Directed Payment for Eligible Out of-State Children’s Hospitals
Directed Payment for Eligible Out of-State Children’s Hospitals The Contractor is required to reimburse inpatient hospital and outpatient hospital services provided by eligible out-of-state children’s hospitals at one hundred thirty percent (130%) of the Medicaid reimbursement rate. This applies to claims for Hoosier Healthwise members that are less than 19 years of age. This reimbursement requirement is effective July 1, 2021, through June 30, 2023, in accordance with House Enrolled Act (HEA) 1305. Eligible out-of-state children’s hospitals are children’s hospitals located in a state that borders Indiana. In addition, the out-of-state children’s hospital must be a freestanding general acute care hospital, or a facility located within a freestanding general acute care hospital that is: ▪ Designated by the Medicare program as a children’s hospital; or ▪ Furnishes inpatient and outpatient health care services to patients who are predominantly individuals less than 19 years of age If a hospital does not meet the requirements of HEA 305, the hospital is not eligible for this reimbursement program and shall be paid at the out-of-network reimbursement rate. In-state children’s hospitals residing within Indiana are not eligible for this reimbursement program as they should be paid using the Hospital Assessment Fee factor. A list of eligible hospitals is provided to the Contractor. The Contractor shall reimburse eligible out-of-state children’s hospitals at one hundred thirty percent (130%) of the Medicaid increased reimbursement rate except for the following: ▪ For inpatient claims, the increase does not apply to the capital per-diem, medical education per-diem (if applicable), or the outlier payment (if applicable). ▪ For outpatient claims, the increase does not apply to clinical laboratory codes, details billed with revenue code 274, or details billed with revenue code 636.
Directed Payment for Eligible Out of-State Children’s Hospitals The Contractor is required to reimburse inpatient hospital and outpatient hospital services provided by eligible out-of-state children’s hospitals at one hundred thirty percent (130%) of the Medicaid reimbursement rate. This applies to claims for Hoosier Care Connect members that are less than 19 years of age. Effective July 1, 2021, through May 31, 2022, in accordance with House Enrolled Act (HEA) 1305 (2021) the Contractor shall reimburse eligible out-of-state children’s hospitals at one hundred thirty percent (130%) of the Medicaid increased reimbursement rate except for the following: • For inpatient claims, the increase does not apply to the capital per-diem, medical education per-diem (if applicable), or the outlier payment (if applicable). • For outpatient claims, the increase does not apply to clinical laboratory codes, details billed with revenue code 274, or details billed with revenue code 636. Effective June 1, 2022 pursuant to Indiana House Enrolled Act (HEA) 1112 (2022) the Contractor is required to reimburse inpatient hospital and outpatient hospital services provided by eligible out-of-state children’s hospitals at one hundred thirty percent (130%) of the Medicaid reimbursement rate. The Contractor shall reimburse eligible out-of-state children’s hospitals at one hundred thirty percent (130%) of the Medicaid increased reimbursement rate except for the following: • For inpatient claims, the increase does not apply to the capital per-diem or medical education per-diem (if applicable). • For outpatient claims, the increase does not apply to clinical laboratory codes, details billed with revenue code 274, or details billed with revenue code 636. Eligible out-of-state children’s hospitals are children’s hospitals located in a state that borders Indiana. In addition, the out-of-state children’s hospital must be a freestanding general acute care hospital, or a facility located within a freestanding general acute care hospital that is: • Designated by the Medicare program as a children’s hospital; or • Furnishes inpatient and outpatient health care services to patients who are predominantly individuals less than 19 years of age • If a hospital does not meet the requirements, the hospital is not eligible for this reimbursement program and shall be paid at the out-of-network reimbursement rate. In-state children’s hospitals residing within Indiana are not eligible for this reimbursement program as they should be paid usi...
Directed Payment for Eligible Out of-State Children’s Hospitals The Contractor is required to reimburse inpatient hospital and outpatient hospital services provided by eligible out-of-state children’s hospitals at one hundred thirty percent (130%) of the Medicaid reimbursement rate. This applies to claims for Hoosier Care Connect members that are less than 19 years of age. Effective July 1, 2021, through May 31, 2022, in accordance with House Enrolled Act (HEA) 1305 (2021) the Contractor shall reimburse eligible out-of-state children’s hospitals at one hundred thirty percent (130%) of the Medicaid increased reimbursement rate except for the following:
EXHIBIT 1. C SCOPE OF WORK
