Common use of Directed Payment for Eligible Out Clause in Contracts

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 using the Hospital Assessment Fee factor. A list of eligible hospitals is provided to the Contractor.

Directed Payment for Eligible Out. of-State Children’s Hospitals The In accordance with IC 12-15-15-1.2, 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. Per 42 CFR 440.20, outpatient hospital services mean preventive, diagnostic, therapeutic, rehabilitative, or palliative services that: (1) are furnished to outpatients; (2) are furnished by or under the direction of a physician or dentist; and (3) are furnished by an institution that: (i) is licensed or formally approved as a hospital by an officially designated authority for State standard-setting; and ▪ (ii) meets the requirements for participation in Medicare as a hospital; and (4) may be limited by a Medicaid agency in the following manner: A Medicaid agency may exclude from the definition of “outpatient hospital services” those types of items and services that are not generally furnished by most hospitals in the State. Effective July 1, 2021, through May 31, 2022, in accordance with House Enrolled Act (HEA) 1305 (2021) IC 12-15-15-1.2 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 using the Hospital Assessment Fee factor. A list of eligible hospitals is provided to the Contractor.

Directed Payment for Eligible Out. of-State Children’s Hospitals The In accordance with IC 12-15-15-1.2, 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. Per 42 CFR 440.20, outpatient hospital services mean preventive, diagnostic, therapeutic, rehabilitative, or palliative services that: EXHIBIT 1. E SCOPE OF WORK (1) are furnished to outpatients; (2) are furnished by or under the direction of a physician or dentist; and (3) are furnished by an institution that: (i) is licensed or formally approved as a hospital by an officially designated authority for State standard-setting; and ▪ (ii) meets the requirements for participation in Medicare as a hospital; and (4) may be limited by a Medicaid agency in the following manner: A Medicaid agency may exclude from the definition of “outpatient hospital services” those types of items and services that are not generally furnished by most hospitals in the State. Effective July 1, 2021, through May 31, 2022, in accordance with House Enrolled Act (HEA) 1305 (2021) IC 12-15-15-1.2 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 using the Hospital Assessment Fee factor. A list of eligible hospitals is provided to the Contractor.network