(1) The medicaid agency measures the effectiveness of budget neutral rebasing by applying a budget neutrality adjustment factor to the base payment rates for both inpatient and outpatient hospitals as needed to maintain aggregate payments under rebased payment systems.
(a) The agency performs budget-neutrality adjustments and measurement by prospectively adjusting conversion factors and rates to offset unintentional aggregate payment system decreases or increases. The agency publishes conversion factors and rates which reflect any required budget neutrality adjustment.
(b) The following rates and factors are not adjusted by the BNAF:
(i) Inpatient per diem;
(ii) Ratio of costs-to-charges (RCC);
(iii) Critical access hospital (CAH) weighted costs-to-charges (WCC);
(iv) Inpatient pain management and rehabilitation (PM&R);
(v) Per-case rates;
(vi) Administrative day rates;
(vii) Long-term acute care (LTAC);
(viii) Chemical-using pregnant women (CUP);
(ix) Outlier parameters;
(x) Outpatient services paid at the resource-based relative value scale (RBRVS) fee;
(xi) Outpatient corneal transplants; and
(xii) Diabetic education.
(2) The agency measures budget neutrality on an ongoing basis after rebased system implementation as follows:
(a) The agency gathers inpatient and outpatient claims and encounter data from the rebased system implementation date to the end of the measurement period.
(i) The first measurement period is the initial six months following rebased payment system implementation.
(ii) Additional measurement periods occur no more frequently than quarterly thereafter.
(iii) The agency performs a final measurement period for data received through June 30, 2016.
(b) The agency sums the aggregate payment amounts separately for inpatient and outpatient services. The agency will make the following adjustments to the base data:
(i) The agency removes any reductions due to third-party liability (TPL), client responsibility, and client spenddown from the payment summary;
(ii) The agency removes any increase awarded by RCW 74.09.611
(2) from inpatient services;
(iii) The agency includes any outpatient service lines which are bundled under the enhanced ambulatory patient group (EAPG) system, but would be otherwise payable under the ambulatory payment classification (APC) system; and
(iv) Other adjustments as necessary.
(c) The agency processes all claims and encounters using the rates, factors, and policies which were in effect on June 30, 2014, with the following exceptions:
(i) The agency uses the RCC effective on the date of service;
(ii) The agency uses the most recent RBRVS values for any outpatient service paid using the RBRVS; and
(iii) The agency updates APC relative weights to reflect the most recent relative weights supplied by CMS;
(iv) The agency adjusts the outpatient budget target adjuster (BTA) to offset the inflation factor applied to OPPS in the CMS OPPS final rule; and
(v) The agency may include other adjustments as necessary to ensure accurate payment determination.
(d) The agency aggregates payment amounts calculated under (c) of this subsection separately for inpatient and outpatient services.
(3) The agency will modify the conversion factors and rates to reflect aggregate changes in the overall payment system as follows:
(a) If the amount calculated in subsection (2)(b) of this section is between ninety-nine percent and one hundred one percent of the amount calculated in subsection (2)(d) of this section, no adjustment will be made to the conversion factors and rates currently in effect;
(b) If the amount calculated in subsection (2)(b) of this section is greater than one hundred one percent of the amount calculated in subsection (2)(d) of this section, the conversion factors and rates will be adjusted to reach a target expenditure of one hundred one percent from the rebased payment system implementation date to the end of the subsequent six-month period;
(c) If the amount calculated in subsection (2)(b) of this section is less than ninety-nine percent of the amount calculated in subsection (2)(d) of this section, the conversion factors and rates will be adjusted to reach a target expenditure decrease of ninety-nine percent from the rebased payment system implementation date to the end of the subsequent six-month period.
(4) The agency applies adjustments to the BNAF to rates prospectively at the beginning of the calendar quarter following the measurement.