Revision: May 21, 2024, 4:01 p.m.
Senate Finance
May 21, 2024
2024-2117s
05/08
Amendment to HB 1593-FN
Amend the title of the bill by replacing it with the following:
AN ACT making an appropriation to the department of health and human services to support recreational activities for individuals with developmental disabilities and relative to the uncompensated care and Medicaid fund.
Amend the bill by replacing all after section 1 with the following:
2 Uncompensated Care and Medicaid Fund; Definition of Hospital. RSA 167:63, IV is repealed and reenacted to read as follows:
IV. "Hospitals" mean general acute care hospitals licensed under RSA 151 that provide inpatient and outpatient hospital services, but shall not include government facilities or special hospitals for rehabilitation.
3 Hospital Medicaid Payments and Medicaid Payment Fund. RSA 167:64 is repealed and reenacted to read as follows:
167:64 Hospital Medicaid Payments and Medicaid Payment Fund; Disproportionate Share Hospital Fund.
I. There is hereby established in the state treasury a Medicaid payment fund, which shall consist of the moneys collected pursuant to RSA 84-A. Moneys paid into the fund shall be exempt from any state budget reductions, and the commissioner of the department of health and human services is authorized to expend these funds, together with matching federal funds, as authorized by this section. Investment earnings of the fund shall be credited to the fund. The moneys in the fund shall be nonlapsing and continually appropriated to the department of health and human services for the purpose of making hospital payments and provider payments and to support Medicaid services and Medicaid programs administered by the department of health and human services in accordance with this section.
II. Beginning in state fiscal year 2025 and continuing every state fiscal year thereafter, the commissioner of the department of health and human services shall provide Medicaid payments, subject to the payment conditions set forth in paragraph V, to the hospitals in an amount equal to 93 percent of the money collected pursuant to RSA 84-A in the prior state fiscal year. Payments to the hospitals shall be made in accordance with this section.
III. The commissioner of the department of health and human services shall determine which payment method or methods are used to make the Medicaid payments subject to this section through Medicaid reimbursement for inpatient or outpatient hospital services, Medicaid supplemental payments, managed care directed payments, disproportionate share hospital payment adjustments, or any other Medicaid payment method allowed by the Centers for Medicare and Medicaid Services (CMS). In determining which Medicaid method or methods to utilize and at what percentage for each method, the commissioner shall seek to prevent to the greatest extent possible year over year hospital reimbursement reductions in the aggregate while at the same time achieving the highest available federal match. The commissioner shall work in collaboration with the hospitals in developing those determinations.
IV. All payments made pursuant to this section shall be subject to approval by CMS, and the department shall secure all necessary waivers or approvals to state plan amendments from CMS.
V. Any payments made under this section through directed payments shall comply with 42 CFR 438.6 or any other applicable federal regulation or guidance. The commissioner shall consult with and consider feedback from the hospitals prior to submission of a payment plan to CMS for approval. If CMS does not approve the hospital directed payment plan, the commissioner shall seek to provide payments through increased hospital rates, disproportionate share hospital payments, supplemental Medicaid payments, or any other allowable Medicaid payment method that provides for federal fund matching. For purposes of determining the portion of the payments to the hospitals that are attributable to CMS approved directed payments, the amount shall be the total amount available for the hospitals to earn under any directed payment, including, but not limited to, any amount of a directed payment that is at risk, value-based, or subject to performance conditions. In no event shall the state be liable for any payments the hospitals fail to earn under any CMS approved directed payments.
VI. In the event the commissioner of the department of health and human services determines there has been a change in federal law, regulations, or CMS guidance that materially impacts payments to the hospitals in accordance with this section or a material change in the amount of money collected pursuant to RSA 84-A, the hospitals and commissioner of the department of health and human services shall collaborate on adjustments, and subject to the commissioner’s determination, to the payment method or methods that are used to make the hospital payments subject to this section. In determining which Medicaid method or methods to utilize and at what percentage for each method, the commissioner shall seek to prevent to the greatest extent possible year over year hospital reimbursement reductions in the aggregate, while at the same time achieving the highest available federal match.
VII.(a) Disproportionate share hospital payments shall only be made to a hospital that is:
(1) A "deemed disproportionate share hospital” as defined by criteria set forth under 42 U.S.C. section 1396r-4 and is not otherwise receiving a disproportionate share hospital payment; or
(2) Meets the minimum criteria for disproportionate share eligibility under relevant federal statutory changes at 42 U.S.C. 1396r-4(d).
(b) For purposes of this paragraph, a hospital’s uncompensated care costs, for purposes of calculating a disproportionate share hospital payment, shall include any charity care cost, and any portion of Medicaid-covered patient care costs unreimbursed by Medicaid payments, that the commissioner determines would meet the criteria under 42 U.S.C. section 1396r-4(g) governing hospital-specific limits on disproportionate share hospital payments under Title XIX of the Social Security Act and the provisions of all federal regulations promulgated thereunder.
VIII. Payment of the federal share of any amount payable under this section to the hospitals is contingent upon New Hampshire receiving those federal funds and any necessary CMS approvals that the department is required to secure pursuant to paragraph IV. In no event shall the state be liable for any payments in excess of such available federal appropriated funds. In the event of a reduction or termination of appropriated federal funds by any federal legislative or executive action that reduces, eliminates, or otherwise modifies the federal appropriation or availability of funding for the federal share, in whole or in part, the commissioner and the hospitals shall collaborate on adjustments, and subject to the commissioner's determination, to the payment method or methods that are used to make the hospitals payments subject to this section. In determining which Medicaid method or methods to utilize and at what percentage for each method, the commissioner shall seek to prevent to the greatest extent possible year over year hospital reimbursement reductions in the aggregate, while at the same time achieving the highest available federal match. The state shall not be required to transfer funds from any other account or source in the event federal funds are reduced or unavailable.
IX. The remaining funds available under this section shall be used to make provider payments and to support Medicaid services and Medicaid programs administered by the department in amounts directed by the budget in each year of the biennium, and from this an amount of at least 7 percent of the money collected pursuant to RSA 84-A in the prior state fiscal year shall be used to support Medicaid services and Medicaid programs administered by the department of health and human services with first priority to funding Medicaid service provider payments to community mental health centers, federally qualified health centers, substance use disorder providers, and other Medicaid service providers as determined by the commissioner of the department of health and human services.
X. One percent of the funds made available for hospital Medicaid payments shall be placed in a separate class line for purposes of the department administering this section.
XI. No hospital shall be entitled to receive any reimbursement under this section unless it meets the definition of a hospital, as defined in RSA 167:63, IV.
XII. For the purpose of making disproportionate share hospital payments only, there is hereby established in the state treasury the disproportionate share hospital fund, which shall be kept separate and distinct from all other funds. All disproportionate share hospital revenue received by the department of health and human services shall be credited to the fund. The moneys in the fund shall be nonlapsing and continually appropriated to the department of health and human services for the purpose of redistributing disproportionate share hospital funds between and among hospitals for compliance with the federally required disproportionate share hospital examinations.
XIII. Prior to implementing any change in the Medicaid payment methodology under paragraph III, VI, or VIII, the commissioner shall submit a document detailing such changes to the fiscal committee of the general court. The document shall be for informational purposes only and fiscal committee approval shall not be required for the department to proceed with implementation.
4 Dedicated Funds; Reference Changed. Amend RSA 6:12, I(b)(338) to read as follows:
(338) Moneys deposited in the [uncompensated care and] Medicaid payment fund and the disproportionate share hospital fund established in RSA 167:64.
5 Medicaid Enhancement Tax; Definitions; Reference Change. Amend RSA 84-A:1, VI to read as follows:
VI. "[Uncompensated care and] Medicaid payment fund" [means the fund] and "disproportionate share hospital fund" mean the funds established in RSA 167:64 to reimburse hospitals for costs associated with uncompensated care and shortfalls in publicly funded programs.
6 Medicaid Enhancement Tax; Method of Payment and Deposit of Tax. Amend RSA 84-A:5, I to read as follows:
I. The payments required by RSA 84-A:3 shall be made by electronic transfer of moneys to the state treasurer and deposited to the [uncompensated care and Medicaid fund] Medicaid payment fund and disproportionate share hospital fund established by RSA 167:64.
7 Uncompensated Care and Medicaid Fund; Effective June 30, 2028. RSA 167:64 is repealed and reenacted to read as follows:
167:64 Uncompensated Care and Medicaid Fund.
I. There is hereby established in the state treasury an uncompensated care and Medicaid fund which shall consist of the moneys collected pursuant to RSA 84-A. Investment earnings of the fund shall be credited to the fund. Moneys paid into the fund shall be exempt from any state budget reductions, and the commissioner is authorized to expend these funds, together with matching federal funds, as follows:
(a)(1) The commissioner shall provide reimbursement for uncompensated care costs from the uncompensated care and Medicaid fund through either Medicaid rate adjustments, Medicaid supplemental payments, MCO directed payments to hospitals, disproportionate share hospital payment adjustments, or any other allowable Medicaid payment, including a combination thereof, provided however that no hospital shall receive any such reimbursement for uncompensated care costs unless it is a qualified hospital as defined in subparagraph (b)(1). Funds available under this section shall also be used to make provider payments and to support Medicaid services and programs administered by the department in amounts directed by the budget in each year of the biennium.
(2) Expenditure of revenues deposited to the uncompensated care and Medicaid fund shall be made for the following purposes in the following order of priority in fiscal years 2018 through 2024. However, no hospital shall be paid uncompensated care cost payments of more than 100 percent of the governing hospital-specific limit on disproportional share hospital payments under Title XIX of the Social Security Act and the provisions of all federal regulations promulgated thereunder:
(A) To make uncompensated care cost payments, including the state share and matching federal share, to New Hampshire hospitals with and without critical access designation in the following order of priority, and in the following amounts: fiscal year 2018-a sum equaling 92.2 percent of money collected pursuant to RSA 84-A for the fiscal year; fiscal year 2019-a sum equaling 90.2 percent of money collected pursuant to RSA 84-A for the fiscal year; and fiscal years 2020 through 2024-a sum equaling 86 percent of money collected pursuant to RSA 84-A for the fiscal year. Notwithstanding the foregoing sums for each fiscal year, in no event shall the amounts paid to hospitals as uncompensated care cost hospital payments, including the New Hampshire Hospital, in any particular fiscal year exceed the state share for matching the maximum state disproportionate share hospital allotment established under 42 U.S.C. section 1396r-4(f) for that fiscal year plus the matching federal share. If the maximum state disproportionate share hospital allotment established under 42 U.S.C. section 1396r-4(f) for any fiscal year, less the uncompensated care cost hospital payments to be made to New Hampshire Hospital, plus state matching funds equal to the available federal state disproportionate share hospital allotment for uncompensated care cost hospital payments is less than a sum equaling the percentage of money collected pursuant to RSA 84-A for the fiscal year, any remaining amount, including state and federal share, of the foregoing sums equaling the percentage of money collected pursuant to RSA 84-A for the fiscal year shall be paid to the hospitals as supplemental Medicaid payments, MCO directed payments to hospitals, increased hospital service provider rates, or any other allowable Medicaid payment:
(i) To support 75 percent of the uncompensated care costs of New Hampshire's hospitals with critical access designation consistent with the requirements of 42 U.S.C. section 1396r-4(g) and any relevant federal regulations promulgated thereunder to be shared among such hospitals in proportion to the amount of uncompensated care provided;
(ii) To make payments for uncompensated care costs to New Hampshire's hospitals without critical access hospital designation in proportion to the amount of uncompensated care provided by each hospital from the sum equal to the remainder of the percentage of money collected pursuant to RSA 84-A for the fiscal year specified in subparagraph (a)(2)(A).
(iii) If there is a change to the federal definition of uncompensated care costs that would result in a decrease to the calculation in subparagraph (i), the percentage of allowable uncompensated care costs for New Hampshire's hospitals with critical access designation percentage of allowable uncompensated care costs shall increase from 75 percent to a percentage that would be equivalent to their receiving 75 percent of uncompensated care costs calculated without regard to payments from Medicare or third party payers as allowable on the date of the enactment of this provision, except that no hospital shall be paid disproportionate share hospital payments of more than 100 percent of the governing hospital-specific limit on disproportional share hospital payments under Title XIX of the Social Security Act. If increasing the percentage of the allowable uncompensated care costs would exceed 100 percent of the governing hospital specific limit, any amount in excess shall be paid to the New Hampshire hospitals with critical access designation as supplemental Medicaid payments, MCO directed payments to hospitals, increased hospital service provider rates, or any other allowable Medicaid payments.
(B) To make a payment for uncompensated care costs to each hospital that meets the criteria set forth for "deemed disproportionate share hospitals" as that term is defined under 42 U.S.C. section 1396r-4 up to $250,000 in each year of the biennium as set forth in subparagraph (b)(1)(A). For fiscal years 2018 and 2019 only, any payment under this subparagraph shall not reduce the payments made under subparagraphs (a)(2)(A)(i)-(iii).
(C) To increase hospital service provider rates in fiscal year 2020 through fiscal year 2024, by an amount equal to 5 percent of the revenue collected pursuant to RSA 84-A for the fiscal year.
(D) Any remaining funds produced from the Medicaid enhancement tax shall be used to support provider payments and to support Medicaid services and programs administered by the department.
(E) Hospitals entitled to payments under subparagraphs (a)(2)(A)(i)-(iii) or (a)(2)(C) have a vested contractual right to receive these payments in fiscal years 2018 through 2024 as limited by paragraph IV.
(b)(1) The commissioner is hereby authorized and directed to develop and implement a schedule of payments for reimbursement of the uncompensated care costs consistent with the level of funding made available for such payments in each year of any biennium, incurred by those hospitals that are qualified as follows:
(A) The hospital is a "deemed disproportionate share hospital" as defined by criteria set forth under 42 U.S.C. section 1396r-4 and is not otherwise receiving a disproportionate share hospital payment; or
(B) The hospital:
(i) Meets the minimum criteria for disproportionate share eligibility under relevant federal statutory changes at 42 U.S.C. 1396r-4(d);
(ii) Is not a special hospital for rehabilitation; and
(iii) Participates in the provider network of the state Medicaid care management program.
(2) The reimbursement of uncompensated care costs paid in state fiscal year 2015 and thereafter shall be in accordance with the schedule of payments to hospitals consistent with this section and shall be structured in a manner that is consistent with all federal laws and regulations governing (i) Title XIX disproportionate share hospital payment adjustments and other rate payments, (ii) conditions for receiving federal financial participation, and (iii) permissible sources of state financial participation as provided for under 42 C.F.R. part 433 and all other applicable federal regulations. Disproportionate share hospital payments shall be made under this paragraph by May 31 in any fiscal year.
(c) For purposes of this section, uncompensated care costs shall include: any charity care cost, and any portion of Medicaid-covered patient care costs unreimbursed by Medicaid payments, that the commissioner determines would meet the criteria under 42 U.S.C. section 1396r-4(g) governing hospital-specific limits on disproportionate share hospital payments under Title XIX of the Social Security Act and the provisions of all federal regulations promulgated thereunder.
(d) One percent of the funds made available for uncompensated care payments shall be placed in a separate class line reserved for the expenses of the department in administering this subdivision.
II. Moneys in the uncompensated care and Medicaid fund shall be continually appropriated to the department for the purposes of this subdivision.
III. The department shall secure all necessary waivers pursuant to 42 C.F.R. section 433.68 and approvals of state plan amendments from the Centers for Medicare and Medicaid Services (CMS).
IV. Payment of the federal share of uncompensated care cost hospital payments, supplemental Medicaid payments, MCO directed payments to hospitals, increased hospital service provider rates, and any other allowable Medicaid payment under this section is contingent upon New Hampshire receiving those federal funds and any necessary CMS approvals that the department is required to secure pursuant to paragraph III.
8 Dedicated Funds; Reference Changed; Effective June 30, 2028. Amend RSA 6:12, I(b)(338) to read as follows:
(338) Moneys deposited in the [Medicaid payment fund and the disproportionate share hospital fund] uncompensated care and Medicaid fund established in RSA 167:64.
9 Medicaid Enhancement Tax; Definitions; Reference Change; Effective June 30, 2028. Amend RSA 84-A:1, VI to read as follows:
VI. ["Medicaid payment fund" and "disproportionate share hospital fund" mean the funds] Uncompensated care and Medicaid fund means the fund established in RSA 167:64 to reimburse hospitals for costs associated with uncompensated care and shortfalls in publicly funded programs.
10 Medicaid Enhancement Tax; Method of Payment and Deposit of Tax; Effective June 30, 2028. Amend RSA 84-A:5, I to read as follows:
I. The payments required by RSA 84-A:3 shall be made by electronic transfer of moneys to the state treasurer and deposited to the [Medicaid payment fund and disproportionate share hospital fund] uncompensated care and Medicaid fund established by RSA 167:64.
I. Sections 2-6 of this act shall take effect July 1, 2024.
II. Sections 7-10 of this act shall take effect June 30, 2028.
III. The remainder of this act shall take effect upon its passage.
2024-2117s
AMENDED ANALYSIS
This bill:
I. Makes an appropriation to the department of health and human services to fund recreational activities for individuals with developmental disabilities.
II. Temporarily restructures the uncompensated care and Medicaid fund under RSA 167:64 as the Medicaid payment fund and disproportionate share hospital fund, administered by the department of health and human services. The bill sunsets changes to the funding distribution mechanism June 30, 2028.