The SSI ratio is a critical factor in determining the amount of Medicare DSH Reimbursement.
CMS Ruling 1498-R3 (dated March 3, 2024) revoked CMS Ruling 1498-R2 (dated April 22, 2010) and provided additional guidance ( cms-1498-r3.pdf ). Ruling 1498-R2 gave providers rights to choose between what are generally referred to as Covered Days or Total Days in the calculation of the SSI ratio for their hospital. ( cms1498-r2.pdf ).
Central to Covered Days and Total Days was the Becerra v. Empire Health Foundation Supreme Court Case decided along a 5-4 vote as decided June 24, 2022 ( 20-1312_j42l.pdf (supremecourt.gov). Ruling 1498-R3 was noted by CMS as being necessary to comply with the June 24, 2022 ruling.
The nuances of Ruling 1498-R3 and the Supreme Court case fundamentally address the concepts of patients who exhausted their Medicare Part A benefits and the non-covered Medicare Part A patient days.
The specifics of SSI strategies, of 1498-R3, and of the circumstances under which negative adjustments may be proposed are very important.
As one example, providers should not conclude or accept at face value negative proposed adjustments. Ruling 1498-R3 notes specifically that providers have a right to appeal the damaging effects of 1498-R3. GDS believes there are a few possible developing scenarios and potential stances for appeal and litigation.
Providers should take note of specifically what falls under 1498-R3. Providers should not conclude at this time that everything prior to October 1, 2004 falls under 1498-R3. GDS believes there are considerations for potential appeal and litigation if CMS is not forthcoming with additional guidance.
One clear take away is that for open cost reports and "appeals" (written in 1498-R3 as "DSH appeal", "pending appeals", "pending administrative appeals", "appealed cost reports", "properly pending appealed") the use of Total Days is mandated.
Contact Adam Blackwell at adamblackwell@govdataservices.com to further discuss strategies pertaining to SSI realignment, SSI ratio settlements, and Medicare DSH.
