Hospital Access Payment. Within the limits of the budgeted allocation from the hospital assessment fund, the Department will pay the HMO a monthly hospital inpatient access payment and a monthly hospital outpatient access payment. The Department’s monthly hospital access payments to the HMOs are made as prospective “per member per month” payments, unadjusted for CDPS and rate region realignment. Within 15 calendar days after receipt of the monthly amounts, the HMO shall make payments to eligible hospitals based on the number of qualifying discharges and visits in the previous month. These payments are in addition to any amount the HMO is required by agreement to pay the hospital for provision of services to HMO members. An “eligible hospital” means a Wisconsin hospital that is not a critical access hospital, an institution for mental disease, or a general psychiatric hospital for which the Department has issued a certificate of approval that applies only to the psychiatric hospital and that is not a satellite of an acute care hospital. A list of qualifying hospitals is available from the Department upon request. “Qualifying discharges and visits” are inpatient discharges and outpatient visits for which the HMO made payments in the month preceding the Department’s monthly access payment to the HMO for services to the HMO’s Medicaid and BadgerCare Plus members, other than Core Plan members or members who are eligible for both Medicaid and Medicare. HMOs shall exclude all members who are dually-eligible and all dual-eligible claims. If a third party pays the claim in full, and the HMO does not make a payment, the claim shall not count as a qualifying claim for the hospital access payment. If the HMO pays any part of the claim, even if there is a third party payer, the claim will be counted as a qualifying claim for the hospital access payment.
Hospital Access Payment. Within the limits of the budgeted allocation from the hospital assessment fund, the Department will pay the HMO a monthly hospital inpatient access payment and a monthly hospital outpatient access payment. The Department’s monthly hospital access payments to the HMOs are made as prospective “per member per month” payments, unadjusted for CDPS and rate region realignment. Within 15 calendar days after receipt of the monthly amounts, the HMO shall make payments to eligible hospitals based on the number of qualifying discharges and visits in the previous month. These payments are in addition to any amount the HMO is required by agreement to pay the hospital for provision of services to HMO members. An “eligible hospital” means a Wisconsin hospital that is not a critical access hospital, an institution for mental disease, or a general psychiatric hospital for which the Department has issued a certificate of approval that applies only to the psychiatric hospital and that is not a satellite of an acute care hospital. A list of qualifying hospitals is available from the Department upon request. “Qualifying discharges and visits” are paid inpatient discharges and paid outpatient visits made in the month preceding the Department’s monthly access payment to the HMO for services to the HMO’s Medicaid and BadgerCare Plus members, other than Core Plan members or members who are eligible for both Medicaid and Medicare.
