67:16:03:06.01.   Basis of reimbursement -- Outpatient services other than outpatient laboratory and outpatient surgical procedures. Reimbursement for outpatient hospital services for an in-state acute care hospital that had more than 30 inpatient Medicaid discharges in the hospital's fiscal year ending after June 30, 1996, and before July 1, 1997, is based on reasonable costs as determined by the hospital's Medicare Cost Report from fiscal year 2010 with the following exceptions:

          (1)  Costs associated with the certified registered nurse anesthetist services that relate to outpatient services are included as allowable costs; and

          (2)  All capital and education costs incurred for outpatient services will be included as allowable costs.

          Reimbursement for outpatient hospital services for the remaining in-state acute care hospitals is at 90 percent of their usual and customary charge for the service provided.

          Reimbursement for out-of-state hospital outpatient services is calculated at 33.07 percent of their usual and customary charge.

          Costs for outpatient services incurred within three days immediately preceding the inpatient stay are included in the inpatient charges unless the outpatient service is not related to the inpatient stay. This provision applies only if the facilities providing the services are owned by the entity.

          Outpatient laboratory services are excluded from the provisions of this rule and are payable according to § 67:16:03:06.07.

          Outpatient surgical procedures are payable according to § 67:16:03:06.11.

          The amount of reimbursement calculated above is reduced by 11.48 percent after any cost sharing amount due from the patient and any third party liability amounts have been deducted and then increased by 0.5 percent for in-state hospitals that are not classified as Medicare Critical Access or Medicaid Access Critical. Hospitals that are classified as Medicare Critical Access or Medicaid Access Critical are exempt from the 11.48 percent reduction in reimbursement. The rate of reimbursement is increased by 1.8 percent for in-state hospitals that are classified as Medicare Critical Access or Medicaid Access Critical.

          For outpatient costs for Medicaid Access Critical facilities the department uses the facility's cost report to determine whether any adjustment to reimbursement is necessary for amounts due the provider.

          Source: 12 SDR 6, effective July 28, 1985; 15 SDR 2, effective July 17, 1988; 16 SDR 235, effective July 5, 1990; 17 SDR 180, effective May 27, 1991; 18 SDR 198, effective June 3, 1992; 22 SDR 143, effective May 9, 1996; 23 SDR 232, effective July 10, 1997; 25 SDR 116, effective March 24, 1999; 30 SDR 26, effective September 3, 2003; 31 SDR 107, effective February 1, 2005; 36 SDR 215, effective July 1, 2010; 36 SDR 215, adopted June 11, 2010, effective July 1, 2011; 37 SDR 236, effective June 28, 2011; 37 SDR 236, adopted June 8, 2011, effective July 1, 2012; 39 SDR 15, effective August 6, 2012.

          General Authority: SDCL 28-6-1.

          Law Implemented: SDCL 28-6-1.