Thursday 23 March 2017

Medicare DSH formula

TYPE OF DAY  - General Assistance Patient Days

DESCRIPTION - Days for patients covered under a State-only (or countryonly) general assistance program (whether or not any payment is available for health care services under the program). These patients are not Medicaid-eligible under the State plan.

TYPE OF DAY  - Other State-Only Health Program Patient Days

DESCRIPTION - Days for patients covered under a State-only health program. These patients are not Medicaid-eligible under the State plan.

TYPE OF DAY  - Charity Care Patient Days

DESCRIPTION -Days for patients not eligible for Medicaid or any other third-party payer, and claimed as uncompensated care by a hospital. These patients are not Medicaid-eligible under the State plan. 

TYPE OF DAY  - Actual 1902(r)(2) and 1931(b) Days

DESCRIPTION -Days for patients eligible under a State plan based on a 1902(r)(2) or 1931(b) election. These patients are Medicaid-eligible under the Title XIX State plan under the authority of these provisions, which is exercised by the State in the context of the approved State plan

TYPE OF DAY  - Medicaid Optional Targeted Low-Income Children (CHIP-related) Days

DESCRIPTION -Days for patients who are Title XIX-eligible and who meet the definition of "optional targeted low-income children" under §1905(u)(2). The difference between these children and other Title XIX children is the enhanced FMAP rate available to the State. These children are fully Medicaid-eligible under the State plan.

TYPE OF DAY  - Separate CHIP Days

DESCRIPTION -Days for patients who are eligible for benefits under a non-Medicaid State program furnishing child health assistance to targeted low-income children. These children are, by definition, not Medicaid-eligible under a State plan.

TYPE OF DAY  - §1915(c) Eligible Patient (the "217" group) Days

DESCRIPTION -Days for patients in the eligibility group under the State plan for individuals under a Home and Community Based Services waiver. This group includes individuals who would be Medicaid-eligible if they were in a medical institution. Under this special eligibility group, they are Medicaid-eligible under the State plan.

TYPE OF DAY  - Retroactive Eligible Days

DESCRIPTION -Days for patients not enrolled in the Medicaid program at the time of service, but found retroactively eligible for Medicaid benefits for the days at issue. These patients are Medicaid-eligible under the State plan

TYPE OF DAY  - Medicaid Managed Care Organization Days

DESCRIPTION -Days for patients who are eligible for Medicaid under a State plan when the payment to the hospital is made by an MCO for the service. An MCO is the financing mechanism for Medicaid benefits, and payment for the service through the MCO does not affect eligibility

TYPE OF DAY  - Medicaid DSH Days

DESCRIPTION -Days for patients who are not eligible for Medicaid benefits, but are considered in the calculation of Medicaid DSH payments by the State. These patients are not Medicaid-eligible

Sometimes Medicaid State plans specify that Medicaid DSH payments are based upon a hospital's amount of charity care or general assistance days. This, however, is not "payment" for those days, and does not mean that the patient is eligible for Medicaid benefits or can be counted as such in the Medicare formula

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