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PDFWAC 182-550-7500

OPPS rate.

(1) The medicaid agency calculates hospital-specific outpatient prospective payment system (OPPS) rates using all of the following:
(a) A base conversion factor established by the agency;
(b) An adjustment for direct graduate medical education (DGME); and
(c) The latest wage index information established and published by the centers for medicare and medicaid services (CMS) when the OPPS rates are set for the upcoming year. Wage index information reflects labor costs in the cost-based statistical area (CBSA) where a hospital is located.
(2) Base conversion factors. The agency calculates the base enhanced ambulatory patient group (EAPG) conversion factor during a hospital payment system rebasing. The base is calculated as the maximum amount that can be used, along with all other payment factors and adjustments described in this chapter, to maintain aggregate payments across the system. The agency will publish base conversion factors on its website.
(3) Wage index adjustments reflect labor costs in the CBSA where a hospital is located.
(a) The agency determines the labor portion of the base rate by multiplying the base rate by the labor factor established by medicare; then
(b) Multiplying the amount in (a) of this subsection is multiplied by the most recent wage index information published by CMS when the rates are set; then
(c) The agency adds the nonlabor portion of the base rate to the amount in (b) of this subsection to produce a hospital-specific wage adjusted factor.
(4) DGME. The agency obtains the DGME information from the hospital's most recently filed medicare cost report as available in the CMS health care cost report information system (HCRIS) dataset.
(a) The hospital's medicare cost report must cover a period of twelve consecutive months in its medicare cost report year.
(b) If a hospital's medicare cost report is not available on HCRIS, the agency may use the CMS Form 2552-10 to calculate DGME.
(c) In the case where a hospital has not submitted a CMS medicare cost report in more than eighteen months from the end of the hospital's cost reporting period, the agency may remove the hospital's DGME adjustment.
(d) The agency calculates the hospital-specific DGME by dividing the DGME cost reported on worksheet B, part 1 of the CMS cost report by the adjusted total costs from the CMS cost report.
(5) The formula for calculating the hospital's final specific conversion factor is:
EAPG base rate × (.6(wage index) + .4)/(1-DGME)
(6) The agency considers an in-state hospital a sole community hospital if all the following conditions apply. The hospital must:
(a) Be certified by CMS as a sole community hospital as of January 1, 2013.
(b) Have a level III adult trauma service designation from the department of health as of January 1, 2014.
(c) Have less than one hundred fifty acute care licensed beds in fiscal year 2011.
(d) Be owned and operated by the state or a political subdivision.
(7) If the hospital meets the agency's sole community hospital (SCH) criteria listed in subsection (6) of this section, effective:
(a) January 1, 2015, through June 30, 2018, the agency multiplies the hospital's specific conversion factor by 1.25;
(b) July 1, 2018, through June 30, 2021, the agency multiplies an in-state hospital's specific EAPG conversion factor by 1.50;
(c) July 1, 2021, the agency multiplies an in-state hospital's specific EAPG conversion factor by 1.25.
(8) The formula for calculating a sole community hospital's final conversion factor is:
[EAPG base rate × (.6(wage index) + .4)/(1-DGME)] x SCH Factor
[Statutory Authority: RCW 41.05.021, 41.05.160, and 2019 c 415 § 211(14). WSR 20-01-075, § 182-550-7500, filed 12/11/19, effective 1/11/20. Statutory Authority: RCW 41.05.021, 41.05.160, and 2018 c 299 § 213 (1)(fff). WSR 18-16-059, § 182-550-7500, filed 7/26/18, effective 8/26/18. Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 14-22-003, § 182-550-7500, filed 10/22/14, effective 11/22/14. Statutory Authority: RCW 41.05.021 and chapter 74.60 RCW. WSR 14-14-049, § 182-550-7500, filed 6/25/14, effective 7/26/14. WSR 11-14-075, recodified as § 182-550-7500, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, 74.09.500, and 2009-11 Omnibus Operating Budget (ESHB 1244). WSR 09-12-062, § 388-550-7500, filed 5/28/09, effective 7/1/09. Statutory Authority: RCW 74.08.090, 74.09.500. WSR 07-13-100, § 388-550-7500, filed 6/20/07, effective 8/1/07; WSR 04-20-061, § 388-550-7500, filed 10/1/04, effective 11/1/04.]
Reviser's note: The brackets and enclosed material in the text of the above section occurred in the copy filed by the agency.
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