§495.306 Establishing patient volume.
(a) General rule. A Medicaid provider must annually meet patient volume requirements of §495.304, as these requirements are established through the State‘s SMHP in accordance with the remainder of this section.
(b) State option(s) through SMHP. A State must submit through the SMHP the option or options it has selected for measuring patient volume. A State must select the methodology described in either paragraph (c) or paragraph (d) of section (or both methodologies). In addition, or as an alternative, a State may select the methodology described in paragraph (g) of this section.
(c) Methodology, patient encounter.
(1) EPs. To calculate Medicaid patient volume, an EP must divide:
(i) The total Medicaid patient encounters in any representative, continuous 90-day period in the preceding calendar year; by
(ii) The total patient encounters in the same 90-day period.
(2) Eligible hospitals. To calculate Medicaid patient volume, an eligible hospital must divide—
(i) The total Medicaid encounters in any representative, continuous 90-day period in the preceding fiscal year; by
(ii) The total encounters in the same 90-day period.
(3) Needy individual patient volume. To calculate needy individual patient volume, an EP must divide—
(i) The total needy individual patient encounters in any representative, continuous 90- day period in the preceding calendar year; by
(ii) The total patient encounters in the same 90-day period.
(d) Methodology, patient panel.
(1) EPs. To calculate Medicaid patient volume, an EP must divide:
(i) (A) The total Medicaid patients assigned to the EP‘s panel in any representative, continuous 90-day period in the preceding calendar year when at least one Medicaid encounter took place with the Medicaid patient in the year prior to the 90-day period; plus
(B) Unduplicated Medicaid encounters in the same 90-day period; by
(ii)(A) The total patients assigned to the provider in that same 90-day period with at least one encounter taking place with the patient during the year prior to the 90-day period; plus
(B) All unduplicated patient encounters in the same 90-day period.
(2) Needy individual patient volume. To calculate needy individual patient volume an EP must divide—
(i)(A) The total Needy Individual patients assigned to the EP‘s panel in any representative, continuous 90-day period in the preceding calendar year when at least one Needy Individual encounter took place with the Medicaid patient in the year prior to the 90-day period; plus
(B) Unduplicated Needy Individual encounters in the same 90-day period, by
(ii)(A) The total patients assigned to the provider in that same 90-day period with at least one encounter taking place with the patient during the year prior to the 90-day period, plus
(B) All unduplicated patient encounters in the same 90-day period.
(e) For purposes of this section, the following rules apply:
(1) For purposes of calculating EP patient volume, a Medicaid encounter means services rendered to an individual on any one day where—
(i) Medicaid (or a Medicaid demonstration project approved under section 1115 of the Act) paid for part or all of the service; or
(ii) Medicaid (or a Medicaid demonstration project approved under section 1115 of the Act) paid all or part of the individual‘s premiums, co-payments, and cost-sharing.
(2) For purposes of calculating hospital patient volume, both of the following definitions in paragraphs (e)(2)(i) and (e)(2)(ii) of this section may apply:
(i) A Medicaid encounter means services rendered to an individual per inpatient discharge where—
(A) Medicaid (or a Medicaid demonstration project approved under section 1115 of the Act) paid for part or all of the service; or
(B) Medicaid (or a Medicaid demonstration project approved under section 1115 of the Act) paid all or part of the individual‘s premiums, co-payments, and/or cost-sharing.
(ii) A Medicaid encounter means services rendered in an emergency department on any one day where—
(A) Medicaid (or a Medicaid demonstration project approved under section 1115 of the Act) paid for part or all of the service; or
(B) Medicaid (or a Medicaid demonstration project approved under section 1115of the Act) paid all or part of the individual‘s premiums, co-payments, and cost-sharing.
(3) For purposes of calculating needy individual patient volume, a needy patient encounter means services rendered to an individual on any one day where—
(i) Medicaid or CHIP (or a Medicaid or CHIP demonstration project approved under section 1115 of the Act) paid for part or all of the service;
(ii) Medicaid or CHIP (or a Medicaid or CHIP demonstration project approved under section 1115 of the Act) paid all or part of the individual‘s premiums, co-payments, or costsharing;
(iii) The services were furnished at no cost; and calculated consistent with §495.310(h); or
(iv) The services were paid for at a reduced cost based on a sliding scale determined by the individual’s ability to pay.
(f) Exception. A children‘s hospital is not required to meet Medicaid patient volume requirements.
(g) Establishing an alternative methodology. A State may submit to CMS for review and approval through the SMHP an alternative from the options included in paragraphs (c) and (d) of this section, so long as it meets the following requirements:
(1) It is submitted consistent with all rules governing the SMHP at §495.332.
(2) Has an auditable data source.
(3) Has received input from the relevant stakeholder group.
(4) It does not result, in the aggregate, in fewer providers becoming eligible than the methodologies in either paragraphs (c) and (d) of this section.
(h) Group practices. Clinics or group practices will be permitted to calculate patient volume at the group practice/clinic level, but only in accordance with all of the following limitations:
(1) The clinic or group practice’s patient volume is appropriate as a patient volume methodology calculation for the EP.
(2) There is an auditable data source to support the clinic’s or group practice‘s patient volume determination.
(3) All EPs in the group practice or clinic must use the same methodology for the payment year.
(4) The clinic or group practice uses the entire practice or clinic‘s patient volume and does not limit patient volume in any way.
(5) If an EP works inside and outside of the clinic or practice, then the patient volume calculation includes only those encounters associated with the clinic or group practice, and not the EP‘s outside encounters.
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