Alaska Native Tribal Health Consortium Issues Public Comment on Centers for Medicare & Medicaid Services Proposed Rule
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The
I write to submit our comment and recommendations on the
Proposed change to the DSH Methodology for IHCP hospitals
For ANTHC, the most important element of the proposed rule is the proposal to change the methodology for Indian health care provider (IHCP) hospital Medicare Disproportionate Share (DSH) payments. The proposed rule explains that CMS will continue to use the low-income insured days as a proxy to calculate Factor 3 for IHCP hospital payments in FY 2021. In the subsequent years, CMS is proposing to adjust payments to IHCP hospitals through the creation of a new IHCP hospital Medicare DSH payment. CMS explains the methodology for determining this IHCP hospital Medicare DSH payment would mirror the calculation of the Medicare DSH payment under the Social Security Act Sec. 1886(d)(5)(F), except that the payment would be determined at 100% of the calculated amount rather than 25% of the calculated amount as required under section 3133 of the Affordable Care Act.
Recommendations
In general, ANTHC is supportive of the proposed change however, recognizing that not all IHCP are similarly situated, we recommend additional steps be taken by CMS that we discuss below. To support the proposed CMS transition, we recommend the following:
1. In addition to the new CMS proposed methodology for IHCP hospital DSH payments, ANTHC recommends CMS allow IHCP hospitals the option to continue to use the current proxy measure for UCC.
2. If CMS transitions to a new payment methodology for IHCP hospital Medicare DSH payments, it should take additional time to consult with the CMS-TTAG, IHS, and tribal hospitals to refine the proposed methodology.
3. Alleviate the impact of the 12% DHS payment cap on IHCP hospitals. The imposition of the 12% cap on IHCP hospital Medicare DSH payments impact IHS and tribal hospitals who serve many low-income Medicare patients with significantly lower health status and are costlier to treat on average than other Medicare patients with the same diagnosis. While the Medicare DSH cap may only affect a relatively small number of urban and rural hospitals, it effects 93% of the IHS and tribal hospitals./1
To the extent that the 12% cap cannot be waived without a statutory fix, we urge CMS to adopt changes to its methodology for calculating uncompensated and charity care that is specific to the Indian health system as it has for other uniquely situated providers in a manner that makes up for the disproportionate impact the 12% cap has on IHCP hospitals.
4. ANTHC recommends CMS issue Tribal guidance on completing Worksheet S-10. A significant challenge for IHS and tribal hospitals is that CMS may not interpret that IHCPs do not have uncompensated care costs under Worksheet S-10, because base funding for the costs of patient care is provided through congressional appropriations, and might construe this as all care being considered compensated. This is hardly the case, since IHS appropriations are less than adequate to fully fund the costs of care. Many tribal health programs invest non-Federal resources in their health care programs to furnish care that could easily be classified as uncompensated care because IHCPs may not charge beneficiaries to receive care and, thus, may not have the accounting methods to track these costs. As a result, IHCP hospitals are currently unable to report charity care and non-Medicare bad debt consistent with the proposed definition of uncompensated care in the regulation.
We thank you for the opportunity to provided our comments and recommendation on the proposed rule and hope you find our recommendations helpful to improving the proposed methodology for IHS and tribal hospital Medicare Disproportionate Share (DSH) payments.
Sincerely,
Intergovernmental Affairs
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Footnote:
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The proposed rule can be viewed at: https://www.regulations.gov/document?D=CMS-2020-0052-0002
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