Attachment+A+-+ND+Medicaid+State+Plan.pdf

STATE: North Dakota Attachment 4.19-A

TN No.: 24-0009 Supersedes Approval Date: _______________ Effective Date: 07-01-2024 TN No.: 22-0007

METHOD FOR REIMBURSING INPATIENT HOSPITAL SERVICES

1. Hospitals paid using Prospective Payment System (PPS).

a. In-state hospital service reimbursement paid to all hospitals and distinct part units, except those hospitals and distinct part units specifically identified in Section 2, will be made on the basis of a Prospective Payment System (PPS). The system generally follows the Medicare PPS in terms of the application of the system. PPS uses diagnostic related groups (DRG) to pay for services upon discharge. Medical education costs are excluded from the PPS.

b. The base year used for the calculation of the base rate is the years ending December 31, 2019 and December 31, 2020. The base year used for the calculation of the capital rate is the year ending June 30, 2007. The base rate established for hospitals paid by PPS is effective July 1, 2022. The capital rate established for hospitals paid by PPS is effective July 1, 2009. The base rate and capital rate shall be increased by two percent effective July 1, 2024.

c. Vacated.

d. Effective July 1, 2022 the DRG classification and grouper system is the All Patient Refined Diagnosis Related Grouper version 39.

e. Vacated

f. Vacated.

g. A capital payment will be included in the PPS payment for all discharges. Capital payments may not be paid to a transferring hospital.

h. Outlier Payments.

(1) A cost outlier payment is made when costs exceed a threshold of two times the DRG rate or $60,000, whichever is greater. Costs above the threshold will be paid at 60 percent of billed charges.

(2) For DRG's 580-640 relating to neonates the cost outlier thresholds are the greater of 1.5 times the DRG rate or $57,000. Costs above the threshold will be paid at 80 percent of billed charges.

August 7, 2024

Attachment A North Dakota Medicaid State Plan 4.19-A

TN No.: 24-0009 Supersedes Approval Date: _______________ Effective Date: 07-01-2024 TN No.: 23-0014

i. Transfers. Payment will be the full DRG payment, inclusive of outliers and capital, to the final hospital. Per diem payments will be made to the transferring hospitals.

Total per diem payments to transferring hospitals may not exceed the full DRG payment, exclusive of outliers and capital. Per diem is the basic DRG payment divided by the arithmetic untrimmed average length of stay. A patient may be transferred to another hospital and then transferred back to the original hospital which becomes the final hospital, in such case, the original hospital will not receive per diem payments for the portion of the stay occurring prior to the transfer. The days of stay in the original hospital prior to the transfer out and back will be included as part of the calculation of the full DRG payment, inclusive of outliers and capital.

2. Payments for hospitals excluded from prospective payment system.

a. Excluded from hospitals paid using PPS are psychiatric, rehabilitation, cancer, long term care, and children's hospitals and psychiatric and rehabilitation distinct part units of hospitals, and hospitals designated as Critical Access Hospitals.

b. Payment for inpatient psychiatric and rehabilitation services are made using a prospective per diem rate. Effective July 1, 2009 the hospital or distinct part unit per diem rate is calculated based on the lesser of a maximum prospective per diem rate established for each type of service or the hospital's cost to provide the service based on the hospital cost report for the year ended June 30, 2007. The hospital's calculated per diem rate shall be inflated by three percent effective July 1, 2024.

The maximum prospective per diem rate effective July 1, 2009 is $1,020.48 per day for psychiatric services and $1,519.80 for rehabilitation services.

c. Effective July 1, 2009 inpatient services furnished by a hospital having an average inpatient length of stay greater than 25 days and designated a long-term care hospital by Medicare shall be paid on a prospective basis using a percentage of charges established using the hospital's most recent audited Medicare cost report available as of June 1 of each year. The percentage of charges as established shall be adjusted annually on July 1. The payment based on a percentage of charges is an all-inclusive rate and is not subject to cost settlement.

d. Payments to cancer and children’s hospitals are made based on a reasonable cost basis, using the Medicare methods and standards set forth in 42 CFR 413. An interim payment rate based on the hospital’s cost to charge ratio from the latest available cost report will be made until such time as a cost settlement is made. The interim cost to charge ratio for a hospital which has not filed a cost report shall be 70%.

e. Indian Health Hospitals are paid inpatient per diem rates in accordance with the most recently published Federal Register notice.

f. Effective July 1, 2007, payments to hospitals designated as Critical Access Hospitals shall be made based on reasonable costs using the Medicare methods and standards set forth in 42 CFR 413. An interim per diem payment rate shall be

August 7, 2024

3 STATENorhDakotaAttachment419APage2abasedonthehospitalsMedicareintermperdiemratedecreasedby1olowillbemadeuntilsuchtimeasacostsettlementismadeCostsettlementtoreasonablecostforTitleXXserviceswillbebasedontheMedicarecostreportandwilloccurafterthehospitalsMedicarecostreporthasbeenauditedandfinalizedbytheMedicarefiscalintermediarySVACATEDDisproportonaleShareHospitalDSHAdjustmentsaHospitalswhchprovideservcestoadsproporüonateshareofMedicaidrecipientsshallreceiveaDSHpaymentsubjecttoanylmitationssetforthinthissectionbThefollowingcriteramustbemetbeforeahospitalisdeierminedtobeeligibleforaDSHpaymentadjustment1AhospitalmusthaveaAMedicaidinpatientutilizationrateofatleastITNNo180026SupersedesTNNo13004 ApprovialDateFFRqßzntqEffectiveDate02012019

STATE: North Dakota Attachment 4.19 -A and at least one standard deviation above the mean Medicaid inpatient utilization rate for hospitals receiving Medicaid payments or payments made on behalf of Medicaid eligible recipients by managed care entities, or a low -income inpatient utilization rate exceeding 25 percent;

and

b) At least two obstetricians with staff privileges at the hospital who have agreed to provide obstetric services to individuals entitled to such services under a State Medicaid Plan. In the case of a hospital located in a rural area, (that is, an area outside of a metropolitan statistical area, as defined by the Executive Office of Management and Budget), the term obstetrician" includes any physician with staff privileges at the hospital to perform non - emergency obstetric procedures;

2) A hospital which meets the criteria in Section 3.b(1)(a) but not 3.b(1)(b) is eligible if:

a) The inpatients of a hospital are predominantly individuals under 18 years of age; or

b) The hospital did not offer non- emergency obstetric services as of December 21, 1987; or

3) A state -owned psychiatric hospital is eligible if the hospital's Medicaid inpatient utilization rate exceeds 1 %.

C. The Medicaid inpatient utilization rate for a hospital shall be computed as the total number of Medicaid inpatient days and managed care inpatient days for Medicaid eligible recipients in a cost reporting period, divided by the total number of the hospital's inpatient days in the same period.

d. The low- income utilization rate is the sum (expressed as a percentage) of the fraction, calculated as follows:

1) Total Medicaid inpatient revenues paid to the hospital, plus revenues paid to the hospital from managed care entities on behalf of Medicaid eligible recipients, plus the amount of the cash subsidies received directly from State and local governments in a cost reporting period, divided by the total amount of revenues of the hospital for inpatient services (including the amount of such case subsidies) in the same cost reporting period; and,

2) The total amount of the hospital's charges for inpatient hospital services attributable to charity care (care provided to individuals who have no source of payment, third -party or personal resources) in a cost reporting period, divided by the total amount of

TN No. 01 -003 1'9

Supersedes Approval Date 0(0 TN No. 95 -012

41P / 1D / Effective Date D/ 1 o J

State: North Dakota Attachment 4.19 -A inpatient services in the same period. The total number of inpatient charges attributed to charity care shall not include contractual allowances and discounts other than for indigent patients not eligible for medical assistance under an approved Medicaid State Plan) that is, reductions in charges given to other third -party payers, such as HMO's, Medicare, or Blue Cross.

e. A hospital which wishes to be considered for disproportionate share payments based on a low income utilization rate must submit, annually, a request indicating this desire and information sufficient to enable the computation of the low income utilization rate by April 1.

f. For the purpose of paying disproportionate share hospitals, there are four categories of hospitals: hospitals paid using PPS; the state psychiatric hospital; critical access hospitals, and other hospitals.

g. DSH payment adjustments are calculated as follows:

1) Eligible hospitals paid using PPS and eligible critical access hospitals will receive a DSH payment adjustment equal to four percent plus an additional one percent for each percentage point that the hospital's Medicaid utilization rate exceeds one standard deviation above the state's mean inpatient utilization rate for all hospitals receiving Medicaid payments. The eligible hospital's base DRG payment or the per diem payment for the quarter being reported on form 64 will be multiplied times the DSH adjustment percentage to determine the DSH payment amount for the quarter.

2) Eligible other hospitals will receive a DSH payment adjustment equal to $1.00 plus one -tenth of one percent for each percentage point that the hospital's Medicaid utilization rate exceeds one standard deviation above the state's mean inpatient utilization rate for all hospitals receiving Medicaid payments. The eligible hospital's actual interim payments for the quarter being reported on form 64 will be multiplied times the DSH adjustment percentage to establish the hospital's DSH payment adjustment. The DSH payment adjustment is final and no recoupment or additional payment for DSH will be made when a settlement of the interim payment to reasonable cost is made.

TN No: 09-027

Supersedes Approval Date: MAR 2 2 2010 Effective Date: 01 -01 -2010

TN No: 04007

STATE: North Dakota Attachment 4. 19- A

3) If eligible, the state psychiatric hospital will receive a DSH payment adjustment calculated as an amount equal to $ 1. 00 plus the state' s disproportionate share allotment less the quarterly DSH payment adjustments made to all other eligible hospitals. The DSH payment adjustment to the state hospital will be made quarterly. The quarterly payment will be calculated by dividing the state' s annual disproportionate share allotment by four and subtracting all disproportionate share payments made to other eligible hospitals in that quarter. Any adjustments to the state's disproportionate allotment will be corrected in the quarter the adjustment is made.

h. DSH payment adjustments will be limited as follows:

1) Effective July 1, 1995 the DSH payment adjustment for any eligible hospital may not exceed the greater of the total of the unreimbursed costs of providing services to Medicaid recipients and of providing services to uninsured patients or the limitations set forth in section 1923( g) of the Act.

2) If requested by the department, eligible hospitals must submit information on unreimbursed costs of providing hospital services to Medicaid recipients and of providing hospital services to uninsured patients before a DSH payment adjustment can be made.

3) Total DSH payment adjustments paid to all eligible hospitals may not exceed the state' s DSH allotment.

An independent certified audit will be submitted to CMS for each completed Medicaid State plan rate year, consistent with 42 CFR Part 455, Subpart D.

1) To the extent that audit findings demonstrate that DSH payments exceed the documented hospital specific cost limits, the overpayments will be collected and redistributed.

2) Any overpayments collected will be redistributed to the other hospitals that were eligible and received payments during the corresponding DSH year.

The payment will be based on the eligible hospital' s proportion of uninsured cost relative to aggregate of uninsured costs of all eligible hospitals who received payments during the corresponding DSH year and who do not exceed their hospital specific DSH limit.

4. Out -of -State Inpatient Hospital Service Payments.

a. Out-of-state inpatient hospital service payments, except as identified below, shall be paid based on a percent of billed charges established by the Medicaid agency which shall not be Tess than 35%. The percent paid may be adjusted annually on July 1.

b. The department may negotiate a payment methodology for organ transplants performed by out-of-state hospitals.

c. Out-of-state children' s hospital payments will be based on the per diem rate established by the Medicaid agency in the state where the hospital is located.

TN No. 16- 0013

Supersedes Approval DateWOV 17 2016 Effective Date 07- 01- 2016

TN No. 11- 005

Page 5a

5. Inpatient Psychiatric Services for Individuals Under 21.

a. Payments for inpatient psychiatric services for individuals under twenty -one provided in licensed residential treatment centers will be made using a prospective payment system developed by the state specifically for residential treatment centers as set forth in North Dakota Administrative Code, 75- 02 -09.

b. Payments for inpatient psychiatric services for individuals under twenty -one provided for in private psychiatric hospitals or psychiatric distinct part units will be made using the per diem rate established per paragraph 2.b.

C. Payments for inpatient psychiatric services for individuals under twenty -one provided for in the state hospital will be made based on reasonable costs. The state hospital will be paid on an interim basis using a cost to charge ratio until a cost settlement is made.

TN No. 11 -005

Supersedes Approval Date: SEP — 6 201 Effective Date: 7-01-2011

TN No. 02 -015

6. Payment for inappropriate level of care days provided in an inpatient hospital setting will be made at the statewide average nursing facility rate effective January 1 of each calendar year or the average of the rates for non -state owned intermediate care facilities in effect on January 1 of each year. Payment is available only if the following criteria are met:

a. The individual must be screened in need of nursing facility or intermediate care for the mentally retarded services using the level of care criteria applicable to nursing facilities or intermediate care facilities for the mentally retarded;

b. Services must not be otherwise available;

C. The hospital may not be participating as a swing bed hospital;

and

d. The criteria in paragraph a and b must be redetermined and met every 90 days following the initial determinations required in paragraphs a and b.

TN No. 4 <5- /

Supersedes Approval Date Effective Dated C t

TN No. New

STATE: North Dakota Attachment 4.19 A flwz 7

The State has in place a public process which complies with the requirements of Section 1902(a)(13)(A) of the Social Security Act.

Approval Date ID I Cie Plan # 98 -002

Effective Date M1 0) Ify Supersedes Plan # New

TN No: 23-0024 Approval Date: ______________ Effective Date: 7-01-2023 Supersedes TN No: 09-023

State: North Dakota Attachment 4.19-A

In-State PPS Hospital Value-Based Program

Effective July 1, 2023, in-state Prospective Payment System (PPS) hospitals shall participate in the North Dakota Medicaid Value-Based Purchasing (VBP) Program.

The North Dakota VBP program seeks to hold providers accountable for providing high quality care to Medicaid members, to be a part of the solution to reduce health disparities in the healthcare system, to maximize benefits to patients, to eliminate unnecessary procedures, and focus on keeping patients healthy rather than trying to increase the volume of services to ensure reimbursement.

Under the North Dakota VBP model, a portion of PPS hospital system inpatient reimbursement will be at risk. PPS hospital systems will be held financially accountable for satisfying program requirements and for improvement over time or maintaining high performance on a suite of quality and utilization metrics for the systems’ attributed populations identified through a standardized attribution process utilizing retrospective claims data. If the systems can hit provider-specific, reasonable targets, they will see no loss of revenue. If the systems fail to hit the targets, up to 4% of Medicaid revenue, for inpatient claims dollars, incurred at PPS hospitals for attributed members would be returned to the state. Providers that achieve targets on performance measures are given a second opportunity to earn the revenue back through a redistribution pool. Any revenue that is earned back through the redistribution pool will be paid in a single aggregate payment for each performance period through the State’s MMIS.

The first performance period will be 18 months (July 1, 2023 through December 31, 2024), with payment settlement by July 31, 2025. All subsequent performance periods will be on a calendar year basis with payment settlement by July 31st of the year following the performance year.

Complete details including technical information regarding program eligibility, performance measures, performance periods and payments are available on the North Dakota Department of Health and Human Services website at the following address:

https://www.hhs.nd.gov/healthcare/medicaid/provider/vbp.

February 27, 2024

TN No. 23-0023 Supersedes Approval Date_____________ Effective Date_07-01-2023___ TN No. 21-0019

Supplemental Payment for Inpatient Hospital Services provided by Critical Access Hospitals.

Effective July 1, 2023, a North Dakota critical access hospital shall receive up to two supplemental payments payable with the first payment being made no sooner than the quarter ending September 30, 2023 but not later than the quarter ending June 30, 2024 and the second payment being made no sooner than the quarter ending September 30, 2024 but no later than the quarter ending June 30, 2025. The supplemental payment shall be made in combination with the cost settlement to reasonable costs.

The supplemental payment established in accordance with this provision may not exceed the difference between the inpatient Medicaid expenditures and the Medicare upper payment limit, in the aggregate, for inpatient hospital services, as defined in 42 CFR 447.272. If a payment is made during the first, second or third quarter of the state fiscal year (SFY), it will not exceed 25, 50 or 75 percent of the available UPL, respectively. If the payment amount is not paid in its entirety due to its exceeding the UPL availability for any given quarter, then the remainder not paid during that quarter will be paid in the following quarter, up to the available UPL room left for the SFY.

Qualifying providers are exempt from the cost limitations on page 2 of this section.

This supplemental payment is for nonstate governmental and private ownership categories.

October 6, 2023

Page 9a

TN No. 23-0023 Supersedes Approval Date______________ Effective Date__07-01-2023__ TN No. 21-0019

The provider allotments for the period ending June 30, 2025 are:

Ashley Medical Center $ 24,000

St. Andrew' s Health Center $ 41,700

Southwest Healthcare Services $ 30,000

Towner County Medical Center $ 40,000

Carrington Health Center $ 48,000

Pembina County Memorial Hospital $ 26,400

Cooperstown Medical Center $ 40,600

St. Luke' s Hospital $ 44,000

Mercy Hospital of Devils Lake $ 750,000

St. Joseph' s Hospital & Health Center $ 900,000

Jacobson Memorial Hospital $ 48,000

Garrison Memorial Hospital $ 28,000

Unity Medical Center $ 80,000

St. Aloisius Medical Center $ 28,500

Sakakawea Medical Center $ 50,000

West River Regional Medical Center $ 60,000

Sanford Hillsboro $ 40,000

Jamestown Regional Medical Center $ 520,000

Kenmare Community Hospital $ 24,000

Cavalier County Memorial Hospital $ 30,000

Linton Hospital $ 40,000

Lisbon Area Health Services $ 48,000

Sanford Mayville $ 28,000

Nelson County Health System $ 20,000

Northwood Deaconess $ 40,000

Oakes Community Hospital $ 48,000

First Care Health Center $ 30,000

Presentation Medical Center $ 420,000

Heart of America Medical Center $ 110,000

Mountrail County Medical Center $ 40,000

Tioga Medical Center $ 40,000

Community Memorial Hospital $ 30,000

Mercy Hospital of Valley City $ 90,000

McKenzie County Medical Center $ 120,000

Mercy Medical Center $ 400,000

Wishek Community Hospital $ 40,000

October 6, 2023

State: North Dakota Attachment 4. 19- A

Citation Payment Adiustment for Provider Preventable Conditions

42 CFR 447, The Medicaid agency meets the requirements of 42 CFR Part 447, 434, 438; and Subpart A, and sections 1902( a)( 4), 1902( a)( 6), and 1903 with respect 1902( a)( 4), to non- payment for provider- preventable conditions.

1902( a)( 6), and 1903

Health Care- Acquired Conditions

The State identifies the following Health Care- Acquired Conditions for non- payment:

X Hospital- Acquired Conditions as identified by Medicare other than Deep Vein Thrombosis( DVT)/Pulmonary Embolism( PE) following total knee replacement or hip replacement surgery in pediatric and obstetric patients.

Prospective Payment( PPS) Hospitals- For claims with dates of service on or after March 1, 2012, when a health care- acquired condition occurs during hospitalization and the condition was not present on admission, claims shall be paid as though the health care acquired diagnosis is not present.

Hospitals excluded from prospective payment system- For claims with dates of service on or after

March 1, 2012, when a health care- acquired condition occurs during hospitalization and the condition was not present on admission, payment on claims shall be decreased by a percentage reduction. The percentage reduction is calculated as the covered charges for the health care-acquired conditions divided by the total charges.

Other Provider- Preventable Conditions

The State identifies the following Other Provider- Preventable Conditions for non- payment:

X Wrong surgical or other invasive procedure performed on a patient; surgical or other invasive procedure performed on the wrong body part; surgical or other invasive procedure performed on the wrong patient.

North Dakota Medicaid will adopt the baseline for other provider preventable conditions as identified by Medicare. The following reimbursement changes will apply:

Payment will be denied for these conditions in any health care setting and any other settings where these events may occur such as operating room, clinic, physician' s office, etc. For any

TN No. 12- 005 APR 27 2012Supersedes Approval Date_ Effective Date 03- 01- 2012

TN No. NEW , CMS ID: 7982E

State: North Dakota Attachment 4. 19-A

Citation Payment Adiustment for Provider Preventable Conditions ( cont.)

42 CFR 447, The Medicaid agency meets the requirements of 42 CFR Part 447, 434, 438; and Subpart A, and sections 1902( a)( 4), 1902( a)( 6), and 1903 with respect 1902( a)( 4), to non- payment for provider- preventable conditions.

1902( a)( 6), and 1903

Other Provider-Preventable Conditions( continued)

North Dakota Medicaid claim with dates of service on or after March 1, 2012, that contains one of these diagnosis codes, these claims will be denied and will not be reimbursed.

No reduction in payment will be made for a provider preventable condition when the condition existed prior to the initiation of treatment by that provider.

Reduction in payment will be made for a provider preventable condition when the condition existed after to the initiation of treatment by that provider.

Reduction in provider payment may be limited to the extent that the following apply:

1. The identified provider- preventable condition would otherwise result in an increase in payment; and

2. The portion of the payment directly related to treatment for, and related to, the provider-preventable condition can be reasonably isolated.

Non-payment for provider-preventable conditions does not prevent access to services for Medicaid beneficiaries.

If individual cases are identified throughout the PPC implementation period, the State will adjust reimbursement accordingly to the methodologies above.

TN No. 12- 005

APR 2 1ZSupersedes Approval Date Effective Date 03- 01- 2012 TN No. NEW

CMS ID: 7982E