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Chris Cusimano Mar 17, 2023 11:00:00 AM 2 min read

Instructions Relating to Section 1115 Waiver Days in DSH Calculation

On March 16, 2023, CMS issued Transmittal 11912 / Change Request 12669 - Instructions Relating to the Evaluation of Section 1115 Waiver Days in the Calculation of Disproportionate Share Hospital Reimbursement. This transmittal provides updated direction to Medicare Administrative Contractors (MACs) related to the evaluation of Section 1115 Waiver days in the calculation of Disproportionate Share Hospital (DSH) reimbursement for open cost reports and cost reports currently under administrative appeal.

This direction arises out of the decision in favor of providers in Bethesda Health Inc v. Azar (DC Circuit 2020).

MACs are instructed to review the 1115 Waiver Days being claimed as Medicaid eligible, as follows.

1. The MAC will review the program documents to verify the program is 
◾ an 1115 Waiver UCP or 
◾ provides assistance to uninsured and underinsured patients in paying their health insurance premiums, or other similar waiver programs.
2. The MAC must select a sample for review.
3. The MAC will review the sample to verify the days are
◾ inpatient days properly claimed as part of that program and
◾ inpatient days on the 1115 waiver program log.
4. The MAC will review the length of stay and type of unit where the care took place to verify the days are:
◾ for acute inpatient care and
◾ in a routine inpatient care area of the hospital.

The MAC is instructed to allow the days in the numerator of the Medicaid Fraction of the Medicare DSH DPP calculation if all four of those elements are met.

Florida, Kansas, Massachusetts, New Mexico, Tennessee, and Texas operate approved Uncompensated Care Pool 1115 demonstrations.

Arkansas, Massachusetts, Oklahoma, Rhode Island, Tennessee, Utah, and Vermont currently operate approved premium assistance section 1115 demonstrations.

The CR is effective April 17, 2023, with an Implementation Date of May 17, 2023.

Please contact me or your GDS representative for a link to the Transmittal or to discuss whether and how it impacts your Medicare DSH reimbursement. #hospital #reimbursement #costreport #medicarecostreport