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D.C. Municipal Regulations (Last Updated: September 13, 2017) |
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Title 29. PUBLIC WELFARE |
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Chapter 29-48. MEDICAID PROGRAM: REIMBURSEMENT |
Section 29-4899. DEFINITIONS
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4899.1For the purposes of this chapter, the following terms shall have the meanings ascribed:
Acute care hospital: The term “acute care hospital” shall include those hospitals providing inpatient services as defined at 42 C.F.R. § 440.10.
APR-DRG Relative Weight: A numerical value which reflects the relative resource requirements for the DRG to which it is assigned.
Base year: The standardized year on which rates for all hospitals for inpatient hospital services are calculated to derive a prospective payment system.
Capital add-on: An add-on payment per discharge that contributes toward hospitals’ capital costs by adding supplemental monies to inpatient claim payments.
Diagnosis Related Group (DRG): A patient classification system that reflects clinically cohesive groupings of inpatient hospitalizations utilizing similar hospital resources.
Direct medical education (DME): An add-on payment to reimburse teaching hospitals for direct costs associated with graduate medical education (GME).
District-wide Base Rate: A standardized base amount used to reimburse hospitals reimbursed by DRG. The base rate is the basis of payment for DRG stays.
General Hospital: A hospital that has the facilities and provides the services that are necessary for the general medical and surgical care of patients, including the provision of emergency care by an Emergency Department pursuant to 22-B DCMR § 2099.
Hospital: As defined in the Medicare Act, which definition is incorporated herein (currently set forth in 42 U.S.C. § 1395x(e), as revised 1988).
High-cost outliers: Claims in which the computed loss to the hospital exceeds the outlier threshold to qualify for an additional payment.
Indirect medical education (IME): A component of the DRG base rate that is associated with indirect graduate medical education (GME costs and included in the hospital-specific base rate for each in-District general hospital paid under the APR-DRG PPS.
In-District hospitals: Any hospital located within the District of Columbia
Ineligible day: Any day that a patient was not eligible for District Medicaid on the day of service.
Low-cost outliers: Claims in which the computed gain to the hospital exceeds the outlier threshold to qualify for an adjustment to the DRG payment.
Marginal cost factor: A factor used to determine the additional payment for a high-cost outlier.
Medicaid Care Category (MCC): A categorization accepted by DHCF to categorize DRGs into clinical care groupings. Each DRG is categorized into one MCC.
Normal Newborn: A liveborn neonate whose diagnosis is categorized by APR-DRG.
Outlier threshold: The annual minimum dollar amount that the hospital’s loss or gain for a claim under APR-DRG PPS must meet in order for a high or low-cost outlier adjustment to DRG payment to be applied, e.g., high cost outlier threshold ($65,000) and low cost outlier threshold ($30,000).
Out-of-District hospital: Any hospital that is not located within the District of Columbia. The term does not include hospitals located in the State of Maryland and specialty hospitals identified at 22-B DCMR § 2099.
Pediatric (Children’s) hospital: A hospital engaged in furnishing services to inpatients who are predominantly individuals under the age of twenty-one (21).
Rebase: To review and/or update hospital reimbursement rates when necessary based upon a review of claims history and other relevant financial information.
Specialty Hospital: A hospital that meets the definition of “special hospital” as set forth in 22-B DCMR § 2099 as follows: (a) defines a program of specialized services, such as obstetrics, mental health, orthopedics, long term acute care, rehabilitative services or pediatric services; (b) admits only patients with medical or surgical needs within the defined program; and (c) has the facilities for and provides those specialized services.
Specialty Hospital Per-Diem Payment Method: A payment method which reimburses specific specialty hospitals on a daily basis.
Specialty Hospital Per-Stay Payment Method: A payment method which reimburses specific specialty hospitals based upon the entire time a person is hospitalized.
Transition Rate: An interim PS-APR-DRG or PD-APR-DRG rate established to allow for changes in reimbursement for specialty hospital discharges occurring October 1, 2014 - September 30, 2015.