Title: Section 86-1.20 - Add-ons to the case payment rate per discharge

86-1.20 Add-ons to the case payment rate per discharge. Rates of payment computed pursuant to this Subpart shall be further adjusted in accordance with the following:

(a) A direct graduate medical education (GME) payment per discharge shall be added to the case payment rates of teaching general hospitals after the application of SIW and WEF adjustments to the statewide base price and shall be calculated for each hospital by dividing the facility's total reported Medicaid direct GME costs by its total reported Medicaid discharges pursuant to section 86-1.16(b)(2) of this Subpart. Direct GME costs shall be those costs defined in section 86-1.15(f)(1) of this Subpart, derived from the same base period used to calculate the statewide base price for the applicable rate period and trended forward to such rate period in accordance with applicable provisions of section 2807-c(10) of the Public Health Law, and shall be excluded from the cost included in the statewide base price.

(b)(1) An indirect GME payment per discharge shall be added to the case payment rates of teaching general hospitals after the application of SIW and WEF adjustments to the statewide base price and shall be calculated by multiplying such rates by the indirect teaching cost percentage determined by the following formula:

(1 – (1 / (1 + 1.03(((1 + r) ^0.0405) – 1))))

where "r" equals the ratio of residents and fellows to beds based on the medical education statistics for the hospital for the period ended June 30, 2005 as contained in the survey document submitted by the hospital to the department as of June 30, 2009 and the staffed beds for the general hospital reported in the 2005 institutional cost report and submitted to the department no later than June 30, 2009, but excluding exempt unit beds and nursery bassinettes.

(2) Indirect GME costs are those costs defined in section 86-1.15(f)(2) of this Subpart, derived from the same base period used to calculate the statewide base price for the applicable rate period and trended forward to such rate period in accordance with applicable provisions of section 2807-c(10) of the Public Health Law, and shall be excluded from computation of the statewide base price. The amount of such exclusion shall be determined by multiplying the total reported Medicaid costs less reported direct GME costs by the following formula:

1.03(((1 + r) ^0.0405) – 1)

where "r" equals the ratio of residents and fellows to beds as determined in accordance with paragraph (1) of this subdivision.

(c) A non-comparable payment per discharge shall be added to case payment rates after the application of SIW and WEF adjustments to the statewide base price and shall be calculated for each hospital by dividing the facility's total reported Medicaid costs for qualifying non-comparable cost categories by its total reported Medicaid discharges pursuant to section 86-1.16(b)(2) of this Subpart. Non-comparable hospital costs are those costs defined in section 86-1.15(l) of this Subpart, derived from the same base period used to calculate the statewide base price for the applicable rate period and trended forward to such rate period in accordance with applicable provisions of section 2807-c(10) of the Public Health Law, and shall be excluded from the cost included in the statewide base price.

(d) For dates of service occurring on or after April 1, 2020 through December 31, 2020, and each calendar year thereafter, an Upper Payment Limit (UPL) payment per discharge shall be added to the case payment rates after the application of SIW and WEF adjustments to the statewide base price (hereinafter, “add-ons”). Such add-ons shall only apply to eligible public general hospitals or public health systems, other than those operated by the state of New York or the state university of New York, located in a city having a population of one million or more and shall be in lieu of any aggregate UPL payment. Such add-ons shall be calculated for each hospital by dividing the hospital’s latest approved UPL demonstration payment, by its Medicaid fee-for-service acute discharges, as reported in its most recently submitted Institutional Cost Report. Each hospital’s add-on shall be subject to and contingent upon the terms of a binding memorandum of understanding executed between the Department of Health and the public general hospital or public health system receiving an add-on, and shall be subject to termination or adjustment based on the terms of that agreement. The total amount paid for the add-on shall be included in the applicable annual UPL demonstration. If the annual UPL demonstration yields an amount that is more or less than the aggregate amount paid for the add-on, the add-on shall be adjusted to reflect the demonstration amount.