The Department is proposing to update payment rates based on current methodologies and to reflect more recent hospital cost reports and/or other information relevant to hospital reimbursement. The final rates will apply to Medicaid payments for outpatient hospital visits in the state fiscal year beginning July 1, 2001.
Provisions of
2001 Wisconsin Act 16 direct the Department of Health and Family Services to submit a plan for 14-day passive review to the Wisconsin Legislature Joint Committee on Finance to distribute Medicaid and BadgerCare funds for outpatient hospital services provided through fee-for-service and through managed care. The Joint Committee on Finance has approved the Department's plan.
As required by federal statute and regulations, the proposed payment rates are restricted by the federal Medicare upper limit requirement and target a share of funding to hospitals that serve a disproportionate number of low-income patients.
Outpatient Hospital Services
Wisconsin Medicaid reimburses hospitals for outpatient services in accordance with all current and future applicable Federal and State laws and regulations.
Under the Wisconsin Medicaid Outpatient State Plan, outpatient hospital services are paid at an interim rate per visit with a retrospective final settlement for the fiscal year based on the hospital's audited cost report.
Provisions of
2001 Wisconsin Act 16 (the 2001-2003 state budget) authorized funding to increase payments to hospitals and managed care providers for acute care outpatient hospital services. The Department's plan provides a 12 percent increase to total statewide outpatient hospital payments and a 12% increase to the outpatient hospital portion of the monthly HMO (managed care) capitation payment. The Act included a hold harmless clause that establishes that if a hospital's outpatient rate per visit is lower than their outpatient rate per visit for the previous rate year, the hospital shall be paid at the previous rate year's outpatient rate per visit. Therefore, under this methodology, a hospital's rate will not be less than the same hospital's June 30, 2001 rate.
Interim Rate. The Wisconsin Medicaid outpatient rate per visit is calculated as follows:
The Wisconsin Medicaid costs and visits for the most recent audited cost report available to the department as of the 31st of May prior to the start of the rate year are used to calculate the Wisconsin Medicaid outpatient rate per visit.
For each hospital, using the audited cost report, the total outpatient costs are divided by the total outpatient visits to calculate the hospital's specific cost per visit.
The hospital specific cost per visit is inflated to the end of the rate year using the DRI inflation index.
The inflated hospital specific cost per visit is multiplied by the budget neutrality factor. The budget neutrality factor is established by dividing the total dollars budgeted for hospital outpatient services by the total estimated inflated hospital outpatient costs for the budget year. The total estimated inflated outpatient costs for the budget year is the sum of all of the individual hospitals' Hospital Specific Cost per Visit times the Medicaid outpatient visits for the previous calendar year. The result of this calculation is the hospital specific outpatient rate per visit for the rate year.
Final Settlement. Final settlement of outpatient reimbursement for the settlement year shall be a hospital's allowable audited outpatient costs in the final settlement year as determined according to applicable Medicare and Medicaid standards and principles of reimbursement. The resulting amount is limited by the lesser of the following amounts:
1. Customary outpatient charges in the final settlement year;
2. The sum of the rate per outpatient visit effective for the final settlement year multiplied by the number of Medicaid outpatient visits for the period; or
3. The sum of the interim clinical diagnostic laboratory reimbursement plus the lower of cost or charges for other services.
Major and Minor Border Status Hospitals. Outpatient hospital services provided at major and minor border status hospitals, and all other out-of-state hospitals, are reimbursed at 50% of allowable charges.
Hospitals Paid for Critical Access Hospital Outpatient Services
Critical Access Hospitals. Critical access hospitals (CAH) located in Wisconsin will be reimbursed according to a determination of the hospital's allowable audited costs for Medicaid outpatient services.
Interim Payment Rate Per Visit. Critical access hospitals may request an adjustment to be paid for allowable costs for outpatient services. Hospitals that receive such an adjustment under this section are not eligible to receive a rural hospital adjustment for outpatient services. The interim payment rate per visit will be determined based on a hospital's most recent audited cost report and additional information provided by the hospital to the Department to provide a reasonable estimate of the final settlement.
Final Settlement. The rate per visit limitation will not include any “Critical Access Hospital Interim Cost Payment Adjustment." The critical access hospital will be reimbursed any additional reimbursement that results from the following calculations.
Calculation of Reimbursable Critical Access Hospital Cost. The reimbursable critical access hospital cost of providing outpatient hospital services for Medicaid recipients will be determined as the lesser of:
1. Customary outpatient charges in the final settlement year; or
2. The sum of the interim clinical diagnostic laboratory reimbursement plus the lesser of the following for the other services (other than the above laboratory services):
(a) Total outpatient charges for other services in the final settlement year; or
(b) Total audited costs for other services in the final settlement year.
Limits on Final Settlement:
If the final settlement results in an amount due to the WMAP, this amount may be applied to any amount owed to the hospital under the critical access hospital inpatient reimbursement provisions.
If the reimbursable critical access hospital costs exceed the total final settlement amount, the Department will reimburse the hospital the amount by which costs exceed payments after such amount is reduced by the amount, if any, by which payments exceed costs under section 5900 of the Inpatient Hospital Plan relating to critical access hospital outpatient reimbursement.
If payments exceed costs, the Department will not recover excess payments from the hospital. However, excess payments may be applied to any amount owed to the hospital under the critical access hospital outpatient reimbursement provisions.
If the reimbursable critical access hospital costs exceed the total final settlement amount, the Department will reimburse the hospital the amount by which costs exceed payments after such amount is reduced by the amount, if any, by which payments exceed costs under the Inpatient Hospital Services provisions relating to critical access hospital inpatient reimbursement.
Proposed Outpatient Hospital Rates for the 2001-2002 Rate Year
Attachment A: Outpatient rate per visit for each hospital.
The Wisconsin Medicaid Outpatient Hospital State Plans include a complete description of hospital payment methodology.
Copies of Proposed Changes and Proposed Payment Rates
Copies of the proposed changes are sent to every county social services or human services department main office where they will be available for public review. For more information, interested persons may fax or write to:
Hospitals, Physicians and Clinics Section
FAX (608) 266-1096
Bureau of Fee-for-Service Health Care Benefits
Division of Health Care Financing
P. O. Box 309
Madison, WI 53701-0309
Written Comments
Written comments on the proposed changes are welcome and should be sent to the above address. The comments received on the changes will be available for public review between the hours of 7:45 a.m. and 4:30 p.m. daily at:
Division of Health Care Financing
Room 350, State Office Building
One West Wilson Street
Madison, WI
Attachment A
Outpatient Hospital Rates Effective 7/1/01
Provider Rates per % of
Name City Number Visit Charges
FOND DU LAC MENTAL HEALTH FOND DU LAC 10062400
50%
MILWAUKEE PSYCHIATRIC WAUWATOSA 10062800 36.04
MILWAUKEE CO MENTAL HEALTH MILWAUKEE 10062900 210.29
WINNEBAGO WINNEBAGO 10063000 50%
WAUKESHA CO M H WAUKESHA 10063300 50%
MENDOTA MADISON 10063400 31.87
NORTH CENTRAL H C WAUSAU 10063700 81.18
ROGERS MEMORIAL OCONOMOWOC 10063800 50%
NORWOOD H C MARSHFIELD 10063900 50%
BROWN CO MENTAL HEALTH GREEN BAY 10064500 71.62
LIBERTAS GREEN BAY 10065600 66.58
BELLIN PSYCH GREEN BAY 10065900 73.14
ROGERS MEMORIAL WEST ALLIS 10066300 24.58
FROEDTERT MILWAUKEE 11000400 224.22
CHIPPEWA VALLEY DURAND 11000500 147.59
SOUTHWEST HEALTH CTR PLATTEVILLE 11000600 125.03
ST MARY'S RHINELANDER 11000700 120.28
SACRED HEART TOMAHAWK 11000800 168.44
BAY AREA MARINETTE 11001400 131.98
REEDSBURG MEM REEDSBURG 11001500 94.89
HAYWARD AREA HAYWARD 11001600 108.29
MERITER MADISON 11001700 167.93
ST MICHAEL'S STEVENS POINT 11006100 135.57
MYRTLE WERTH MENOMONIE 11006200 75.86
FRANCISCAN SKEMP MED. CTR LA CROSSE 11006300 78.34
TAYLOR CO MEDFORD 11006400 141.51
VICTORY MEM STANLEY 11006500 158.58
WAUKESHA MEM WAUKESHA 11006600 103.19
ST ELIZABETH APPLETON 11006700 113.58
RIVER FALLS AREA RIVER FALLS 11006800 115.06
LAKEVIEW MED CTR RICE LAKE 11006900 177.27
SACRED HEART EAU CLAIRE 11007100 88.94
STOUGHTON STOUGHTON 11007200 101.50
GOOD SAMARITAN MERRILL 11007300 90.43
ST JOSEPH'S HILLSBORO 11007400 157.04
ST JOSEPH'S CHIPPEWA FALLS 11007500 87.01
APPLE RIVER HOSPITAL AMERY 11007600 167.85
KENOSHA MEMORIAL KENOSHA 11007800 86.91
VERNON MEM VIROQUA 11008000 106.21
WAUPUN MEM WAUPUN 11008100 143.28
HOLY FAMILY NEW RICHMOND 11008200 103.06
ST MARY'S MEQUON 11008300 139.63
ST CLARE MONROE 11008400 132.03
WAUSAU WAUSAU 11008500 161.80
COMMUNITY MEMORIAL EDGERTON 11008600 132.62
MEMORIAL HOSP OF IOWA CO DODGEVILLE 11008700 100.03
RIVERVIEW WIS. RAPIDS 11008800 155.76
AURORA MEDICAL CENTER TWO RIVERS 11008900 144.78
SHEBOYGAN MEM SHEBOYGAN 11009000 118.85
ST JOSEPH'S MARSHFIELD 11009100 214.57
HARTFORD MEMORIAL HARTFORD 11009200 143.00
RUSK CO MEMORIAL LADYSMITH 11009300 94.37
ST MICHAEL MILWAUKEE 11009400 107.86
DIVINE SAVIOR PORTAGE 11009500 93.88
ST NICHOLAS SHEBOYGAN 11009800 182.59
THEDA CLARK NEENAH 11009900 93.01
COMMUNITY MEMORIAL SPOONER 11010000 121.93
MERCY MEDICAL OSHKOSH 11010100 113.23
BELLIN GREEN BAY 11010200 56.02
ST MARY'S MILWAUKEE 11010300 144.82
NEW LONDON NEW LONDON 11010400 106.76
MEMORIAL OF NEILLSVILLE NEILLSVILLE 11010500 63.96
BURLINGTON MEM BURLINGTON 11010900 203.03
BERLIN MEMORIAL BERLIN 11011000 114.93
OCONOMOWOC MEMORIAL OCONOMOWOC 11011100 116.81
ST JOSEPH'S WEST BEND 11011200 118.63
MERCY JANESVILLE 11011400 142.89
CUMBERLAND MEM CUMBERLAND 11011600 96.48
LUTHER EAU CLAIRE 11011800 99.24
FT ATKINSON MEMORIAL FT ATKINSON 11011900 103.00
ADAMS CO MEM FRIENDSHIP 11012000 209.08
ST VINCENT GREEN BAY 11012100 113.64
BEAVER DAM BEAVER DAM 11012200 144.32
OCONTO MEMORIAL OCONTO 11012300 136.16
ST FRANCIS MILWAUKEE 11012400 173.03
COLUMBUS COMMUNITY COLUMBUS 11012800 108.70
GUNDERSON LUTHERAN LA CROSSE 11012900 146.10
ST AGNES FOND DU LAC 11013000 126.40
RIPON MEM RIPON 11013200 133.46
HOWARD YOUNG WOODRUFF 11013300 160.70
SHAWANO SHAWANO 11013400 151.65
ST LUKE'S RACINE 11013500 113.04
SAUK PRAIRIE MEM PRAIRIE DU SAC 11013600 120.09
ST MARY'S RACINE 11013700 109.42
ST MARY'S GREEN BAY 11013800 100.90
BELOIT MEMORIAL BELOIT 11014000 104.84
OCONTO FALLS COM MEM OCONTO FALLS 11014100 125.04
COMMUNITY MEMORIAL MENOMONEE FALLS 11014300 128.89
HOLY FAMILY MANITOWOC 11014600 108.46
HESS MEMORIAL MAUSTON 11014700 79.04
MEMORIAL HOSP OF LAFAYETTE CO DARLINGTON 11014800 171.80
ST CROIX VALLEY MEM ST CROIX FALLS 11015000 186.84
AREA HEALTH CARE BOSCOBEL 11015200 79.36
CALUMET MED CTR CHILTON 11015300 122.79
WATERTOWN MEM WATERTOWN 11015400 117.26
RICHLAND RICHLAND CTR 11015500 132.16
OSSEO AREA OSSEO 11015600 117.40
FRANCIS SKEMP MED CTR SPARTA 11015900 168.27
TRI CO MEM WHITEHALL 11016000 70.51
COMMUNITY MEMORIAL BALDWIN 11016100 143.20
MEMORIAL MEDICAL CNTR BARRON 11016200 126.57
BURNETT GENERAL GRANTSBURG 11016600 128.18
FLAMBEAU MED CTR PARK FALLS 11016700 132.16
PRAIRIE DU CHIEN MEM PRAIRIE DU CHIEN 11016900 108.77
ST JOSEPH'S MILWAUKEE 11017100 141.81
ST LUKE'S MILWAUKEE 11017200 135.52
WEST ALLIS MEM WEST ALLIS 11017300 108.59
COLUMBIA MILWAUKEE 11017400 131.89
FRANCIS SKEMP MEDICAL CENTER ARCADIA 11017600 126.86
TOMAH MEMORIAL TOMAH 11017800 132.26
GRANT REGIONAL MEMORIAL LANCASTER 11018000 100.75
LANGLADE MEMORIAL ANTIGO 11018100 149.80
WILD ROSE WILD ROSE 11018200 130.24
BLACK RIVER MEM BLACK RIVER FALLS 11018300 159.67
DOOR CO MEMORIAL STURGEON BAY 11018400 117.77
BLOOMER COMMUNITY MEMORIAL BLOOMER 11018500 112.86
RIVERSIDE WAUPACA 11018600 109.51
HUDSON MEMORIAL HUDSON 11018700 186.96
LADD MEMORIAL OSCEOLA 11018800 130.63
EAGLE RIVER MEM EAGLE RIVER 11018900 177.19
APPLETON MEDICAL CENTER APPLETON 11019000 111.52
ELMBROOK MEM BROOKFIELD 11019400 163.83
MEMORIAL MEDICAL CENTER ASHLAND 11019500 123.36
CHILDREN'S OF WISCONSIN MILWAUKEE 11019700 189.85
SACRED HEART MILWAUKEE 11020000 120.03
SINAI SAMARITAN MILWAUKEE 11020400 151.18
INDIANHEAD MED CTR SHELL LAKE 11020700 114.63
KINDRED GREENFIELD 11021400 50%
LAKELAND ELKHORN 11021600 98.57
VALLEY VIEW PLYMOUTH 11021700 135.20
UNIVERSITY OF WISCONSIN MADISON 11022000 138.00
LAKEVIEW REHABILITATION WATERFORD 11022100 150.25
ST. MARY'S SUPERIOR 11022400 115.31
AURORA HEALTH CARE KENOSHA 11022500 50%
ST. CLARE BARABOO 11022800 112.06
ST. MARY'S MADISON 11022900 176.20
CHILDREN'S HOSPITAL KENOSHA 11023000 50%
SELECT SPECIALTIES WEST ALLIS 11023200 50%
NEXTCARE SPECIALTY HOSPITAL MILWAUKEE 11023300 50%
CHILDREN'S HOSPITAL NEENAH 11023400 50%
OUT OF STATE HOSPITALS 50%
