Indiana Code 12-15-15-1.2. Reimbursement for children’s hospital bordering Indiana; limitations; expiration
(1) a freestanding general acute care hospital that:
Terms Used In Indiana Code 12-15-15-1.2
- Amendment: A proposal to alter the text of a pending bill or other measure by striking out some of it, by inserting new language, or both. Before an amendment becomes part of the measure, thelegislature must agree to it.
- United States: includes the District of Columbia and the commonwealths, possessions, states in free association with the United States, and the territories. See Indiana Code 1-1-4-5
(B) furnishes inpatient and outpatient health care services to patients who are predominantly individuals less than nineteen (19) years of age; or
(2) a facility located within a freestanding general acute care hospital that:
(A) is designated by the Medicare program as a children’s hospital; or
(B) furnishes inpatient and outpatient health care services to patients who are predominately individuals less than nineteen (19) years of age.
(b) This section applies to reimbursement for inpatient Medicaid services and outpatient Medicaid services provided to a Medicaid recipient who is less than nineteen (19) years of age at a children’s hospital that is located in a state bordering Indiana. This section does not apply to reimbursement for non-emergency medical transportation.
(c) As used in this subsection, “cost outlier case” means a Medicaid stay that exceeds a predetermined threshold, defined as the greater of twice the diagnosis-related group (DRG) rate or a fixed dollar amount that has been established by the office. The office shall reimburse a children’s hospital for covered services provided to a Medicaid recipient that is described in subsection (b) at a rate set by the secretary that is based on a reimbursement formula that is:
(1) comparable to the current federal Medicare reimbursement rate for the service provided by the children’s hospital; or
(2) one hundred thirty percent (130%) of the Medicaid reimbursement rate for a service that does not have a Medicare reimbursement rate.
The reimbursement methodology under this subsection must factor in any cost outlier case in a manner that results in the final reimbursement rate made to a hospital meeting the reimbursement requirements specified in this subsection. The office may, upon factoring in the cost outlier case in determining the final reimbursement rate, make retroactive reimbursements to an out of state children’s hospital to the date of the initial Medicaid waiver application.
(d) Before September 1, 2021, the office shall apply to the United States Department of Health and Human Services for any state plan amendment or Medicaid waiver necessary to implement and administer this section. Before June 1, 2022, the office shall apply for an amendment to the Medicaid waiver concerning reimbursement under this section that is necessary to implement the changes required by amendments made to this section concerning factoring in any cost outlier case.
(e) The office may adopt rules under IC 4-22-2 necessary for the implementation of this section.
(f) This section expires July 1, 2025.
As added by P.L.132-2021, SEC.2. Amended by P.L.142-2022, SEC.3; P.L.76-2023, SEC.2.