205.6405 Definitions for KRS 205.6405 to 205.6408.
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/ky/chapter-205/205-6405A research copy — for the controlling text, always check the official state or federal source. Not legal advice.
As used in KRS 205.6405 to 205.6408:
(1)"Assessment" means the hospital assessment authorized by KRS 205.6406;
(2)"Commissioner" means the commissioner of the Department for Medicaid Services;
(3)"Department" means the Department for Medicaid Services;
(4)"Excess disproportionate share taxes" means any excess provider tax revenues
collected under KRS 142.303 that are not needed to fund the state share of hospital
disproportionate share payments under KRS 205.640 due to federal
disproportionate share allotments being reduced and limited to the portion of
provider tax revenues collected under KRS 142.303 necessary to fund the state
share of the difference between the unreduced disproportionate share allotment and
the reduced disproportionate share allotment;
(5)"Intergovernmental transfer" means any transfer of money by or on behalf of a
public agency for purposes of qualifying funds for federal financial participation in
accordance with 42 C.F.R. sec. 433.51;
(6)"Long-term acute hospital" means an in-state hospital that is certified as a long-term
care hospital under 42 U.S.C. sec. 1395ww(d)(1)(B)(iv);
(7)"Managed care" means the provision of Medicaid benefits through managed care
organizations under contract with the department pursuant to 42 C.F.R. sec. 438;
(8)"Managed care gap" means:
(a)For hospital inpatient services, the difference between the maximum
actuarially sound amount that can be included in managed care rates for
hospital inpatient services provided by qualifying hospitals and the amount of
total payments for hospital inpatient services provided by qualifying hospitals
paid by managed care organizations. For purposes of the managed care gap,
total payments shall exclude payments established under KRS 205.6405 to
205.6408; and
(b)For hospital outpatient services, the difference between the maximum
actuarially sound amount that can be included in managed care rates for
hospital outpatient services provided by qualifying hospitals and the amount
of total payments for hospital outpatient services provided by qualifying
hospitals paid by managed care organizations. For purposes of the managed
care gap, total payments shall exclude payments established under KRS
205.6405 to 205.6408;
(9)"Managed care organization" means an entity contracted with the department to
provide Medicaid benefits pursuant to 42 C.F.R. sec. 438;
(10)"Non-state government-owned hospital" means the same as non-state government-
owned or operated facilities in 42 C.F.R. sec. 447.272 and represents one
(1)group
of hospitals for purposes of estimating the upper payment limit;
(11)"Pediatric teaching hospital" means the same as in KRS 205.565;
(12)"Private hospitals" means the same as privately owned and operated facilities in 42
C.F.R. sec. 447.272 and represents one
(1)group of hospitals for purposes of
estimating the upper payment limit;
(13)"Program year" means the state fiscal year during which an assessment is assessed
and rate improvement payments are made;
(14)"Psychiatric access hospital" means an in-state psychiatric hospital licensed under
KRS Chapter 216B that:
(a)Is not located in a Metropolitan Statistical Area;
(b)Provides at least sixty-five thousand (65,000) days of inpatient care as
reflected in the department's hospital rate data for state fiscal year 1998-1999;
(c)Provides at least twenty percent (20%) of inpatient care to Medicaid-eligible
recipients as reflected in the department's hospital rate data for state fiscal
year 1998-1999; and
(d)Provides at least five thousand (5,000) days of inpatient psychiatric care to
Medicaid recipients in a state fiscal year;
(15)"Qualifying hospital":
(a)Means a Medicaid-participating, in-state hospital licensed under KRS Chapter
216B, including a long-term acute hospital, but excluding a university hospital
and a state mental hospital as defined in KRS 205.639. The department may,
but is not required to, exclude critical access hospitals and rural emergency
hospitals from the definition of "qualifying hospital" for purposes of
calculating the quarterly assessments. Notwithstanding the permission
referenced in this subsection, or any other provision of the law to the contrary,
the department may include critical access hospitals and rural emergency
hospitals for purposes of calculating and paying the quarterly supplemental
payments authorized in KRS 205.6406; and
(b)Notwithstanding paragraph
(a)of this subsection, a university hospital that is
not located on the affiliated university's primary campus may be deemed to be
a qualifying hospital if the university hospital does not participate in a
separate directed payment program for university hospitals;
(16)"Qualifying hospital disproportionate share percentage" means a percentage equal
to the amount of hospital provider taxes paid pursuant to KRS 142.303 by
qualifying hospitals in state fiscal year 2016-2017 divided by the amount of hospital
provider taxes paid pursuant to KRS 142.303 by all hospitals in state fiscal year
2016-2017;
(17)"University hospital" means a state university teaching hospital, owned or operated
by either the University of Kentucky College of Medicine or the University of
Louisville School of Medicine, including a hospital owned or operated by a related
organization pursuant to 42 C.F.R. sec. 413.17;
(18)"University hospital disproportionate share percentage" means a percentage equal to
the amount of hospital provider taxes paid pursuant to KRS 142.303 by university
hospitals and state mental hospitals, as defined in KRS 205.639, in state fiscal year
2016-2017 divided by the amount of hospital provider taxes paid pursuant to KRS
142.303 by all hospitals in fiscal year 2016-2017;
(19)"Upper payment limit" or "UPL" means the methodology permitted by federal
regulation to achieve the maximum allowable amount on aggregate hospital
Medicaid payments to non-state government-owned hospitals and private hospitals
under 42 C.F.R. sec. 447.272. A separate UPL shall be estimated for non-state
government-owned hospitals and private hospitals; and
(20)"UPL gap" means the difference between the UPL and amount of total fee-for-
service payments paid by the department for hospital inpatient services provided by
non-state government-owned hospitals and private hospitals to Medicaid
beneficiaries and excluding payments established under KRS 205.6405 to
205.6408. A separate UPL gap shall be estimated for the non-state government-
owned hospitals and private hospitals.