and
(2) established and operated under IC 16-22-2, IC 16-22-8, or
IC 16-23.
This section does not apply during the period that the office is
assessing a hospital fee authorized by IC 16-21-10.
(b) For a state fiscal year ending after June 30, 2003, in addition
to reimbursement received under section 1 of this chapter, a hospital
is entitled to reimbursement in an amount calculated as follows:
STEP ONE: The office shall identify the aggregate inpatient
hospital services, reimbursable under this article and under the
state Medicaid plan, that were provided during the state fiscal
year by hospitals established and operated under IC 16-22-2,
IC 16-22-8, or IC 16-23.
STEP TWO: For the aggregate inpatient hospital services
identified under STEP ONE, the office shall calculate the
aggregate payments made under this article and under the state
Medicaid plan to hospitals established and operated under
IC 16-22-2, IC 16-22-8, or IC 16-23, excluding payments under
IC 12-15-16, IC 12-15-17, and IC 12-15-19.
STEP THREE: The office shall calculate a reasonable estimate
of the amount that would have been paid in the aggregate by the
office for the inpatient hospital services described in STEP ONE
under Medicare payment principles.
STEP FOUR: Subtract the amount calculated under STEP TWO
from the amount calculated under STEP THREE.
STEP FIVE: Subject to subsection (g), from the amount
calculated under STEP FOUR, allocate to a hospital established
and operated under IC 16-22-8 an amount not to exceed one
hundred percent (100%) of the difference between:
(A) the total cost for the hospital's provision of inpatient
services covered under this article for the hospital's fiscal
year ending during the state fiscal year; and
(B) the total payment to the hospital for its provision of
inpatient services covered under this article for the hospital's
fiscal year ending during the state fiscal year, excluding
payments under IC 12-15-16, IC 12-15-17, and IC 12-15-19.
STEP SIX: Subtract the amount calculated under STEP FIVE
from the amount calculated under STEP FOUR.
STEP SEVEN: Distribute an amount equal to the amount
calculated under STEP SIX to the eligible hospitals established
and operated under IC 16-22-2 or IC 16-23 described in
subsection (c) in an amount not to exceed each hospital's
Medicaid shortfall as defined in subsection (f).
(c) Subject to subsection (e), reimbursement for a state fiscal year
under this section consists of payments made after the close of each
state fiscal year. A hospital is not eligible for a payment described in
this subsection unless an intergovernmental transfer or certification
of expenditures is made under subsection (d).
(d) Subject to subsection (e):
(1) an intergovernmental transfer may be made by or on behalf
of the hospital; or
(2) a certification of expenditures as eligible for federal financial
participation may be made;
after the close of each state fiscal year. An intergovernmental transfer
under this subsection must be made to the Medicaid indigent care
trust fund in an amount equal to a percentage, as determined by the
office, of the amount to be distributed to the hospital under this
section. The office shall use the intergovernmental transfer to fund
payments made under this section.
(e) A hospital that makes a certification of expenditures or makes
or has an intergovernmental transfer made on the hospital's behalf
under this section may appeal under IC 4-21.5 the amount determined
by the office to be paid the hospital under subsection (b). The periods
described in subsections (c) and (d) for the hospital or another entity
to make an intergovernmental transfer or certification of expenditures
are tolled pending the administrative appeal and any judicial review
initiated by the hospital under IC 4-21.5. The distribution to other
hospitals under subsection (b) may not be delayed due to an
administrative appeal or judicial review instituted by a hospital under
this subsection. If necessary, the office may make a partial
distribution to the other eligible hospitals under subsection (b)
pending the completion of a hospital's administrative appeal or
judicial review, at which time the remaining portion of the payments
due to the eligible hospitals shall be made. A partial distribution may
be based upon estimates and trends calculated by the office.
(f) For purposes of this section:
(1) the Medicaid shortfall of a hospital established and operated
under IC 16-22-2 or IC 16-23 is calculated as follows:
STEP ONE: The office shall identify the inpatient hospital
services, reimbursable under this article and under the state
Medicaid plan, that were provided during the state fiscal year
by the hospital.
STEP TWO: For the inpatient hospital services identified
under STEP ONE, the office shall calculate the payments
made under this article and under the state Medicaid plan to
the hospital, excluding payments under IC 12-15-16,
IC 12-15-17, and IC 12-15-19.
STEP THREE: The office shall calculate a reasonable
estimate of the amount that would have been paid by the
office for the inpatient hospital services described in STEP
ONE under Medicare payment principles; and
(2) a hospital's Medicaid shortfall is equal to the amount by
which the amount calculated in STEP THREE of subdivision
(1) is greater than the amount calculated in STEP TWO of
subdivision (1).
(g) The actual distribution of the amount calculated under STEP
FIVE of subsection (b) to a hospital established and operated under
IC 16-22-8 shall be made under the terms and conditions provided for
the hospital in the state plan for medical assistance. Payment to a
hospital under STEP FIVE of subsection (b) is not a condition
precedent to the tender of payments to hospitals under STEP SEVEN
of subsection (b).
As added by P.L.126-1998, SEC.4. Amended by P.L.113-2000,
SEC.2; P.L.283-2001, SEC.19; P.L.66-2002, SEC.5; P.L.120-2002,
SEC.13; P.L.1-2003, SEC.56; P.L.255-2003, SEC.16; P.L.212-2007,
SEC.1; P.L.218-2007, SEC.11; P.L.229-2011, SEC.128;
P.L.205-2013, SEC.190.
IC 12-15-15-1.3
Reimbursement to hospitals for outpatient hospital services;
intergovernmental transfers; calculating Medicaid shortfall
Sec. 1.3. (a) This section applies to a hospital that is:
(1) licensed under IC 16-21; and
(2) established and operated under IC 16-22-2, IC 16-22-8, or
IC 16-23.
This section does not apply during the period that the office is
assessing a hospital fee authorized by IC 16-21-10.
(b) For a state fiscal year ending after June 30, 2003, in addition
to reimbursement received under section 1 of this chapter, a hospital
is entitled to reimbursement in an amount calculated as follows:
STEP ONE: The office shall identify the aggregate outpatient
hospital services, reimbursable under this article and under the
state Medicaid plan, that were provided during the state fiscal
year by hospitals established and operated under IC 16-22-2,
IC 16-22-8, or IC 16-23.
STEP TWO: For the aggregate outpatient hospital services
identified under STEP ONE, the office shall calculate the
aggregate payments made under this article and under the state
Medicaid plan to hospitals established and operated under
IC 16-22-2, IC 16-22-8, or IC 16-23, excluding payments under
IC 12-15-16, IC 12-15-17, and IC 12-15-19.
STEP THREE: The office shall calculate a reasonable estimate
of the amount that would have been paid in the aggregate by the
office under Medicare payment principles for the outpatient
hospital services described in STEP ONE.
STEP FOUR: Subtract the amount calculated under STEP TWO
from the amount calculated under STEP THREE.
STEP FIVE: Subject to subsection (g), from the amount
calculated under STEP FOUR, allocate to a hospital established
and operated under IC 16-22-8 an amount not to exceed one
hundred percent (100%) of the difference between:
(A) the total cost for the hospital's provision of outpatient
services covered under this article for the hospital's fiscal
year ending during the state fiscal year; and
(B) the total payment to the hospital for its provision of
outpatient services covered under this article for the
hospital's fiscal year ending during the state fiscal year,
excluding payments under IC 12-15-16, IC 12-15-17, and
IC 12-15-19.
STEP SIX: Subtract the amount calculated under STEP FIVE
from the amount calculated under STEP FOUR.
STEP SEVEN: Distribute an amount equal to the amount
calculated under STEP SIX to the eligible hospitals established
and operated under IC 16-22-2 or IC 16-23 described in
subsection (c) in an amount not to exceed each hospital's
Medicaid shortfall as defined in subsection (f).
(c) A hospital is not eligible for a payment described in this
section unless:
(1) an intergovernmental transfer is made by the hospital or on
behalf of the hospital; or
(2) the hospital or another entity certifies the hospital's
expenditures as eligible for federal financial participation.
(d) Subject to subsection (e):
(1) an intergovernmental transfer may be made by or on behalf
of the hospital; or
(2) a certification of expenditures as eligible for federal financial
participation may be made;
after the close of each state fiscal year. An intergovernmental transfer
under this subsection must be made to the Medicaid indigent care
trust fund in an amount equal to a percentage, as determined by the
office, of the amount to be distributed to the hospital under
subsection (b). The office shall use the intergovernmental transfer to
fund payments made under this section.
(e) A hospital that makes a certification of expenditures or makes
or has an intergovernmental transfer made on the hospital's behalf
under this section may appeal under IC 4-21.5 the amount determined
by the office to be paid by the hospital under subsection (b). The
periods described in subsections (c) and (d) for the hospital or other
entity to make an intergovernmental transfer or certification of
expenditures are tolled pending the administrative appeal and any
judicial review initiated by the hospital under IC 4-21.5. The
distribution to other hospitals under subsection (b) may not be
delayed due to an administrative appeal or judicial review instituted
by a hospital under this subsection. If necessary, the office may make
a partial distribution to the other eligible hospitals under subsection
(b) pending the completion of a hospital's administrative appeal or
judicial review, at which time the remaining portion of the payments
due to the eligible hospitals must be made. A partial distribution may
be calculated by the office based upon estimates and trends.
(f) For purposes of this section:
(1) the Medicaid shortfall of a hospital established and operated
under IC 16-22-2 or IC 16-23 is calculated as follows:
STEP ONE: The office shall identify the outpatient hospital
services, reimbursable under this article and under the state
Medicaid plan, that were provided during the state fiscal year
by the hospital.
STEP TWO: For the outpatient hospital services identified
under STEP ONE, the office shall calculate the payments
made under this article and under the state Medicaid plan to
the hospital, excluding payments under IC 12-15-16,
IC 12-15-17, and IC 12-15-19.
STEP THREE: The office shall calculate a reasonable
estimate of the amount that would have been paid by the
office for the outpatient hospital services described in STEP
ONE under Medicare payment principles; and
(2) a hospital's Medicaid shortfall is equal to the amount by
which the amount calculated in STEP THREE of subdivision
(1) is greater than the amount calculated in STEP TWO of
subdivision (1).
(g) The actual distribution of the amount calculated under STEP
FIVE of subsection (b) to a hospital established and operated under
IC 16-22-8 shall be made under the terms and conditions provided for
the hospital in the state plan for medical assistance. Payment to a
hospital under STEP FIVE of subsection (b) is not a condition
precedent to the tender of payments to hospitals under STEP SEVEN
of subsection (b).
As added by P.L.120-2002, SEC.14. Amended by P.L.255-2003,
SEC.17; P.L.212-2007, SEC.2; P.L.218-2007, SEC.12;
P.L.229-2011, SEC.129; P.L.205-2013, SEC.191.
IC 12-15-15-1.5
Additional reimbursements to certain hospitals; appeal of amount
of distribution
Sec. 1.5. (a) This section applies to a hospital that:
(1) is licensed under IC 16-21;
(2) is not a unit of state or local government; and
(3) is not owned or operated by a unit of state or local
government.
This section does not apply during the period that the office is
assessing a hospital fee authorized by IC 16-21-10.
(b) For a state fiscal year ending after June 30, 2003, and before
July 1, 2007, in addition to reimbursement received under section 1
of this chapter, a hospital eligible under this section is entitled to
reimbursement in an amount calculated as follows:
STEP ONE: The office shall identify the total inpatient hospital
services and the total outpatient hospital services, reimbursable
under this article and under the state Medicaid plan, that were
provided during the state fiscal year by the hospitals described
in subsection (a).
STEP TWO: For the total inpatient hospital services and the
total outpatient hospital services identified under STEP ONE,
the office shall calculate the aggregate payments made under
this article and under the state Medicaid plan to hospitals
described in subsection (a), excluding payments under
IC 12-15-16, IC 12-15-17, and IC 12-15-19.
STEP THREE: The office shall calculate a reasonable estimate
of the amount that would have been paid in the aggregate by the
office for the inpatient hospital services and the outpatient
hospital services identified in STEP ONE under Medicare
payment principles.
STEP FOUR: Subtract the amount calculated under STEP TWO
from the amount calculated under STEP THREE.
STEP FIVE: Distribute an amount equal to the amount
calculated under STEP FOUR to the eligible hospitals described
in subsection (a) as follows:
(A) Subject to the availability of funds under
IC 12-15-20-2(8)(D) to serve as the nonfederal share of such
payment, the first ten million dollars ($10,000,000) of the
amount calculated under STEP FOUR for a state fiscal year
shall be paid to a hospital described in subsection (a) that has
more than sixty thousand (60,000) Medicaid inpatient days.
(B) Following the payment to the hospital under clause (A)
and subject to the availability of funds under
IC 12-15-20-2(8)(D) to serve as the nonfederal share of such
payments, the remaining amount calculated under STEP
FOUR for a state fiscal year shall be paid to all hospitals
described in subsection (a). The payments shall be made on
a pro rata basis based on the hospitals' Medicaid inpatient
days or other payment methodology approved by the Centers
for Medicare and Medicaid Services. For purposes of this
clause, a hospital's Medicaid inpatient days are the hospital's
in-state and paid Medicaid fee for service and managed care
days for the state fiscal year for which services are identified
under STEP ONE, as determined by the office.
(C) Subject to IC 12-15-20.7, in the event the entirety of the
amount calculated under STEP FOUR is not distributed
following the payments made under clauses (A) and (B), the
remaining amount may be paid to hospitals described in
subsection (a) that are eligible under this clause. A hospital
is eligible for a payment under this clause only if the
nonfederal share of the hospital's payment is provided by or
on behalf of the hospital. The remaining amount shall be
paid to those eligible hospitals:
(i) on a pro rata basis in relation to all hospitals eligible
under this clause based on the hospitals' Medicaid inpatient
days; or
(ii) other payment methodology determined by the office
and approved by the Centers for Medicare and Medicaid
Services.
(c) As used in this subsection, "Medicaid supplemental payments"
means Medicaid payments for hospitals that are in addition to
Medicaid fee-for-service payments, Medicaid risk-based managed
care payments, and Medicaid disproportionate share payments, and
that are included in the Medicaid state plan, including Medicaid
safety-net payments, and payments made under this section and
sections 1.1, 1.3, 9, and 9.5 of this chapter. For a state fiscal year
ending after June 30, 2007, in addition to the reimbursement received
under section 1 of this chapter, a hospital eligible under this section
is entitled to reimbursement in an amount calculated as follows:
STEP ONE: The office shall identify the total inpatient hospital
services and the total outpatient hospital services reimbursable
under this article and under the state Medicaid plan that were
provided during the state fiscal year for all hospitals described
in subsection (a).
STEP TWO: For the total inpatient hospital services and the
total outpatient hospital services identified in STEP ONE, the
office shall calculate the total payments made under this article
and under the state Medicaid plan to all hospitals described in
subsection (a). A calculation under this STEP excludes a
payment made under the following:
(A) IC 12-15-16.
(B) IC 12-15-17.
(C) IC 12-15-19.
STEP THREE: The office shall calculate, under Medicare
payment principles, a reasonable estimate of the total amount
that would have been paid by the office for the inpatient hospital
services and the outpatient hospital services identified in STEP
ONE.
STEP FOUR: Subtract the amount calculated under STEP TWO
from the amount calculated under STEP THREE.
STEP FIVE: Distribute an amount equal to the amount
calculated under STEP FOUR to the eligible hospitals described
in subsection (a) as follows:
(A) As used in this clause, "Medicaid inpatient days" are the
hospital's in-state paid Medicaid fee for service and
risk-based managed care days for the state fiscal year for
which services are identified under STEP ONE, as
determined by the office. Subject to the availability of funds
transferred to the Medicaid indigent care trust fund under
STEP FOUR of IC 12-16-7.5-4.5(c) and remaining in the
Medicaid indigent care trust fund under IC 12-15-20-2(8)(G)
to serve as the nonfederal share of the payments, the amount
calculated under STEP FOUR for a state fiscal year shall be
paid to all hospitals described in subsection (a). The
payments shall be made on a pro rata basis, based on the
hospitals' Medicaid inpatient days or in accordance with
another payment methodology determined by the office and
approved by the Centers for Medicare and Medicaid
Services.
(B) Subject to IC 12-15-20.7, if the entire amount calculated
under STEP FOUR is not distributed following the payments
made under clause (A), the remaining amount shall be paid
as described in clauses (C) and (D) to a hospital that is
described in subsection (a) and that is described as eligible
under this clause. A hospital is eligible for a payment under
clause (C) only if the hospital:
(i) has less than sixty thousand (60,000) Medicaid inpatient
days annually;
(ii) was eligible for Medicaid disproportionate share
hospital payments in the state fiscal year ending June 30,
1998, or the hospital met the office's Medicaid
disproportionate share payment criteria based upon state
fiscal year 1998 data and received a Medicaid
disproportionate share payment for the state fiscal year
ending June 30, 2001; and
(iii) received a Medicaid disproportionate share payment
under IC 12-15-19-2.1 for state fiscal years 2001, 2002,
2003, and 2004.
The payment amount under clause (C) for an eligible hospital
is subject to the availability of the nonfederal share of the
hospital's payment being provided by the hospital or on
behalf of the hospital.
(C) For state fiscal years ending after June 30, 2007, but
before July 1, 2009, payments to eligible hospitals described
in clause (B) shall be made as follows:
(i) The payment to an eligible hospital that merged two (2)
hospitals under a single Medicaid provider number
effective January 1, 2004, shall equal one hundred percent
(100%) of the hospital's hospital-specific limit for the state
fiscal year ending June 30, 2005, when the payment is
combined with any Medicaid disproportionate share
payment made under IC 12-15-19-2.1, Medicaid, and other
Medicaid supplemental payments, paid or to be paid to the
hospital for a state fiscal year.
(ii) The payment to an eligible hospital described in clause
(B) other than a hospital described in item (i) shall equal
one hundred percent (100%) of the hospital's hospital
specific limit for the state fiscal year ending June 30, 2004,
when the payment is combined with any Medicaid
disproportionate share payment made under
IC 12-15-19-2.1, Medicaid, and other Medicaid
supplemental payments, paid or to be paid to the hospital
for a state fiscal year.
(D) For state fiscal years beginning after June 30, 2009,
payments to an eligible hospital described in clause (B) shall
be made in a manner determined by the office.
(E) Subject to IC 12-15-20.7, if the entire amount calculated
under STEP FOUR is not distributed following the payments
made under clause (A) and clauses (C) or (D), the remaining
amount may be paid as described in clause (F) to a hospital
described in subsection (a) that is described as eligible under
this clause. A hospital is eligible for a payment for a state
fiscal year under clause (F) if the hospital:
(i) is eligible to receive Medicaid disproportionate share
payments for the state fiscal year for which the Medicaid
disproportionate share payment is attributable under
IC 12-15-19-2.1, for a state fiscal year ending after June
30, 2007; and
(ii) does not receive a payment under clauses (C) or (D) for
the state fiscal year.
A payment to a hospital under this clause is subject to the
availability of nonfederal matching funds.
(F) Payments to eligible hospitals described in clause (E)
shall be made:
(i) to best use federal matching funds available for
hospitals that are eligible for Medicaid disproportionate
share payments under IC 12-15-19-2.1; and
(ii) by using a methodology that allocates available
funding under this clause, Medicaid supplemental
payments, and payments under IC 12-15-19-2.1, in a
manner in which all hospitals eligible under clause (E)
receive payments in a manner that takes into account the
situation of eligible hospitals that have historically
qualified for Medicaid disproportionate share payments
and ensures that payments for eligible hospitals are
equitable.
(G) If the Centers for Medicare and Medicaid Services does
not approve the payment methodologies in clauses (A)
through (F), the office may implement alternative payment
methodologies that are eligible for federal financial
participation to implement a program consistent with the
payments for hospitals described in clauses (A) through (F).
(d) A hospital described in subsection (a) may appeal under
IC 4-21.5 the amount determined by the office to be paid to the
hospital under STEP FIVE of subsections (b) or (c). The distribution
to other hospitals under STEP FIVE of subsection (b) or (c) may not
be delayed due to an administrative appeal or judicial review
instituted by a hospital under this subsection. If necessary, the office
may make a partial distribution to the other eligible hospitals under
STEP FIVE of subsection (b) or (c) pending the completion of a
hospital's administrative appeal or judicial review, at which time the
remaining portion of the payments due to the eligible hospitals shall
be made. A partial distribution may be based on estimates and trends
calculated by the office.
As added by P.L.255-2003, SEC.18. Amended by P.L.212-2007,
SEC.3; P.L.218-2007, SEC.13; P.L.3-2008, SEC.92; P.L.229-2011,
SEC.130; P.L.205-2013, SEC.192.
IC 12-15-15-1.6
Alternative payment methodology for payments to hospitals
Sec. 1.6. (a) This section applies only if the office determines,
based on information received from the United States Centers for
Medicare and Medicaid Services, that payments made under section
1.5(b) STEP FIVE (A), (B), or (C) of this chapter will not be
approved for federal financial participation. This section does not
apply during the period that the office is assessing a hospital fee
authorized by IC 16-21-10.
(b) If the office determines that payments made under section
1.5(b) STEP FIVE (A) of this chapter will not be approved for
federal financial participation, the office may make alternative
payments to payments under section 1.5(b) STEP FIVE (A) of this
chapter if:
(1) the payments for a state fiscal year are made only to a
hospital that would have been eligible for a payment for that
state fiscal year under section 1.5(b) STEP FIVE (A) of this
chapter; and
(2) the payments for a state fiscal year to each hospital are an
amount that is as equal as possible to the amount each hospital
would have received under section 1.5(b) STEP FIVE (A) of
this chapter for that state fiscal year.
(c) If the office determines that payments made under section
1.5(b) STEP FIVE (B) of this chapter will not be approved for federal
financial participation, the office may make alternative payments to
payments under section 1.5(b) STEP FIVE (B) of this chapter if:
(1) the payments for a state fiscal year are made only to a
hospital that would have been eligible for a payment for that
state fiscal year under section 1.5(b) STEP FIVE (B) of this
chapter; and
(2) the payments for a state fiscal year to each hospital are an
amount that is as equal as possible to the amount each hospital
would have received under section 1.5(b) STEP FIVE (B) of
this chapter for that state fiscal year.
(d) If the office determines that payments made under section
1.5(b) STEP FIVE (C) of this chapter will not be approved for federal
financial participation, the office may make alternative payments to
payments under section 1.5(b) STEP FIVE (C) of this chapter if:
(1) the payments for a state fiscal year are made only to a
hospital that would have been eligible for a payment for that
state fiscal year under section 1.5(b) STEP FIVE (C) of this
chapter; and
(2) the payments for a state fiscal year to each hospital are an
amount that is as equal as possible to the amount each hospital
would have received under section 1.5(b) STEP FIVE (C) of
this chapter for that state fiscal year.
(e) If the office determines, based on information received from
the United States Centers for Medicare and Medicaid Services, that
payments made under subsection (b), (c), or (d) will not be approved
for federal financial participation, the office shall use the funds that
would have served as the nonfederal share of these payments for a
state fiscal year to serve as the nonfederal share of a payment
program for hospitals to be established by the office. The payment
program must distribute payments to hospitals for a state fiscal year
based upon a methodology determined by the office to be equitable
under the circumstances.
As added by P.L.78-2004, SEC.4. Amended by P.L.229-2011,
SEC.131; P.L.205-2013, SEC.193.
IC 12-15-15-2
Rates adopted for hospital licensed under IC 16-21; prospective or
retrospective application
Sec. 2. The rates adopted under this chapter for a hospital licensed
under IC 16-21 may be the following:
(1) Prospective.
(2) Retroactive.
(3) A combination of prospective and retroactive.
As added by P.L.2-1992, SEC.9. Amended by P.L.2-1993, SEC.94.
IC 12-15-15-2.5
Payment for physician services in emergency department
Sec. 2.5. (a) Payment for physician services provided in the
emergency department of a hospital licensed under IC 16-21 must be
at a rate of one hundred percent (100%) of rates payable under the
Medicaid fee structure.
(b) The payment under subsection (a) must be calculated using the
same methodology used for all other physicians participating in the
Medicaid program.
(c) For services rendered and documented in an individual's
medical record, physicians must be reimbursed for federally required
medical screening exams that are necessary to determine the presence
of an emergency using the appropriate Current Procedural
Terminology (CPT) codes 99281, 99282, or 99283 described in the
Current Procedural Terminology Manual published annually by the
American Medical Association, without authorization by the
enrollee's primary medical provider.
(d) Payment for all other physician services provided in an
emergency department of a hospital to enrollees in the Medicaid
primary care case management program must be at a rate of one
hundred percent (100%) of the Medicaid fee structure rates, provided
the service is authorized, prospectively or retrospectively, by the
enrollee's primary medical provider.
(e) This section does not apply to a person enrolled in the
Medicaid risk-based managed care program.
As added by P.L.153-1995, SEC.10. Amended by P.L.119-1997,
SEC.5; P.L.245-1999, SEC.1; P.L.223-2001, SEC.10.
IC 12-15-15-3
Services provided at hospitals operating under IC 16-24-1;
prospective payment rate
Sec. 3. Payment of a service provided in a hospital operating
under IC 16-24-1 shall be determined in accordance with a
prospective payment rate for the service.
As added by P.L.2-1992, SEC.9. Amended by P.L.2-1993, SEC.95.
IC 12-15-15-4
Per diem rate for services provided in hospitals operating under
IC 16-24-1
Sec. 4. The office shall establish a per diem rate for the service
provided in a hospital operating under IC 16-24-1 under rules
adopted under IC 4-22-2 by the secretary.
As added by P.L.2-1992, SEC.9. Amended by P.L.2-1993, SEC.96.
IC 12-15-15-4.5
Payment for HIV test; limitation
Sec. 4.5. Payment to a hospital for a test required under
IC 16-41-6-4 must be in an amount equal to the hospital's actual cost
of performing the test and may not reduce or replace the
reimbursement of other services that are provided to the patient under
the state Medicaid program. The total cost to the state may not be
more than twenty-four thousand dollars ($24,000) in a state fiscal
year.
As added by P.L.237-2003, SEC.2.
IC 12-15-15-5
Repealed
(Repealed by P.L.126-1998, SEC.22.)
IC 12-15-15-6
Fees in addition to infant delivery fees
Sec. 6. (a) In addition to a payment due to a hospital for the
delivery of a newborn infant, the office shall tender a payment to the
hospital for the hospital's collection, handling, and delivery of a
specimen for testing under IC 16-41-17-2(a)(10).
(b) Payment to a hospital required under subsection (a) must be in
an amount equal to the total of the following costs:
(1) The cost incurred by the hospital to collect, handle, and
deliver the specimen obtained for testing under
IC 16-41-17-2(a)(10).
(2) Any fee assessed against the hospital for a laboratory's
testing of the specimen under IC 16-41-17-2(a)(10).
(3) Any newborn screening fee or other fee assessed against the
hospital by the state department of health in connection with the
testing of the specimen under IC 16-41-17-2(a)(10).
As added by P.L.149-2001, SEC.2.
IC 12-15-15-8
Repealed
(Repealed by P.L.126-1998, SEC.21.)
IC 12-15-15-9
Attribution of payable claim to county; amount of payment on
payable claims; conditions on payments; funds available for
payments
Sec. 9. (a) For purposes of this section and IC 12-16-7.5-4.5, a
payable claim is attributed to a county if the payable claim is
submitted to the division by a hospital licensed under IC 16-21-2 for
payment under IC 12-16-7.5 for care provided by the hospital to an
individual who qualifies for the hospital care for the indigent program
under IC 12-16-3.5-1 or IC 12-16-3.5-2 and:
(1) who is a resident of the county;
(2) who is not a resident of the county and for whom the onset
of the medical condition that necessitated the care occurred in
the county; or
(3) whose residence cannot be determined by the division and
for whom the onset of the medical condition that necessitated
the care occurred in the county.
This section does not apply during the period that the office is
assessing a hospital fee authorized by IC 16-21-10.
(b) For each state fiscal year ending after June 30, 2003, and
before July 1, 2007, a hospital licensed under IC 16-21-2 that submits
to the division during the state fiscal year a payable claim under
IC 12-16-7.5 is entitled to a payment under subsection (c).
(c) Except as provided in section 9.8 of this chapter and subject to
section 9.6 of this chapter, for a state fiscal year, the office shall pay
to a hospital referred to in subsection (b) an amount equal to the
amount, based on information obtained from the division and the
calculations and allocations made under IC 12-16-7.5-4.5, that the
office determines for the hospital under STEP SIX of the following
STEPS:
STEP ONE: Identify:
(A) each hospital that submitted to the division one (1) or
more payable claims under IC 12-16-7.5 during the state
fiscal year; and
(B) the county to which each payable claim is attributed.
STEP TWO: For each county identified in STEP ONE, identify:
(A) each hospital that submitted to the division one (1) or
more payable claims under IC 12-16-7.5 attributed to the
county during the state fiscal year; and
(B) the total amount of all hospital payable claims submitted
to the division under IC 12-16-7.5 attributed to the county
during the state fiscal year.
STEP THREE: For each county identified in STEP ONE,
identify the amount of county funds transferred to the Medicaid
indigent care trust fund under IC 12-16-7.5-4.5.
STEP FOUR: For each hospital identified in STEP ONE, with
respect to each county identified in STEP ONE, calculate the
hospital's percentage share of the county's funds transferred to
the Medicaid indigent care trust fund under IC 12-16-7.5-4.5.
Each hospital's percentage share is based on the total amount of
the hospital's payable claims submitted to the division under
IC 12-16-7.5 attributed to the county during the state fiscal year,
calculated as a percentage of the total amount of all hospital
payable claims submitted to the division under IC 12-16-7.5
attributed to the county during the state fiscal year.
STEP FIVE: Subject to subsection (j), for each hospital
identified in STEP ONE, with respect to each county identified
in STEP ONE, multiply the hospital's percentage share
calculated under STEP FOUR by the amount of the county's
funds transferred to the Medicaid indigent care trust fund under
IC 12-16-7.5-4.5.
STEP SIX: Determine the sum of all amounts calculated under
STEP FIVE for each hospital identified in STEP ONE with
respect to each county identified in STEP ONE.
(d) For state fiscal years beginning after June 30, 2007, a hospital
that received a payment determined under STEP SIX of subsection
(c) for the state fiscal year ending June 30, 2007, shall be paid in an
amount equal to the amount determined for the hospital under STEP
SIX of subsection (c) for the state fiscal year ending June 30, 2007.
(e) A hospital's payment under subsection (c) or (d) is in the form
of a Medicaid supplemental payment. The amount of a hospital's
Medicaid supplemental payment is subject to the availability of
funding for the non-federal share of the payment under subsection (f).
The office shall make the payments under subsection (c) and (d)
before December 15 that next succeeds the end of the state fiscal
year.
(f) The non-federal share of a payment to a hospital under
subsection (c) or (d) is funded from the funds transferred to the
Medicaid indigent care trust fund under IC 12-16-7.5-4.5.
(g) The amount of a county's transferred funds available to be used
to fund the non-federal share of a payment to a hospital under
subsection (c) is an amount that bears the same proportion to the total
amount of funds of the county transferred to the Medicaid indigent
care trust fund under IC 12-16-7.5-4.5 that the total amount of the
hospital's payable claims under IC 12-16-7.5 attributed to the county
submitted to the division during the state fiscal year bears to the total
amount of all hospital payable claims under IC 12-16-7.5 attributed
to the county submitted to the division during the state fiscal year.
(h) Any county's funds identified in subsection (g) that remain
after the non-federal share of a hospital's payment has been funded
are available to serve as the non-federal share of a payment to a
hospital under section 9.5 of this chapter.
(i) For purposes of this section, "payable claim" has the meaning
set forth in IC 12-16-7.5-2.5(b)(1).
(j) For purposes of subsection (c):
(1) the amount of a payable claim is an amount equal to the
amount the hospital would have received under the state's
fee-for-service Medicaid reimbursement principles for the
hospital care for which the payable claim is submitted under
IC 12-16-7.5 if the individual receiving the hospital care had
been a Medicaid enrollee; and
(2) a payable hospital claim under IC 12-16-7.5 includes a
payable claim under IC 12-16-7.5 for the hospital's care
submitted by an individual or entity other than the hospital, to
the extent permitted under the hospital care for the indigent
program.
(k) The amount calculated under STEP FIVE of subsection (c) for
a hospital with respect to a county may not exceed the total amount
of the hospital's payable claims attributed to the county during the
state fiscal year.
As added by P.L.126-1998, SEC.5. Amended by P.L.113-2000,
SEC.3; P.L.283-2001, SEC.20; P.L.1-2002, SEC.52; P.L.120-2002,
SEC.15; P.L.1-2003, SEC.57; P.L.255-2003, SEC.19; P.L.78-2004,
SEC.5; P.L.212-2007, SEC.4; P.L.218-2007, SEC.14; P.L.229-2011,
SEC.132; P.L.205-2013, SEC.194.
IC 12-15-15-9.5
Attribution of payable claim to county; funds available for
payments; limitation on payments
Sec. 9.5. (a) For purposes of this section and IC 12-16-7.5-4.5, a
payable claim is attributed to a county if the payable claim is
submitted to the division by a hospital licensed under IC 16-21-2 for
payment under IC 12-16-7.5 for care provided by the hospital to an
individual who qualifies for the hospital care for the indigent program
under IC 12-16-3.5-1 or IC 12-16-3.5-2 and:
(1) who is a resident of the county;
(2) who is not a resident of the county and for whom the onset
of the medical condition that necessitated the care occurred in
the county; or
(3) whose residence cannot be determined by the division and
for whom the onset of the medical condition that necessitated
the care occurred in the county.
This section does not apply during the period that the office is
assessing a hospital fee authorized by IC 16-21-10.
(b) For each state fiscal year ending after June 30, 2003, but
before July 1, 2007, a hospital licensed under IC 16-21-2:
(1) that submits to the division during the state fiscal year a
payable claim under IC 12-16-7.5; and
(2) whose payment under section 9(c) of this chapter was less
than the total amount of the hospital's payable claims under
IC 12-16-7.5 submitted by the hospital to the division during the
state fiscal year;
is entitled to a payment under subsection (c).
(c) Subject to section 9.6 of this chapter, for a state fiscal year, the
office shall pay to a hospital referred to in subsection (b) an amount
equal to the amount, based on information obtained from the division
and the calculations and allocations made under IC 12-16-7.5-4.5,
that the office determines for the hospital under STEP EIGHT of the
following STEPS:
STEP ONE: Identify each county whose transfer of funds to the
Medicaid indigent care trust fund under IC 12-16-7.5-4.5 for the
state fiscal year was less than the total amount of all hospital
payable claims attributed to the county and submitted to the
division during the state fiscal year.
STEP TWO: For each county identified in STEP ONE, calculate
the difference between the amount of funds of the county
transferred to the Medicaid indigent care trust fund under
IC 12-16-7.5-4.5 and the total amount of all hospital payable
claims attributed to the county and submitted to the division
during the state fiscal year.
STEP THREE: Calculate the sum of the amounts calculated for
the counties under STEP TWO.
STEP FOUR: Identify each hospital whose payment under
section 9(c) of this chapter was less than the total amount of the
hospital's payable claims under IC 12-16-7.5 submitted by the
hospital to the division during the state fiscal year.
STEP FIVE: Calculate for each hospital identified in STEP
FOUR the difference between the hospital's payment under
section 9(c) of this chapter and the total amount of the hospital's
payable claims under IC 12-16-7.5 submitted by the hospital to
the division during the state fiscal year.
STEP SIX: Calculate the sum of the amounts calculated for each
of the hospitals under STEP FIVE.
STEP SEVEN: For each hospital identified in STEP FOUR,
calculate the hospital's percentage share of the amount
calculated under STEP SIX. Each hospital's percentage share is
based on the amount calculated for the hospital under STEP
FIVE calculated as a percentage of the sum calculated under
STEP SIX.
STEP EIGHT: For each hospital identified in STEP FOUR,
multiply the hospital's percentage share calculated under STEP
SEVEN by the sum calculated under STEP THREE. The
amount calculated under this STEP for a hospital may not
exceed the amount by which the hospital's total payable claims
under IC 12-16-7.5 submitted during the state fiscal year
exceeded the amount of the hospital's payment under section
9(c) of this chapter.
(d) For state fiscal years beginning after June 30, 2007, a hospital
that received a payment determined under STEP EIGHT of
subsection (c) for the state fiscal year ending June 30, 2007, shall be
paid an amount equal to the amount determined for the hospital under
STEP EIGHT of subsection (c) for the state fiscal year ending June
30, 2007.
(e) A hospital's payment under subsection (c) or (d) is in the form
of a Medicaid supplemental payment. The amount of the hospital's
add-on payment is subject to the availability of funding for the
nonfederal share of the payment under subsection (f). The office shall
make the payments under subsection (c) or (d) before December 15
that next succeeds the end of the state fiscal year.
(f) The nonfederal share of a payment to a hospital under
subsection (c) or (d) is derived from funds transferred to the Medicaid
indigent care trust fund under IC 12-16-7.5-4.5 and not expended
under section 9 of this chapter.
(g) Except as provided in subsection (h), the office may not make
a payment under this section until the payments due under section 9
of this chapter for the state fiscal year have been made.
(h) If a hospital appeals a decision by the office regarding the
hospital's payment under section 9 of this chapter, the office may
make payments under this section before all payments due under
section 9 of this chapter are made if:
(1) a delay in one (1) or more payments under section 9 of this
chapter resulted from the appeal; and
(2) the office determines that making payments under this
section while the appeal is pending will not unreasonably affect
the interests of hospitals eligible for a payment under this
section.
(i) Any funds transferred to the Medicaid indigent care trust fund
under IC 12-16-7.5-4.5 remaining after payments are made under this
section shall be used as provided in IC 12-15-20-2(8).
(j) For purposes of subsection (c):
(1) "payable claim" has the meaning set forth in
IC 12-16-7.5-2.5(b);
(2) the amount of a payable claim is an amount equal to the
amount the hospital would have received under the state's
fee-for-service Medicaid reimbursement principles for the
hospital care for which the payable claim is submitted under
IC 12-16-7.5 if the individual receiving the hospital care had
been a Medicaid enrollee; and
(3) a payable hospital claim under IC 12-16-7.5 includes a
payable claim under IC 12-16-7.5 for the hospital's care
submitted by an individual or entity other than the hospital, to
the extent permitted under the hospital care for the indigent
program.
As added by P.L.255-2003, SEC.20. Amended by P.L.78-2004,
SEC.6; P.L.212-2007, SEC.5; P.L.218-2007, SEC.15; P.L.3-2008,
SEC.93; P.L.229-2011, SEC.133; P.L.205-2013, SEC.195.
IC 12-15-15-9.6
Limitation on total amount of payments
Sec. 9.6. For state fiscal years beginning after June 30, 2007, the
total amount of payments to hospitals under sections 9 and 9.5 of this
chapter may not exceed the amount paid to hospitals under sections
9 and 9.5 of this chapter for the state fiscal year ending June 30,
2007.
As added by P.L.255-2003, SEC.21. Amended by P.L.212-2007,
SEC.6; P.L.218-2007, SEC.16.
IC 12-15-15-9.8
Repealed
(Repealed by P.L.212-2007, SEC.31; P.L.218-2007, SEC.52.)
IC 12-15-15-10
Payments to providers under Medicaid disproportionate share
provider program
Sec. 10. (a) This section applies to a hospital that:
(1) is licensed under IC 16-21; and
(2) qualifies as a provider under IC 12-15-16, IC 12-15-17, or
IC 12-15-19 of the Medicaid disproportionate share provider
program.
(b) The office may, after consulting with affected providers, do
one (1) or more of the following:
(1) Establish a nominal charge hospital payment program.
(2) Establish any other permissible payment program.
(c) A program expanded or established under this section is
subject to the availability of:
(1) intergovernmental transfers;
(2) funds certified as being eligible for federal financial
participation; or
(3) other permissible sources of non-federal share dollars.
(d) The office may not implement a program under this section
until the federal Centers for Medicare and Medicaid Services
approves the provisions regarding the program in the amended state
plan for medical assistance.
(e) The office may determine not to continue to implement a
program established under this section if federal financial
participation is not available.
As added by P.L.113-2000, SEC.4. Amended by P.L.66-2002, SEC.6;
P.L.212-2007, SEC.7; P.L.218-2007, SEC.17.
IC 12-15-15-11
Nominal charge hospitals
Sec. 11. Hospitals licensed under IC 16-21 that are established and
operated under IC 16-22, IC 16-22-8, or IC 16-23 are nominal charge
hospitals for purposes of the Medicaid program.
As added by P.L.283-2001, SEC.21.
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