In addition to the definitions contained in §B of this regulation, definitions set forth in COMAR 10.09.06.01 are applicable to this chapter. Terms Defined. “Charity care” means hospital care for which the costs are not reimbursed through any patient or third party. “Charity care inpatient costs” means hospital costs that are not reimbursed through any patient or third party, reduced by the amount of gifts, restricted grants, or income from endowments. For the purposes of this chapter, third party payments include Medicaid payments for the cost of care, but do not include disproportionate share payments. “Low-income hospital costs” means the sum of a hospital's: Inpatient Medicaid costs; State and local government inpatient cash subsidies; and Charity care inpatient costs. “Low-income utilization rate” means, for a hospital, the sum of: A fraction, expressed as a percentage: The numerator of which is the sum, for a fiscal year, of the total revenues paid the hospital for patient services under a Medical Assistance Program, and the amount of cash subsidies for patient services received directly from State and local governments, and The denominator of which is the total amount of revenues of the hospital for patient services, including the amount of the cash subsidies in the fiscal year; and A fraction, expressed as a percentage: The numerator of which is the total amount of the hospital's charges for inpatient hospital services that are attributable to charity care in a fiscal year, less the portion of any cash subsidies described in §B(4)(a)(i) of this regulation in the period reasonably attributable to inpatient hospital services, and The denominator of which is the total amount of the hospital's charges for inpatient hospital services in the hospital in the period reasonably attributable to inpatient hospital services. “Medicaid cost” means an amount equal to Medicaid payments by the Medicaid program. “Medicaid inpatient utilization rate” means a fraction, expressed as a percentage: The numerator of which is the hospital's number of inpatient days attributable to patients who were eligible for Medical Assistance benefits under Title XIX of the Social Security Act for a fiscal year; and The denominator of which is the total number of the hospital's inpatient days for the fiscal year in §B(6)(a) of this regulation. “State and local government inpatient cash subsidies” means the payments for hospital costs from State or local government health agencies that are not intended as reimbursement for costs directly associated with particular patients, but are provided more generally for operating costs of the institution. These subsidies do not include Medicaid payments or disproportionate share payments. A Maryland hospital is considered a disproportionate share hospital for purposes of a disproportionate share payment if the hospital's: Medicaid inpatient utilization rate is at least one standard deviation above the mean Medicaid inpatient utilization rate for Maryland hospitals that are Medicaid providers; or Low-income utilization rate exceeds 25 percent. To be considered a disproportionate share hospital, a hospital shall have at least two obstetricians with staff privileges who have agreed to provide obstetrical services to individuals who are entitled to Medical Assistance for services under Title XIX of the Social Security Act. The requirements set forth in §B of this regulation do not apply to a hospital if: Inpatients are predominately individuals younger than 18 years old; or The hospital did not provide nonemergency obstetric services as of December 22, 1987. Data for §A(1) and (2) of this regulation relate to the State fiscal year occurring 2 years before the fiscal year during which payments are made. Free-Standing Acute General, Chronic, or Pediatric/Rehabilitation Hospitals. Except as set forth in §A(2) of this regulation, the disproportionate share payment for disproportionate share hospitals that are free-standing hospitals licensed as acute general, chronic, or jointly as pediatric and rehabilitation equals an amount determined in accordance with 42 CFR §412.106, but only if the hospital qualifies as a disproportionate share hospital under 42 CFR §412.106. Free-standing hospitals that are approved by the Program for reimbursement according to rates established by the HSCRC receive a bad debt allowance, which is recognized as a disproportionate share payment equal to or greater than the amount set forth in §A(1) of this regulation, and an additional payment may not be made under this chapter. The disproportionate share payment rate relating to Program payments on or after October 1, 1992 for free-standing hospitals licensed exclusively as: Psychiatric with charity care inpatient costs: Exceeding 40 percent of total inpatient hospital costs equals the greater of the: Hospital's annual low income costs divided by its annual inpatient Medicaid costs, minus 1, all multiplied by 2, and then multiplied by its inpatient Medicaid payment, or Minimum payment required by federal law; Less than or equal to 40 percent of total inpatient hospital costs equals the minimum payment required by federal law; Rehabilitation with charity care inpatient costs: Exceeding 20 percent of total inpatient hospital costs equals the greater of the: Hospital's annual low income costs divided by its annual inpatient Medicaid costs, minus 1, multiplied by its inpatient Medicaid payment, or Minimum payment required by federal law; Less than or equal to 20 percent of total inpatient hospital costs equals the minimum required by federal law. If a hospital qualifies under both §§A(2) and B of this regulation, it is governed by §A(2) of this regulation. Payments according to §A or B of this regulation shall be: Based on data on annual low-income hospital costs, annual inpatient Medicaid costs, and data pertaining to 42 CFR §412.106 from the complete State fiscal year occurring 2 years before the fiscal year during which payments are made; Made in one or more payments covering the complete fiscal year; and Made to appropriate hospital providers that comply with all regulations set forth in COMAR 10.09.92—10.09.95. Out-of-State hospitals determined by the host state Medicaid Program to be a disproportionate share hospital shall be paid a disproportionate share adjustment as determined by the host state Medicaid Program, with a hospital's total adjustment not to exceed 1 percent of the total Maryland Medical Assistance payments to that hospital in a fiscal year. Qualification Requirements. Except as set forth in §F(2) of this regulation, to qualify as a disproportionate share hospital, a hospital shall supply to the Program, 6 months before the start of the applicable fiscal year: Information necessary to determine if the hospital qualifies as a disproportionate share hospital; and Data required under §D(1) of this regulation. For payments in fiscal year 93, the information required in this section shall be presented to the Department within 10 days of the effective date of these regulations. A free-standing hospital licensed exclusively as psychiatric or rehabilitation for at least 2 years, that has not been a Maryland Medicaid provider for at least 2 years, shall receive a disproportionate share payment, for any year, not greater than the hospital's low-income hospital costs in the complete State fiscal year occurring 2 years before the fiscal year during which payments are made. If it is determined that a payment made to any hospital under this regulation exceeds the actual amount of uncompensated care and would result in reverting funds to CMS, the overpayment shall be used for another provider that received less than that provider was eligible to receive. The redistribution shall be available to all providers that are eligible for disproportionate share payments except those whose rates are set by HSCRC. Except when the language of a specific regulation indicates an intent by the Department to provide reimbursement for covered services to Program recipients without regard to the availability of federal financial participation, State regulations shall be interpreted in conformity with applicable federal statutes and regulations. Health-General Article, §§2-104(b), 15-103, and 15-105, Annotated Code of Maryland Effective date: Regulations .01—.04 adopted as an emergency provision effective June 1, 1992 (19:12 Md. R. 1131); adopted permanently September 1, 1992 (19:17 Md. R. 1607) Regulation .03 amended as an emergency provision effective February 17, 1993 (20:5 Md. R. 511); amended permanently effective May 24, 1993 (20:10 Md. R. 852) Regulation .03D amended effective September 25, 2017 (44:19 Md. R. 896) Regulation .03H adopted effective June 24, 2013 (40:12 Md. R. 1042)