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FY
2009 Application Cycle Guidance and Forms, and Related Policies
and Regulations |
Application Guidance and Forms
Related Policies, Regulations and Documents
Intern and Resident Information System (IRIS) Proxy
FY 2009
Application Guidance
OMB No. 0915-0247
Expiration Date: 03/31/2010
Dear Applicant:
The Children’s Hospitals Graduate Medical Education Payment Program
(CHGME PP) application package, which includes all applicable forms,
guidance and instructions, is enclosed. It is very important to
thoroughly read the detailed application guidance and instructions
before completing the required application forms. The material
contains information related to submission of both the initial and
reconciliation applications.
Your completed application must be mailed following the guidance
provided in the “Application Cycle and Deadlines” section of the
attached package. Applications must be received by the stated deadlines
to be considered for CHGME PP funding.
If you have questions regarding the application, please call the
Graduate Medical Education Branch at 301-443-1058 or e-mail at childrenshospitalgme@hrsa.gov.
Sincerely yours,
Marcia K. Brand, Ph.D.
Associate Administrator
Children’s
Hospitals Graduate Medical Education Payment Program (CHGME PP)
Application Package
Table of
Contents
Section
I: Overview of the CHGME PP
Introduction
Administration
|
Section
II: Application Cycle and Deadlines
Initial
Application
Interim Payment Determination and Disbursement (Based Upon
the Initial Application)
Assessment of Resident FTE Counts Reported in Initial Applications
Reconciliation Application
Final Payment Determination and Disbursement (Based Upon
the Reconciliation Application)
Electronic Availability of Application Materials
|
Section
III: CHGME PP Application Forms
Cover
Page with Public Burden Statement
HRSA 99: Demographic and Contact Information
HRSA 99-1: Determination of Weighted and Unweighted Resident
FTE Counts
HRSA 99-2: Determination of Indirect Medical Education
Data Related to the Teaching of Residents
HRSA 99-3: Certification
HRSA 99-4: Government Performance and Results Act Tables
HRSA 99-5: Application Checklist
|
Section
IV: Hospital Eligibility
Eligibility
Criteria
Changes
in Eligibility
|
Section
V: Payment Methodology
Payment
Methodology
|
Section
VI: Hospital Data Needed to Complete the CHGME PP Application
Data
Sources for Children’s Hospitals that File Full MCRs
Data Sources for Children’s Hospitals that File Low- or
No-Utilization MCRs
Data Sources for Children’s Hospitals that Have Not Completed
Three (3) MCR Periods
Data Sources for Children’s Hospitals that Have Not Completed
One (1) MCR Period
|
Section
VII: Determining the Total Number of Resident Full-time Equivalents
Cap
and Cap Year
Adjustments to a Hospital’s Cap
Exceeding the Cap
Eligible Residency Programs (Approved Training Programs)
Eligible Residents
International Medical Graduates (IMGs)
Resident Full-Time Equivalent (FTE) Counts
Initial Residency Period (IRP)
Weighting of Resident FTE Counts
Where Residents are Counted
Hospital Complex
Non-Provider/Non-Hospital Settings and Written Agreements
Partial Resident Full-Time Equivalents (FTEs)
Research Time
Resident FTE Count Accuracy and Documentation
|
Section
VIII: Special Instructions for Calculating Reductions and
Increases to a Hospital’s 1996 Base Year Cap as a Result of
§422 of the Medicare Modernization Act of 2003
Decrease
to a Hospital’s 1996 Base Year Cap (§422 Cap Reduction)
Increase to a Hospital’s 1996 Base Year Cap (§422 Cap Increase)
|
Section
IX: CHGME PP Application Form Instructions
Number
of Inpatient Discharges
Case Mix Index
Number of Available Beds
Intern/Resident to Bed (IRB) Ratio
|
Section
X: References
Determining
the Period of Eligibility
Calculating the Resident FTE Count for an Incomplete Cost
Reporting Period
Calculating the Case Mix Index (CMI) for an Incomplete Cost
Reporting Period
Calculating Discharges for an Incomplete Cost Reporting
Period
Calculating the Number of Available Beds for an Incomplete
Cost Reporting Period
Calculating Inpatient Days for an Incomplete Cost Reporting
Period
Calculating Outpatient Services for an Incomplete Cost Reporting
Period
|
Section
XI: CHGME PP Application Form Instructions
HRSA
99: Hospital Demographic and Contact Information
HRSA 99-1: Determination of Weighted and Unweighted Resident
FTE Counts
HRSA 99-2: Determination of Indirect Medical Education
Data Related to the Teaching of Residents
HRSA 99-3: Hospital Certification
HRSA 99-4: Government Performance and Results Act Tables
HRSA 99-5: Application Checklist
|
Section
XII: References
Commonly
Used Acronyms
|
Section
I
Overview of the CHGME
PP
Introduction
In 1999, Congress
addressed the disparity of explicit graduate medical education (GME)
funding between freestanding children’s teaching hospitals and other
teaching hospitals by passing the Healthcare Research and Quality
Act, which established the Children’s Hospitals Graduate Medical
Education Payment Program (CHGME PP). The act was signed on December
6, 1999 and the legislation authorized the program for Federal fiscal
year (FY) 2000 and FY 2001. On October 17, 2000, the Children’s
Health Act of 2000 amended the Healthcare Research and Quality Act
of 1999 extending the CHGME PP through FY 2005. On December 23,
2004, additional amendments under Public Law 108-490 were made to
Section 340E of the Public Health Service Act affecting the CHGME
PP.
There are more
than 60 freestanding children’s teaching hospitals across the country
that train about 30 percent of the Nation’s pediatricians, nearly
half of pediatric sub-specialists, and provide valuable training
for physicians in many other specialties. These are the physicians
who care for America’s youngest population – its children. Almost
50 percent of the patient care that children’s teaching hospitals
provide is for low-income children, including those covered by Medicaid
and those who are uninsured. In addition, these hospitals are regional
and national referral centers for very sick children, often serving
as the only source of care for many critical pediatric services.
More than 75 percent of inpatient care at children’s hospitals is
devoted to children with one or more chronic conditions.
The CHGME PP
provides a more adequate level of support for GME training in U.S.
children’s teaching hospitals that have a separate Medicare provider
number. These hospitals receive relatively little funding from
Medicare for GME. Funding received by other teaching hospitals
from Medicare was expected to exceed more than $8 billion in FY
2005.
The CHGME PP
law authorized $280 million for payments in FY 2000, $285 million
in FY 2001, and “such sums as necessary” for fiscal years 2002 through
2005. Congress appropriated $40 million for the program in FY 2000,
$235 million in FY 2001, $285 million in FY 2002, $292 million in
FY 2003, $305 million for FY 2004, and $303 million for FY 2005.
For both FY 2004 and FY 2005 Congress implemented a rescission which
reduced the total appropriated amounts. In FY 2005, the CHGME PP
appropriation provided GME support to 60 children's hospitals in
31 states supporting more than 4,100 unweighted resident full-time
equivalents (FTEs) training in these hospitals. Since the inception
of this program, the program has disbursed more than $1.1 billion
in Federal GME support to freestanding children’s teaching hospitals.
Administration
The CHGME PP
is administered by the Graduate Medical Education Branch (GMEB)
of the Division of Medicine and Dentistry (DMD), Bureau of Health
Professions (BHPr), Health Resources and Services Administration
(HRSA), Department of Health and Human Services (DHHS). The objective
of the GMEB is to provide the assistance that freestanding children’s
hospitals need to ensure a future pediatric workforce that will
treat U.S. children.
Questions regarding
the CHGME PP should be directed to the:
Department
of Health and Human Services
Health Resources and Services Administration
Bureau of Health Professions
Division of Medicine and Dentistry
Graduate Medical Education Branch
Parklawn Building
5600 Fishers Lane Room 9A-05
Rockville, Maryland 20857
Telephone: 301-443-1058
Fax: 301-443-1879
Section
II
Application
Cycle and Deadlines
For hospitals
to be considered for CHGME PP funding, they must comply with statutory
eligibility requirements described herein and participate in the
CHGME PP’s application cycle, which consists of specific processes
for any given FY. These processes are guided by the CHGME PP’s
statutes and are described below.
Initial
Application
For children’s
hospitals, meeting all statutory and eligibility requirements, to
receive CHGME PP funding, they must submit a completed initial application
for CHGME PP funding in accordance with the established deadlines
noted below. During the initial application process, eligible children’s
hospitals provide the CHGME PP with information relevant to the
interim determination of payments.
Initial applications
for CHGME PP funding must include the following forms:
- HRSA 99:
Demographic and Contact Information
- HRSA 99-1:
Determination of Weighted and Unweighted Resident FTE Counts
- HRSA 99-2:
Determination of Indirect Medical Education Data Related to the
Teaching of Residents
- HRSA 99-3:
Certification
- HRSA 99-5:
Application Checklist
Applications
accepted for review must be completed following the application
guidance and instructions provided herein, submitted in English,
typed, and include the above completed forms and supporting documentation
as identified in the HRSA 99-5 (Application Checklist). The completed,
signed application package must be postmarked by August 1,
2007, and submitted to the:
Department
of Health and Human Services
Health Resources and Services Administration
Bureau of Health Professions
Division of Medicine and Dentistry
Graduate Medical Education Branch
Parklawn Building
5600 Fishers Lane Room 9A-05
Rockville, Maryland 20857
Application
materials are available electronically via the CHGME
PP website. Applications that are not postmarked by the specified
deadline will not be accepted for processing and funding and will
be returned to the applicant.
Interim
Payment Determination and Disbursement (Based Upon the Initial Application)
In accordance
with CHGME PP statutory requirements, information provided by participating
children’s hospitals in their initial applications for CHGME PP
funding is used by the CHGME PP to calculate payments for all eligible
children’s hospitals prior to the beginning of the FY (October 1st)
for which children’s hospitals have applied for CHGME PP funding.
CHGME PP payments, allocated to eligible children’s hospitals, are
a function of the number of resident full-time equivalents (FTEs)
participating in approved medical residency programs, inpatient
discharges, case mix indexes, and the number of inpatient available
beds, as reported by children’s hospitals in their initial applications
for CHGME PP funding. Payments are awarded for direct medical education
(DME) and indirect medical education (IME) expenses, respectively.
DME and IME payment calculations are subject to all rules, regulations,
and policies governing the CHGME PP.
On or after
October 1st of the FY for which eligible children’s hospitals
have applied for CHGME PP funding, the CHGME PP will begin making
interim payments. CHGME PP payments to eligible children’s hospitals
will be contingent upon the passage of the DHHS’ budget for the
given FY by the President. Children’s hospitals will be notified,
in writing, of the Secretary’s interim payment determination. In
accordance with CHGME PP statutes, payments will reflect a 25 percent
withholding from each interim installment (payment) for both DME
and IME payments, as necessary, to ensure that a hospital will not
be overpaid on an interim basis.
Assessment
of Resident FTE Counts Reported in Initial Applications
The CHGME PP
statute, Public Law 106-310, mandates that “the Secretary shall
determine any changes to the number of residents reported by a hospital
in the (initial) application of the hospital for the current
FY for both direct and indirect expense amounts.” Therefore, prior
to the end of the FY for which children’s hospitals have applied
for CHGME PP funding, the Secretary must determine (reconcile)
any changes to the number of resident FTEs reported by a hospital
in its initial application for the current FY, which will impact
final payments made by the CHGME PP to all eligible children’s hospitals.
This determination is done by conducting a comprehensive assessment
of the resident FTE counts claimed by children’s hospitals in their
initial applications for CHGME PP funding.
The CHGME PP
has contracted with fiscal intermediaries (hereinafter CHGME FIs)
to carry out an assessment of resident FTE counts (hereinafter the
“Resident FTE Assessment Program”) reflected in participating children’s
hospitals initial applications for CHGME PP funding to determine
any changes to the resident FTE counts initially reported. A 100
percent assessment of resident FTE counts reported by children’s
hospitals in their initial applications for CHGME PP funding is
performed regardless of the type(s) of Medicare cost report (MCR)
the hospital files (e.g., full, low- or no-utilization) for purposes
of receiving CHGME PP funding. This process is designed to assess
resident FTE counts for all children’s hospitals in an equitable
fashion and within CHGME PP time constraints.
The Resident
FTE Assessment Program requires participating children’s hospitals
to comply with requests from the CHGME FIs, within the time constraints
provided, as any changes to resident FTE counts in one children’s
hospital’s application for CHGME PP funding affects the distribution
of funds among all eligible children’s hospitals. To minimize public
burden, CHGME FIs use and build upon work previously conducted by
CHGME and/or Medicare FIs in prior years. The CHGME PP has made
available several guidance documents on the CHGME
PP’s website which provide further information about the Resident
FTE Assessment Program and documentation recommendations related
to the assessment of resident FTE counts.
At the conclusion
of the Resident FTE Assessment Program, the CHGME FIs will forward
final assessment reports to the respective children’s hospitals,
the Medicare FIs, and the CHGME PP explaining the results of the
review. The assessment reports include CHGME FI-generated HRSA
99-1’s, which children’s hospitals must use to complete their reconciliation
applications (see Reconciliation Application below). The assessment
reports may also include supporting documentation including, but
not limited to: adjustment reports, updates to the intern and resident
database, adjustments to the Centers for Medicare and Medicaid Services
(CMS) form 2552-96 Worksheet E-3, Part IV, or letters (to the Medicare
FI) requesting the reopening of one or more MCRs.
Reconciliation
Application
During the third
quarter of each FY (typically April 1st) for which payments
are being made, the CHGME PP will release a reconciliation application
for use by participating children’s hospitals to report changes
in the resident FTE counts reported in their initial applications
for CHGME PP funding. For children’s hospitals to continue receiving
CHGME PP funding, they must submit a completed reconciliation application
for CHGME PP funding in accordance with established deadlines noted
below. The resident FTE counts reported by children’s hospitals
in their reconciliation applications must be for the same MCR period(s)
identified in the hospital’s initial application for the subject
FY and consistent with those reported in the CHGME FIs FTE final
assessment report to be accepted by the CHGME PP. The resident
FTE counts from the final assessment reports are used to determine
the final amounts payable to children’s hospitals for the current
FY for both DME and IME. Children’s hospitals whose resident FTE
counts have not changed are not exempt from completing and submitting
a CHGME PP reconciliation application.
Reconciliation
applications for CHGME PP funding must include the following forms:
- HRSA 99:
Hospital Demographic and Contact Information
- HRSA 99-1:
Determination of Weighted and Unweighted Resident FTE Counts
- HRSA 99-2:
Determination of Indirect Medical Education Data Related to the
Teaching of Residents
- HRSA 99-3:
Hospital Certification
- HRSA 99-4:
Government Performance and Results Act Tables
- HRSA 99-5:
Application Checklist
Applications
accepted for review must be completed following the application
guidance and instructions provided herein, submitted in English,
typed, and include the above completed forms and supporting documentation
as identified in the HRSA 99-5 (Application Checklist). The completed,
signed application package must be postmarked by August 1, 2008,
and submitted to the:
Department
of Health and Human Services
Health Resources and Services Administration
Bureau of Health Professions
Division of Medicine and Dentistry
Graduate Medical Education Branch
Parklawn Building
5600 Fishers Lane Room 9A-05
Rockville, Maryland 20857
Application
materials are available electronically via the CHGME
PP website. If a children’s hospital fails to complete and
return a reconciliation application according to the terms and conditions
of the CHGME PP, the DHHS may suspend the award, pending corrective
action, or may terminate the award for cause.
Children’s hospitals
that were not eligible to participate or did not apply for funding
during the initial application process for a given FY are not eligible
to apply for and receive funding during the reconciliation application
process for the same FY. These hospitals must wait until the next
(initial) application cycle to apply for CHGME PP funding.
Final
Payment Determination and Disbursement (Based Upon the Reconciliation
Application)
The Secretary
will determine any balance due or any overpayment made to individual
hospitals following the determination of changes, if any, to the
number of resident FTEs reported by children’s hospitals in their
reconciliation applications as a result of the Resident FTE Assessment
Program. Children’s hospitals will be notified, in writing, of
the Secretary’s final reconciliation payment determination during
the fourth quarter (July 1st – September 30th)
of the FY in which payments are being made.
Children’s hospitals
that have been notified of an overpayment will have 30 days to return
the overpayment to the DHHS without accrual of interest. Children’s
hospitals that fail to return overpayments within the specified
timeframe will accrue and be responsible for any interest.
Reconciliation
payments will be made to individual hospitals on or before the end
of the FY (September 30th) in which payments are being
made. The Secretary will include in the reconciliation payments
funding initially withheld in accordance with statutory requirements.
All hospitals, whether or not they report changes to their resident
FTE counts during the reconciliation process, can expect changes
to their final payment determination as a result of resident FTE
count changes reported by other participating children’s hospitals.
This is due to the methodology used to determine CHGME PP payments.
More detailed information is available on the CHGME PP payment methodology
in Section V of this application package. Information on the payment
formulas is also available on the CHGME
PP website. DME and IME payment calculations are subject to
all rules and regulations governing the CHGME PP statute, including
the June 19, 2000 Federal Register notice for DME, the July 20,
2001 Federal Register notice for IME, and §422 of the Medicare Modernization
Act (MMA) of 2003 and all accompanying policies and regulations.
At the end of
the FY, the CHGME PP may make a final payment to distribute any
remaining funds, including those funds that have been returned to
the DHHS during the course of the FY as a result of overpayment
or hospitals’ loss of eligibility.
Electronic
Availability of Application Materials
Application
materials are available electronically via the CHGME
PP website.
Section
III
CHILDREN’S
HOSPITALS GRADUATE MEDICAL EDUCATION PAYMENT PROGRAM APPLICATION
FORMS
OMB No. 0915-0247
Expiration Date: 03/31/2010
Public Burden Statement
An agency may not conduct or sponsor, and a person is not required
to respond to, a collection of information unless it displays a
currently valid OMB control number. The OMB control number for
this project is 0915-0247. Public reporting burden for the applicant
for this collection of information is estimated to average 69 hours
per response, including the time for reviewing instructions, searching
existing data sources, gathering and maintaining the data needed,
and completing and reviewing the collection of information. Send
comments regarding this burden estimate or any other aspect of this
collection of information, including suggestions for reducing this
burden, to HRSA Reports Clearance Officer, 5600 Fishers Lane, Room
14-33, Rockville, Maryland, 20857.
INSERT CHGME PP APPLICATION FORMS AFTER THIS PAGE
(FORMS HRSA 99, HRSA 99-1, HRSA 99-2, HRSA 99-3, HRSA 99-4,
HRSA 99-5)
Section
IV
Hospital Eligibility
Eligibility Criteria
According to Public Law 106-310, a children’s teaching hospital
must meet the following eligibility criteria for CHGME PP funding.
The hospital must:
- participate in an approved GME program;
- have a Medicare Provider Agreement;
- be excluded from the Medicare inpatient prospective payment
system (PPS) under section 1886(d)(1)(B)(iii) of the Social Security
Act, and its accompanying regulations(1);
and
- operate as a “freestanding” children’s teaching hospital, as
defined by the CHGME PP.(2)
(1) A hospital
with a 3300 series Medicare provider number would meet this criterion
(i.e., 55-3300).
(2)A children’s teaching
hospital is considered “freestanding” if it does not operate under
a Medicare hospital provider number assigned to a larger health
care entity that receives Medicare GME payments.
Additional references:
- § Social Security Act, Section 1886
- § CHGME PP, Federal Register Notice dated March 1, 2001
(66 FR 12940)
Changes in Eligibility
A hospital remains eligible for CHGME PP funding as long as it
meets the eligibility criteria listed above and trains residents
as a “freestanding” children’s hospital during the FY for which
CHGME PP payments are being made.
If a hospital becomes ineligible for payments:
- it must notify the CHGME PP immediately of the change in status
and the date of the change; and
- it will be liable for the reimbursement, with interest, of any
funds received during the period of ineligibility.
Additional references:
- CHGME PP, Federal Register Notice dated March 1, 2001 (66
FR 12940)
Section
V
Payment
Methodology
Payment Methodology
CHGME PP funding to individual children’s hospitals is based upon
a number of variables, including the rolling average of weighted
and unweighted resident FTE counts, which are used to calculate
DME and IME payments, respectively. Payment variables and calculations
are subject to all rules and regulations governing the CHGME PP
statute, including the June 19, 2000 Federal Register notice for
DME, the July 20, 2001 Federal Register notice for IME, and §422
of the MMA of 2003 and all accompanying policies and regulations.
The rolling average is the average of the resident FTE counts reported
by the children’s hospital for the (1):
- most recently filed MCR (or the most recently completed MCR
period); and
- the prior two years.
(1) CHGME PP funding to a children’s
hospital that has not completed three (3) MCR periods will be based
upon the hospital’s resident FTE count from its “most recently filed”
or “most recently completed” MCR period until three (3) MCR periods
have been completed.
The rolling average resident FTE count includes all residents except
those that qualify for an adjustment after the averaging rules are
applied in accordance with 42 CFR 413.77.
The resident FTE count for any MCR period is based upon the number
of:
- allopathic and osteopathic residents following application
of the “cap”, where applicable; and
- dental and podiatric residents.
Effective “for portions of cost reporting periods occurring on
or after July 1, 2005”, the CHGME PP will not include resident FTEs
counted against the §422 cap increase in the 3-year rolling average
calculation for purposes of DME and IME payments. Additional
information regarding the CHGME PP’s implementation of §422 of the
MMA of 2003 is included in Sections VII and VIII of this application
package.
Additional references:
- Social Security Act, Section 1886
- 42 CFR 413.77 (CMS)
- CMS, Federal Register Notice, August 11, 2004 (69 FR 48916)
- CHGME PP, Federal Register Notice dated June 19, 2000 (65
FR 37985)
- CHGME PP, Federal Register Notice dated March 1, 2001 (66
FR 12940)
- CHGME PP, Federal Register Notice dated July 20, 2001 (66
FR 37980)
- CHGME PP, Federal Register Notice dated October 22, 2003
(68 FR 60396)
Applicable to the following application forms: HRSA-99-1,
HRSA-99-2, and HRSA-99-4
Section
VI
Data Sources for Children’s Hospitals that File Full MCRs
To complete a CHGME PP application, hospitals that file full MCRs
(i.e., report residents to Medicare on CMS 2552-96, Worksheet E-3,
Part IV) must use the data as reflected in their:
- most recently filed MCR for the period ending on or before
December 31, 1996 (the “cap year");
- most recently filed MCR; and the
- prior two years.
In addition, hospitals who received adjustments to their cap (increases
or decreases) as a result of §422 of the MMA of 2003 must use data
included in and provide a copy of their written notification from
CMS regarding these adjustments. Additional information regarding
the CHGME PP’s implementation of §422 of the MMA of 2003 is included
in Sections VII and VIII of this application package.
Additional references:
- Social Security Act, Section 1886
- 42 CFR 413.77 (CMS)
- CMS, Federal Register Notice, August 11, 2004 (69 FR 48916)
- CHGME PP, Federal Register Notice dated March 1, 2001 (66
FR 12940)
Applicable to the following application forms: HRSA-99-1,
HRSA-99-2, and HRSA-99-4
Data Sources for Children’s Hospitals that File Low- or No-Utilization
MCRs
To complete a CHGME PP application, hospitals that file low- or
no-utilization MCRs (i.e., do not report residents to Medicare on
CMS 2552-96, Worksheet E-3, Part IV) must use the data as reflected
in their hospital records for the:
- most recently completed MCR period for the period ending on
or before December 31, 1996 (the “cap year”);
- most recently completed MCR period; and the
- completed MCR periods for the prior two years.
In addition, hospitals who received adjustments to their cap (increases
or decreases) as a result of §422 of the MMA of 2003 must use data
included in and provide a copy of their written notification from
CMS regarding these adjustments. Additional information regarding
the CHGME PP’s implementation of §422 of the MMA of 2003 is included
in Sections VII and VIII of this application package.
Hospitals whose most recently completed MCR period ends less
than five (5) months prior to the stated CHGME PP initial
application deadline may report as their most recently completed
MCR period resident FTE counts from their most recently completed
or the previously completed MCR period.
Example:
Charlie’s Angels Children’s Center (CACC) will file a low-utilization
MCR for its 6/30/03 year-end. The CHGME PP application deadline
for FY 2004 is August 1, 2003 (approximately 1 month after CACC’s
year-end). CACC has the option of reporting as its “most recently
completed MCR period” data from its 6/30/02 or 6/30/03 year-end.
Since CACC needs time to close-out its resident FTE counts and
financial records for its 6/30/03 year-end, it decides to use
the resident FTE count data from its 6/30/02 cost reporting period
to complete Section 4 of HRSA-99-1. Consequently, CACC must use
data from its 6/30/01 and 6/30/00 MCR periods to complete Sections
5 and 6 of the HRSA-99-1, respectively. CACC must also use its
hospital data from its 6/30/02 cost reporting period to complete
all subsequent application forms (i.e., HRSA-99-2, HRSA-99-4,
etc.). CACC cannot use the resident FTE count data from its 6/30/03
MCR period until the next CHGME PP initial application cycle (FY
2005).
Additional references:
- Social Security Act, Section 1886
- 42 CFR 413.77 (CMS)
- CMS, Federal Register Notice, August 11, 2004 (69 FR 48916)
- CHGME PP, Federal Register Notice dated March 1, 2001 (66
FR 12940)
Applicable to the following application forms: HRSA-99-1,
HRSA-99-2, and HRSA-99-4
Data Sources for Children’s Hospitals that Have Not Completed
Three (3) MCR Periods
If a hospital has completed at least one (1), but not more than
two (2) MCR periods, CHGME PP funding to the children’s hospital
will be based upon data from the hospital’s “most recently filed”
or “most recently completed” MCR period until three (3) MCR periods
have been completed. Hence, the hospital will not complete sections
5 and 6 of HRSA-99-1 and its DME and IME payments will not
be based upon a three-year rolling average resident FTE count.
Upon completion of three (3) MCR periods, the hospital will complete
sections 5 and 6 of HRSA-99-1 and will receive DME and IME payments
based upon a three-year rolling average resident FTE count.
In addition, hospitals who received adjustments to their cap (increases
or decreases) as a result of §422 of the MMA of 2003 must use data
included in and provide a copy of their written notification from
CMS regarding these adjustments. Additional information regarding
the CHGME PP’s implementation of §422 of the MMA of 2003 is included
in Sections VII and VIII of this application package.
Additional references:
- CHGME PP, Federal Register Notice dated July 20, 2001 (66
FR 37980)
Applicable to the following application forms: HRSA-99-1,
HRSA-99-2, and HRSA-99-4
Data Sources for Children’s Hospitals that Have Not Completed
One (1) MCR Period
New children’s teaching hospitals (new to the CHGME PP) training
residents who were originally trained in a program that received
and will continue to receive funding under the CHGME PP are required
to wait until they have completed a MCR period before applying for
CHGME PP funding. These hospitals must also apply the 3-year rolling
average (to their resident FTE counts) in accordance with Medicare
regulations. Over a 3-year period, the “new children’s teaching
hospital” will gradually increase its number of resident FTEs that
can be claimed in the CHGME PP as the children’s hospital that originally
trained those resident FTEs gradually decreases its resident FTE
count for determining payments from the CHGME PP.
New children’s teaching hospitals (new to the CHGME PP) training
residents previously trained at a hospital that never received (or
is no longer receiving) funding under the CHGME PP are eligible
for CHGME PP funding without having completed a MCR period. In
addition, a hospital that becomes newly eligible for the CHGME PP
by starting its own “new medical residency training program” according
to Medicare regulation 42 CFR 413.79(e)(1) will also be eligible
for CHGME PP funding without having completed a MCR period.
Hospitals that are eligible to receive CHGME PP funding without
having completed a MCR period must follow the guidance provided
in Section X of this application package which provides special
calculation instructions for hospitals that have not completed a
MCR report.
Additional references:
- CHGME PP, Federal Register Notice dated July 20, 2001 (66
FR 37980)
Applicable to the following application forms: HRSA-99-1,
HRSA-99-2, and HRSA-99-4
Section
VII
Cap and Cap Year
Section 1886(d)(5)(B)(v) of the Social Security Act established
“caps” on the number of allopathic and osteopathic residents that
a hospital operating an approved GME program may count when requesting
payment for DME and IME costs. A hospital’s “cap”
(hereinafter the “1996 Base Year Cap”) is currently
defined as the “number of unweighted resident FTEs enrolled in a
hospital’s allopathic and osteopathic residency programs during
the most recent cost reporting period ending on or before December
31, 1996 (the “cap year”).” The cap (i.e., limit) on the number
of allopathic and osteopathic residents is effective for all cost
reporting periods beginning on or after October 1, 1997. Dental
and podiatric residents are exempt from the cap, but
are included in the resident FTE counts for all relevant years to
calculate the rolling average.
The “cap year” is defined as a hospital’s most recent
cost reporting period ending on or before December 31, 1996.
Example:
CACC had 75 resident FTEs enrolled in its allopathic programs,
25 resident FTEs enrolled in its osteopathic programs and 7 resident
FTEs enrolled in its dental and podiatric programs for its 6/30/96
MCR period (its most recent MCR period ending on or before December
31, 1996). Hence, CACC’s cap for Medicare and CHGME PP purposes
is 100 (75+25=100).
Additional references:
- Social Security Act, Section 1886
- 42 CFR 413.79 (CMS)
- CHGME PP, Federal Register Notice dated March 1, 2001 (66
FR 12940)
- CHGME PP, Federal Register Notice dated July 20, 2001 (66
FR 37980)
Applicable to the following application forms: HRSA-99-1
and HRSA-99-2
Adjustments to a Hospital’s Cap
As noted above, Section 1886(d)(5)(B)(v) of the Social Security
Act established caps on the number of allopathic and osteopathic
residents that a hospital operating an approved GME program may
count when requesting payment for DME and IME costs. While Medicare
and the CHGME PP only make DME and IME payments for the number of
allopathic and osteopathic resident FTEs up to a hospital’s “1996
Base Year Cap”, some hospitals have trained allopathic and osteopathic
residents in excess of their 1996 Base Year Cap. There are also
a number of hospitals that have reduced their resident positions
to a level below their 1996 Base Year Cap.
Subsequent legislative actions and related Federal Register notices
provisions have been published addressing these issues allowing
a hospital’s cap to be permanently changed (increased or decreased)
by CMS or temporarily adjusted at the request of the hospital and
approved by CMS. These provisions are detailed below.
§422 of the Medicare Modernization Act of 2003
In December 2003, the President signed the MMA of 2003 (also known
as the Medicare Prescription Drug and Improvement Act of 2003),
Public Law 108-173. §422 of the MMA, added Section 1886(h)(7) to
the SSA. This provision reduced the 1996 Base Year Cap for certain
hospitals and redistributed those positions to other hospitals that
applied for and received an increase to their 1996 Base Year Cap
under §422. Hereinafter, any decreases to a hospital’s 1996 Base
Year Cap as a result of §422 will be referred to as the “§422
Cap Reduction” and any increases to the 1996 Base Year Cap
as a result of §422 will be referred to as the “§422 Cap Increase.”
Authority for implementing §422 of the MMA was delegated to the
CMS. Determinations made and implemented by CMS in response to
§422 are final and not subject to appeal.
Under the CHGME PP statute, by incorporation of the Social Security
Act provisions, the HRSA must implement the counting law and rules
of Medicare, which include those related to the implementation of
§422 of the MMA. Additional information regarding the CHGME PP’s
implementation of §422 of the MMA can be found in Section VIII of
this application package.
Medicare GME Affiliation Agreements and Other Regulations
Allowing the Establishment or Adjustment of a Hospital Cap
Hospitals that were not in existence for the most recent cost reporting
period ending on or before December 31, 1996 do not have a “1996
Base Year Cap” and are, therefore, “capped” to a resident FTE count
of zero “0”. Hence, hospitals must obtain (or adjust) their 1996
Base Year Cap (or lack thereof) in order to receive CHGME PP funding.
To provide an adjustment to a cap, the CHGME PP will allow hospitals
to add resident FTEs to their “1996 Base Year Cap” based on the
following Medicare and CHGME PP regulations:
- the formation of a new medical residency program as described
in 42 CFR 413.79(e)(1); or
- the execution of a Medicare GME Affiliation Agreement for an
aggregate cap, as set forth in 42 CFR 413.79(f) and 63 FR 26338
as published in the Federal Register on May 12, 1998, with the
following exceptions:
- A “new children's teaching hospital” participating in the
CHGME PP for the first year must establish an effective date
of the agreement for purposes of the CHGME PP. For the first
year, unless otherwise specified, the Department will use
as the effective date of the Medicare GME Affiliation Agreement
for an aggregate cap the date that the hospital becomes eligible
for CHGME PP funding. This effective date will only apply
to the CHGME PP. A hospital must also have an effective date
of July 1st for the Medicare Program. Subsequent
to the first year of the Medicare GME Affiliation Agreement,
the effective date must comply with the above-cited Federal
Register final rule, which specifies an effective date of
July 1st for all affiliation agreements.
The CHGME PP allows this exception because hospitals must meet
eligibility criteria and have their caps determined prior to the
CHGME PP application deadline. If the CHGME PP application deadline
occurs before July 1st, some hospitals would have a cap
of zero and thus be excluded from receiving funds. By deviating
from the prescribed Medicare final rule, the CHGME PP will not place
some hospitals in this position.
Unlike the Medicare Program, for the first year that a hospital
is eligible to participate in the CHGME PP, the CHGME PP will not
prorate the cap based on the effective date of the cap. Instead,
the full value of the cap as determined by the Medicare GME Affiliation
Agreement will be used. For purposes of the CHGME PP and its application
forms, a hospital that is now starting to train residents previously
trained at a hospital that never received or is no longer receiving
funds from the CHGME PP will be allowed to use the cap agreed upon
in the Medicare GME Affiliation Agreement until the full value of
the cap is reflected in the MCR. Afterwards, the hospital will
use the resident FTE count and cap from its filed MCR as indicated
in Section VI of this application package.
Example:
CACC opened as a freestanding children’s hospital on January
1, 2003 and would like to apply for FY 2004 CHGME PP funding.
The CHGME PP FY2004 application deadline is August 1, 2003. Since
CACC did not train residents in 1996, it has a cap of zero, but
was able to arrange a Medicare GME Affiliation Agreement for an
aggregate cap with Shirley Temple Medical Center in which CACC’s
current residents had previously trained.
CACC did the following in order to apply for CHGME PP funding:
- Established a cap by forming a Medicare GME Affiliation Agreement
with Shirley Temple Medical Center for an aggregate cap.
- The agreement had an effective date of January 1, 2003 (for
CHGME PP purposes only) and an effective date of July 1, 2003
and expiration date of June 30, 2004 for and in accordance with
Medicare rules and regulations.
- CACC and Shirley Temple Medical Center filed the agreement
with their Medicare FIs (the hospital’s have different Medicare
FIs) before June 30, 2003 (in accordance with Medicare rules and
regulations) and provided a signed copy to the CHGME PP following
acceptance by the FIs.
Hospitals that report residents to Medicare and are part of an
affiliated group may elect to apply the resident FTE limit on an
aggregate basis under Medicare rules and regulations. If the combined
resident FTE counts for the individual members of the group exceed
the aggregate limit, each hospital’s resident FTE cap will be adjusted
per the agreement between the members of the affiliated group.
These adjustments must be reflected in the filed MCR in order to
be considered for the CHGME PP.
Hospitals that receive an increase to their 1996 Base Year Cap
from CMS under §422 of the MMA of 2003 and participate in a Medicare
GME Affiliation Agreement under 42 CFR 413.79(f) on or after July
1, 2005, may only affiliate for the purpose of adjusting their (original)
1996 Base Year Cap. The additional slots that a hospital receives
under §422 may not be aggregated and applied (through Medicare GME
Affiliation Agreements) to the cap of any other hospitals.
Hospitals should refer to 42 CFR 413.79(f) for additional information
on adjustments to the cap.
Additional references:
- Social Security Act, Section 1886
- 42 CFR 413.79(f) (CMS)
- CHGME PP, Federal Register Notice dated March 1, 2001 (66
FR 12940)
- CHGME PP, Federal Register Notice dated July 20, 2001 (66
FR 37980)
Applicable to the following application forms: HRSA-99-1,
HRSA-99-2, and HRSA-99-4
Exceeding the Cap
For DME payment calculations if a hospital’s unweighted
resident FTE count for allopathic and osteopathic residents exceeds
its FTE limit (“cap”), the weighted count is reduced by the ratio
of the resident FTE limit to the actual unweighted resident FTE
count for the subject cost reporting period. Additional information
regarding the CHGME PP’s implementation of §422 of the MMA of 2003
is provided below.
Example:
CACC, per its Medicare GME Affiliation Agreement, has a cap
of 100. For its 6/30/03 MCR, CACC reported an unweighted resident
FTE count of 150 and a weighted count of 105 for its allopathic
and osteopathic programs.
For DME payment purposes, CACC would determine its weighted allopathic
and osteopathic resident FTE count by taking its cap divided by
its total unweighted resident FTE count and multiplying that product
by the total weighted resident FTE for allopathic and osteopathic
residents [(100/150) x 105 = 70.00]. The weighted count of
any dental and podiatric residents trained during this MCR period
would be added to the 70.00 as dental and podiatric residents
are exempt from (i.e., not subject to) the cap.
For IME payment calculations if a hospital’s unweighted
resident FTE count for allopathic and osteopathic residents exceeds
its FTE limit (“cap”), the hospital must report the lesser of the
unweighted resident FTE count or the cap for the subject cost reporting
period. Additional information regarding the CHGME PP’s implementation
of §422 of the MMA of 2003 is provided below.
Example:
CACC, per its Medicare GME Affiliation Agreement, has a cap
of 100. For its 6/30/03 MCR, CACC reported an unweighted resident
FTE count of 150 and a weighted count of 105 for its allopathic
and osteopathic programs.
For IME payment purposes, CACC would report 100.00 [the lesser
of the unweighted allopathic and osteopathic resident FTE count
(150) or the cap (100)]. The unweighted count of any dental
and podiatric residents trained during this MCR period would be
added to the 100.00 as dental and podiatric residents are exempt
from (i.e., not subject to) the cap.
Impact of §422 of the MMA When a Hospital Exceeds It’s
Cap
§422 of the MMA will affect the determination of DME and IME
payments for each of the children’s hospitals participating in
the CHGME PP. The CHGME PP will begin accounting for the redistribution
of the 1996 caps under §422 of the MMA in determining DME and
IME payments starting with “portions of a hospital’s cost reporting
periods occurring on or after July 1, 2005.”
Children’s hospitals whose cap has been reduced under §422 of
the MMA will report and be paid based on the §422 Cap Reduction
effective “for portions of cost reporting periods occurring on
or after July 1, 2005.” The 1996 Base Year Cap will be used for
MCR periods prior to the effective date. Children’s hospitals
will be asked to submit a copy of the letter they received from
CMS informing them of the reduction in their cap that includes
the actual reduction. The full effect of the reduction for a
given hospital will take about three years following implementation
of §422 when all three MCR periods reflected in the hospital’s
application for CHGME PP funding are affected by the §422 Cap
Reduction.
For children’s hospitals who received an increase to their 1996
Base Year Cap under §422 of the MMA, the CHGME PP will not include
resident FTEs counted against the §422 Cap Increase in the 3-year
rolling average calculation for purposes of DME and IME payments
effective for portions of cost reporting periods and discharges
occurring on or after July 1, 2005. In addition, effective for
discharges occurring on or after July 1, 2005, the CHGME PP will
not apply the intern/resident to bed (IRB) ratio cap to the residents
claimed against a hospital’s §422 Cap Increase. However, residents
claimed against the 1996 Base Year Cap will be subject to the
3-year rolling average and will be subject to the IRB ratio cap.
Additional references:
- 42 CFR 413.79 (CMS)
- CHGME PP, Federal Register Notice dated March 1, 2001 (66
FR 12940)
Applicable to the following application forms: HRSA
99-1and HRSA 99-2
Eligible Residency Programs (Approved Training Programs)
Residents may be included in a hospital’s resident FTE count for
CHGME PP purposes if the residency program (in which the resident
is enrolled) meets one of the following criteria:
- The program must be approved by one of the following accrediting
bodies:
- Accreditation Council for Graduate Medical Education (ACGME);
- Committee on Hospitals of the Bureau of Professional Education
of the American Osteopathic Association;
- Commission on Dental Accreditation of the American Dental
Association; or
- Council of Podiatric Medicine Education of the American
Podiatric Medical Association.
- The program may count towards certification of the participant
in a specialty or subspecialty listed in the current edition
of the Directory of Graduate Medical Education Programs (published
by the American Medical Association) or the Annual Report and
Reference Handbook (published by the American Board of Medical
Specialties).
- The program is approved by the ACGME as a fellowship program
in geriatric medicine; or
- The program would be accredited except for the accrediting
agency’s reliance upon an accreditation standard that requires
an entity to perform an induced abortion or require, provide,
or refer for training in the performance of induced abortions,
or make arrangements for such training, regardless of whether
the standard provides exceptions or exemptions.
Additional references:
- Social Security Act, Section 1886
- 42 CFR 413.75(b) (CMS)
Applicable to the following application forms: HRSA-99-1,
HRSA-99-2, and HRSA-99-4
Eligible Residents
In order to be counted in CHGME PP payment calculations, a resident
must be:
- in an approved residency training program (see Eligible
Residency Program above);
and either
- a graduate of an accredited medical school in the U.S. or Canada;
or
- have passed the United States Medical Licensing Examination
(USMLE) Parts I & II (international or foreign medical graduates)
Additional references:
- Social Security Act, Section 1886
- 42 CFR 413.75(b) (CMS)
- 42 CFR 413.80 (CMS)
Applicable to the following application forms: HRSA-99-1,
HRSA-99-2, and HRSA-99-4
International Medical Graduates (IMGs)
An IMG [(formerly known as a foreign medical graduate (FMG)] is
a resident who is not a graduate of a medical, osteopathy, dental,
or podiatry school, respectively, accredited or approved as meeting
the standards necessary for accreditation by the:
- Liaison Committee on Medical Education of the American Medical
Association;
- American Osteopathic Association;
- Commission on Dental Accreditation; or the
- Council on Podiatric Medical Education.
In order for an IMG to be included in a hospital’s resident FTE
count, s/he must have passed Parts I and II of the USMLE and be
enrolled in an eligible residency program.
Additional references:
- Social Security Act, Section 1886
- 42 CFR 413.75(b) (CMS)
- 42 CFR 413.80 (CMS)
Applicable to the following application forms: HRSA-99-1,
HRSA-99-2, and HRSA-99-4
Resident Full-Time Equivalent (FTE) Counts
Resident FTE counts are based on the number of residents training
at the hospital complex and certain non-hospital/non-provider settings/sites
throughout the hospital’s fiscal year. Residents are counted as
FTEs based on the total time necessary to fill a full-time residency
slot for the year.
For purposes of clarification, a resident FTE is measured in terms
of time worked during a residency training year. It is not a measure
of the number of individual residents who are working.
Additional references:
- Social Security Act, Section 1886
- 42 CFR 413.78 (CMS)
Applicable to the following application forms: HRSA-99-1,
HRSA-99-2, and HRSA-99-4
Initial Residency Period (IRP)
Residents are divided into two categories, those in their:
- initial residency period (IRP);
- Effective July 1, 1995, an IRP is defined as the minimum
number of years required for board eligibility.
- For osteopathic, dentistry, and podiatric programs, the
IRP is the minimum number of years of formal training necessary
to satisfy the requirements of the approving body for those
programs.
- Prior to July 1, 1995, an IRP is defined as the minimum
number of years required for board eligibility in a specialty
or subspecialty plus 1 year (not to exceed 5 years with some
exceptions).
- and those beyond their IRP.
Example:
The IRP for pediatrics is 3 years. Therefore, the initial
residency period for all pediatric subspecialties (e.g., pediatric
cardiology) is three years.
The IRP for general surgery is 5 years. Therefore, the initial
residency period of all surgical subspecialties (e.g., pediatric
surgery) is 5 years even if the training program requires a
longer period of training.
A Pediatric Surgery (subspecialty) resident (or fellow) who
previously completed a 5-year general surgery residency program
and is now in his first year of subspecialty training (in Pediatric
Surgery) is beyond his IRP. His IRP was 5 years (general surgery).
Exceptions apply to the IRP for residents enrolled in preventive
medicine, geriatric medicine, transitional year and combined residency
programs. Refer to 42 CFR 413.79(a) for additional information
on the IRP and exceptions.
Additional references:
- Social Security Act, Section 1886
- 42 CFR 413.79(a) (CMS)
Applicable to the following application forms: HRSA-99-1
Weighting of Resident FTE Counts
The CHGME PP, like Medicare, assigns a 0.5 (or ½) weighting factor
to residents who are beyond their IRP. Hence a resident who is
beyond his or her initial residency period is factored by 0.5 regardless
of the number of years or length of the training program in which
s/he is currently enrolled.
Example:
John Doe completed a 3-year pediatric residency program on
June 30, 1999 at CACC. Following completion of his residency
program, John continued his training in a pediatric cardiology
fellowship program also at CACC. During the first year of his
fellowship program (July 1, 1999 to June 30, 2000), John spent
40% of the academic year at CACC and 60% of the academic year
rotating to other teaching hospitals.
CACC’s MCR period is the same as the academic year (July 1 to
June 30). Hence, CACC would report John as 0.20 for the MCR period
ending June 30, 2000 [(40/100) x 0.5 = .20]. CACC must weight
John’s resident FTE count because the IRP for pediatrics is 3
years and John is in his 4th year of training (3 years
of residency training and 1 year of fellowship training).
For CHGME PP purposes, the weighting of resident FTE counts is
also applicable to the increase in resident FTEs based on §422 of
the MMA et al.
Additional references:
- Social Security Act, Section 1886
- 42 CFR 413.79(b) (CMS)
Applicable to the following application forms: HRSA-99-1
Where Residents Are Counted
The time a resident spends anywhere within the hospital complex
(see “Hospital Complex” below) may be included in the resident FTE
count for CHGME PP purposes. In addition, the time spent by residents
in certain non-hospital/non-provider settings/sites is counted if
the criteria identified below (under “Non-Provider/Non-Hospital
Settings and Written Agreements”) are met.
Additional references:
- Social Security Act, Section 1886
- 42 CFR 413.78 (CMS)
- CHGME PP, Federal Register Notice dated March 1, 2001 (66
FR 12940)
Applicable to the following application forms: HRSA-99-1,
HRSA-99-2, and HRSA-99-4
Hospital Complex
The time a resident spends anywhere within the hospital complex
(as defined in 42 CFR 413.65) may be included in the resident FTE
count for CHGME PP purposes.
The CMS final rule implementing the per resident amount (PRA) methodology
for payment of the direct GME costs of approved GME activities defines
a hospital complex as “hospitals and hospital-based providers and
sub providers” (54 FR 40286, September 29, 1989). The term “hospital”
is defined in Section 1861(e) of the Social Security Act as, in
part, an institution which is primarily engaged in providing, by
or under the supervision of physicians, diagnostic and therapeutic
services to inpatients. The term “provider of services” is defined
in Section 1861(u) of the Social Security Act as a hospital, skilled
nursing facility, comprehensive outpatient rehabilitation facility,
home health agency, hospice program, or, for purposes of Section
1814(g) and Section 1835(c), a fund. The term “sub provider” is
defined in the Provider Reimbursement Manual (PRM) Part II, Section
2405(b) as “a portion of a general hospital which has been issued
a sub provider identification number because it offers a clearly
different type of service from the remainder of the hospital, such
as long-term psychiatric.”
The CHGME PP, however, does not differentiate between PPS and non-PPS
locations within a hospital complex.
Additional references:
- Social Security Act, Section 1886
- 42 CFR 413.65 (CMS)
- 42 CFR 413.78(a) (CMS)
- CHGME PP, Federal Register Notice dated March 1, 2001 (66
FR 12940)
Applicable to the following application forms: HRSA-99-1,
HRSA-99-2, and HRSA-99-4
Non-Provider/Non-Hospital Settings and Written Agreements
The time a resident spends in a non-provider (or non-hospital)
setting such as a physician’s office or a freestanding community
health center in connection with an approved program may be included
in the resident FTE count if the criteria in Federal regulation
42 CFR 413.78 are met. For CHGME PP purposes, 42 CFR 413.78 applies
to both DME and IME funding received under the CHGME PP.
Written agreements covering residents’ time spent in non-provider/non-hospital
settings shall cover a period of one year and must commence on the
start of the cost reporting period and must be between the hospital
and the non-hospital setting, not between the related School of
Medicine (SOM), School of Podiatric Medicine (SOPM), or School of
Dentistry (SOD). Refer to 42 CFR 413.78 for additional information
on written agreements.
Additional references and application forms:
- Social Security Act, Section 1886
- 42 CFR 413.78 (CMS)
- CHGME PP, Federal Register Notice dated March 1, 2001 (66
FR 12940)
Applicable to the following application forms: HRSA-99-1,
HRSA-99-2, and HRSA-99-4
Partial Resident Full-Time Equivalents (FTEs)
A partial resident FTE is a resident who does not spend all time
that is part of the approved training program in the hospital complex
or qualified non-hospital setting. A resident will count as a partial
resident FTE based on the proportion of allowable time worked at
the children’s hospital and qualified non-hospital (provider) settings
compared to the total time necessary to fill a full-time residency
slot. Instances where a resident would be counted as a partial
resident FTE include, if the resident:
- is part-time;
- rotates to other hospitals as part of the approved training
program sponsored by the children’s hospital;
- is in a program sponsored by another hospital and spends one
or more rotations at the children's hospital;
- is on maternity leave;
- joins or leaves a program mid-year; or
- passes the USMLE mid-year.
Hospitals should consult with their FIs regarding additional exceptions.
The sum of partial FTE resident counts at all institutions where
an individual resident works as part of his/her approved residency
program may not exceed 1.0 FTE. Also, time spent by residents moonlighting
may not be counted.
Example:
During the course of the year, a full-time resident in orthopedic
surgery spends 90 days at the children’s hospital and 275 days
at the hospital sponsoring the residency program. The resident
would count as a 0.25 FTE at the children’s hospital [90/365 =
0.2465 (rounded to 0.25)].
A part-time third year resident in pediatrics works 4 days week.
The normal workweek for a full time third year pediatric residents
is 6 days per week. The resident would count as 0.67 FTE [4/6
= .6666 (rounded to 0.67)]
During the course of the year, a full-time resident (who is also
a foreign medical graduate) is enrolled in his second year of
a three-year family practice residency program at CACC. The resident
spends the entire academic year (2000-2001) at CACC and does not
rotate to any other sites. The resident took and passed Part
I of the USMLE in September 2000. On May 1, 2001, the resident
sat for Part II of the USMLE and is awaiting the examination results.
In June 2001 the resident learns that he passed Part II of the
USMLE. Since CACC’s year-end is June 30, CACC may count and include
the resident in their resident FTE counts (as a partial FTE) for
the period May 1, 2001 (the date he took the examination) to June
30, 2001 (CACC’s year end). The resident would count as 0.17
FTE [61 days (31 days in May + 30 days in June)/ 365 days = 0.1671
(rounded to 0.17)].
Additional references:
- Social Security Act, Section 1886
- 42 CFR 413.78(b) (CMS)
Applicable to the following application forms: HRSA-99-1,
HRSA-99-2, and HRSA-99-4
Research Time
Research may be included in a hospital’s resident FTE count if
the research is part of the residency program and the resident carries
out the research in:
- the children’s hospital complex (clinical or bench research);
or
- in a non-provider setting where the research involves patient
care and the compensation for both the residents, the faculty
and other teaching costs are paid by the children’s hospital (requirements
listed at 42 CFR 413.78 must be met (66 FR 39896, Aug. 1, 2001)).
Additional references:
- Social Security Act, Section 1886
- 42 CFR 413.75 (CMS)
- 42 CFR 413.78 (CMS)
- CHGME PP, Federal Register Notice dated March 1, 2001 (66
FR 12940)
Applicable to the following application forms: HRSA-99-1,
HRSA 99-2, and HRSA 99-4
Resident FTE Count Accuracy and Documentation
Children’s hospitals are responsible for the accuracy of the resident
FTE counts submitted to HRSA and are subject to audit. More specifically,
the Secretary, by statute, must “determine any changes to the number
of residents reported by a hospital in the (initial) application
of the hospital for the current FY for both direct and indirect
expense amounts.” This mandate is accomplished through the Resident
FTE Assessment Program carried out by the CHGME PP (see “Application
Cycle and Deadlines”). Children’s hospitals are not required to
submit with their completed initial applications for CHGME PP funding,
documentation in support of the resident FTE data reported in their
applications. However, at the time children’s hospitals certify
their applications (i.e., sign and submit form HRSA 99-3 to the
CHGME PP), the hospital should possess documentation in accordance
with 413.75(d) and other applicable Medicare record-keeping regulations.
Hospitals that do not report resident FTE counts to Medicare are
not exempt from this policy.
The CHGME PP has developed a Documentation Guidance (document)
and an accompanying sample documentation binder to assist participating
hospitals in collecting and providing the documentation necessary
to support resident FTEs reported by a children’s hospital in its
initial application for CHGME PP funding. Participating children’s
hospitals can use this document and the accompanying sample binder
for compiling and organizing the information/data to be provided
to the CHGME FI during the Resident FTE Assessment process. The
Documentation Guidance (document) is available at http://bhpr.hrsa.gov/childrenshospitalgme/apply.htm.
Additional references:
- 42 CFR 413.20 (CMS)
- 42 CFR 413.24 (CMS)
- 42 CFR 413.75(d) (CMS)
- CHGME PP, Federal Register Notice dated March 1, 2001 (66
FR 12940)
Applicable to the following application forms: HRSA-99-1,
HRSA 99-2, and HRSA 99-4
Section
VIII
Special Instructions for Calculating Reductions and Increases
to a Hospital’s 1996 Base Year Cap as a Result of §422 of the Medicare
Modernization Act of 2003
Hospitals that received an increase or reduction to their 1996
Base Year Cap as a result of §422 of the MMA must use the following
methodology for calculating and claiming resident FTE counts against
their caps.
Decrease to a Hospital’s 1996 Base Year Cap (§422 Cap Reduction)
Children’s hospitals who received a decrease to their 1996 Base
Year Cap as a result of §422 of the MMA will report and be paid
based on the §422 Cap Reduction effective “for portions of cost
reporting periods occurring on or after July 1, 2005.” The 1996
Base Year Cap will be used for MCR periods prior to the effective
date. Children’s hospitals will be asked to submit a copy of the
letter they received from CMS informing them of the reduction in
their cap that includes the actual reduction amount. The full effect
of the reduction for a given hospital will take about three years
following the implementation of §422 when all three MCR periods
reflected in the hospital’s application for CHGME PP funding are
subject to the §422 Cap Reduction.
Example:
CACC had 75 resident FTEs enrolled in its allopathic programs,
25 resident FTEs enrolled in its osteopathic programs and 7 resident
FTEs enrolled in its dental and podiatric programs for its 6/30/96
MCR period (its most recent MCR period ending on or before December
31, 1996). Hence, CACC’s 1996 Base Year Cap for Medicare and
CHGME PP purposes is 100 (75+25=100). However, in December 2004
CACC received a letter from CMS indicating that their 1996 Base
Year Cap would be reduced by 7.50 resident FTEs under §422 of
the MMA. CACC’s new, revised cap is now 92.50 (1996 Base Year
Cap - §422 Cap Reduction). Any dental and podiatric residents
trained during this MCR period would not be included in the 1996
Base Year Cap or the “new, revised” cap as dental and podiatric
residents are exempt from (i.e., not subject to) the cap.
Increase to a Hospital’s 1996 Base Year Cap (§422 Cap Increase)
Children’s hospitals who received an increase to their 1996 Base
Year Cap as a result of §422 of the MMA will report and be paid
based on the §422 Cap Increase effective “for portions of cost reporting
periods occurring on or after July 1, 2005.” The 1996 Base Year
Cap will be used for MCR periods prior to the effective date. Children’s
hospitals will be asked to submit a copy of the letter they received
from CMS informing them of the adjustment to their cap that includes
the actual increase amount. It is important to note that a §422
Cap Increase is not automatically added to a hospital’s 1996 Base
Year Cap. A hospital’s ability to utilize their §422 Cap Increase
is contingent upon whether the hospital is training above or below
their 1996 Base Year Cap. Examples are provided below.
Examples (for Hospitals Training “Above” Their 1996 Base
Year Cap):
CACC had 75 resident FTEs enrolled in its allopathic programs,
25 resident FTEs enrolled in its osteopathic programs and 7 resident
FTEs enrolled in its dental and podiatric programs for its 6/30/96
MCR period (its most recent MCR period ending on or before December
31, 1996). Hence, CACC’s 1996 Base Year Cap for Medicare and
CHGME PP purposes is 100 (75+25=100). However, in December 2004
CACC received a letter from CMS indicating that their 1996 Base
Year Cap would be increased by 20 resident FTEs under §422 of
the MMA. CACC now has a 1996 Base Year Cap of 100 and a §422
Cap Increase of 20.
Example #1: During CACC’s most recent MCR period, CACC claimed
110 allopathic and osteopathic resident FTEs and 7 dental and
podiatric resident FTEs. Based on CACC’s 1996 Base Year Cap of
100 and §422 Cap Increase of 20, CACC would claim 100 resident
FTEs against its 1996 Base Year Cap and the remaining 10 resident
FTEs would be claimed against its §422 Cap Increase. Any dental
and podiatric residents trained during this MCR period would be
added to the total (un)weighted allopathic and osteopathic resident
FTEs following application of the caps as dental and podiatric
residents are exempt from (i.e., not subject to) the cap.
Example #2: During CACC’s most recent MCR period, CACC claimed
140 allopathic and osteopathic resident FTEs and 7 dental and
podiatric resident FTEs. Based on CACC’s 1996 Base Year Cap of
100 and §422 Cap Increase of 20, CACC would claim 100 resident
FTEs against its 1996 Base Year Cap and the remaining 40 resident
FTEs would be claimed against its §422 Cap Increase. As CACC’s
number of resident FTEs claimed exceeds both its 1996 Base Year
Cap and its §422 Cap Increase, the DME and IME payment calculation
methodology described in Section VII of this application package
(“Exceeding the Cap”) would be followed. Any dental and podiatric
residents trained during this MCR period would be added to the
total (un)weighted allopathic and osteopathic resident FTEs following
application of the caps as dental and podiatric residents are
exempt from (i.e., not subject to) the cap.
Examples (for Hospitals Training “Below” Their 1996 Base
Year Cap):
Example #1: During CACC’s most recent MCR period, CACC claimed
95 allopathic and osteopathic resident FTEs and 7 dental and podiatric
resident FTEs. Based on CACC’s 1996 Base Year Cap of 100 and
a §422 Cap Increase of 20, CACC would claim 95 resident FTEs against
its 1996 Base Year Cap and zero “0” residents against its §422
Cap Increase. Any dental and podiatric residents trained during
this MCR period would be added to the total (un)weighted allopathic
and osteopathic resident FTEs following application of the caps
as dental and podiatric residents are exempt from (i.e., not subject
to) the cap
Additional references:
- Social Security Act, Section 1886(h)(7)
- 42 CFR 413.79(b) (Centers for Medicaid and Medicare Services,
formerly the Health Care Financing Administration)
Applicable to the following application forms: HRSA-99-1
Section
IX
Special Instructions for Calculating
Indirect Medical Education Payment Variables
Hospitals applying for IME payments should follow the instructions
provided below when calculating inpatient discharges, CMI, available
beds, and the intern/resident to bed ratio. Additional information
and “calculation” instructions are provided in Section X of this
application package for hospitals that are eligible to begin receiving
CHGME PP funding without having completed a MCR period.
Number of Inpatient Discharges
The number of inpatient discharges is a measure of a hospital’s
inpatient care. This measure is defined as the sum of all daily
inpatient discharges for the hospital’s most recently filed (or
most recently completed) MCR period from all parts of the hospital
complex including healthy newborns from the healthy newborn nursery.
Pubic Law 108-490 does not exclude inpatient discharges associated
with healthy newborns inpatient stays in the “well baby” nursery.
Additional references:
- Social Security Act, Section 1886
- Public Law 108-490, December 23, 2004
- CHGME PP, Federal Register Notice dated March 1, 2001 (66
FR 12940)
- CHGME PP, Federal Register Notice dated July 20, 2001 (66
FR 37986)
Applicable to the following application forms: HRSA-99-2
Case Mix Index (CMI)
The CMI is the sum of the diagnosis-related group (DRG) weights
for all inpatient discharges excluding healthy newborns from
the most recently filed (or most recently completed) MCR period
divided by the number of inpatient discharges for the same period.
All hospitals applying for IME payments must submit a CMI on all
inpatients discharges using the appropriate CMS DRG version, excluding
healthy newborns. This value must be reported to four decimal
points. The CMS DRG version to be used for CHGME PP purposes is
published, through the CHGME PP alert system each spring, prior
to the beginning of the FY for which payments will be made. The
principles in determining the version of the CMS grouper is delineated
is the July 20, 2001 CHGME PP Federal Register Notice.
Additional references:
- Social Security Act, Section 1886
- Public Law 108-490, December 23, 2004
- CHGME PP, Federal Register Notice dated March 1, 2001 (66
FR 12940)
Applicable to the following application forms: HRSA-99-2
Number of Available Beds
An available bed is defined as an adult or pediatric bed, including
beds or bassinets available for lodging inpatients including beds
in intensive care units, coronary care units, neonatal intensive
care units, short stay units, and other special care inpatient hospital
units. Beds in the following location are excluded: healthy newborn
nursery, labor rooms, post-anesthesia or post-operative recovery
rooms, outpatient areas, emergency rooms, ancillary departments,
nurses’ and other staff residence, and other areas as are regularly
maintained and utilized for purposes other than lodging inpatients.
To be considered an available bed, a bed must be permanently maintained
for lodging inpatients. It must be available for use and housed
in patient rooms or wards (i.e. not in corridors or temporary beds).
CMS in its August 11, 2004, final inpatient PPS Federal Register
Notice, revised its regulations at 42 CFR 412.105(b) and 412.106(a)(1)(ii)
to specify that bed days in a unit that was occupied to inpatient
care for at least one day during the preceding 3 months are included
in the available bed day count for a month. In addition, bed
days for any beds within a unit that would otherwise be considered
occupied should be excluded from the available bed day count for
the current month if the bed has remained unavailable (could not
be made available for patient occupancy within 24 hours) for 30
consecutive days, or if the bed is used to provide outpatient observation
services or swing bed skilled nursing care. This clarified
policy is effective for discharges occurring on or after October
1, 2004.
The available bed count for the current or prior MCR period is
the sum of all available beds per day in the cost reporting period,
excluding beds and bassinets in the healthy newborn nursery,
divided by the number of days in that period.
Additional references:
- Social Security Act, Section 1886
- Public Law 108-490, December 23, 2004
- 42CFR412.105(b)
- 42 CFR 412.106(a)(1)(ii)
- CMS, Federal Register Notice dated August 11, 2004 (69
FR 48916)
- CHGME PP, Federal Register Notice dated March 1, 2001 (66
FR 12940)
- CHGME PP, Federal Register Notice dated July 20, 2001
(66 FR 37980, 37986)
Applicable to the following application forms: HRSA-99-2
Intern/Resident to Bed (IRB) Ratio
The IRB ratio for the most recently filed (or most recently completed)
MCR period is equal to the 3-year unweighted rolling average divided
by the number of available beds for the same period. The
IRB ratio for the previous MCR period is equal to the unweighted
resident FTE count for the previous MCR period divided by the number
of available beds for the same period. To comply as closely as possible
with Medicare rules and regulations, the Department applies a cap
on the IRB ratio pursuant to regulations at 42 CFR 412.105(a)(1),
whereby the ratio from the most recently filed (or most recently
completed) MCR period may not exceed the ratio for the hospital's
prior cost reporting period as defined above. Hospitals that meet
the criteria for an exception or adjustment to their 1996 Base Year
Cap (e.g. through a Medicare GME Affiliation Agreement) should refer
to the CMS August 1, 2001 Federal Register Notice which provides
additional information and guidance in determining the IRB ratio
subject to these exceptions.
Effective for portions of cost reporting periods and discharges
occurring on or after July 1, 2005, the CHGME PP will not include
resident FTEs counted against the §422 cap in the 3-year rolling
average calculation and the CHGME PP will not apply an IRB ratio
cap to the resident FTEs counted against a hospital’s §422 Cap Increase
for purposes of determining IME payments. A §422 IRB calculation
will be implemented as guided by CMS rules and regulations.
Additional references:
- Social Security Act, Section 1886
- 42 CFR 413.77 (Centers for Medicaid and Medicare Services,
formerly the Health Care Financing Administration)
- CMS, Federal Register Notice, dated August 1, 2001 (66 FR
39878)
- CMS, Federal Register Notice, dated August 11, 2004 (69 FR
48916)
- CHGME PP, Federal Register Notice dated June 19, 2000 (65
FR 37985)
- CHGME PP, Federal Register Notice dated March 1, 2001 (66
FR 12940)
- CHGME PP, Federal Register Notice dated July 20, 2001 (66
FR 37980)
- CHGME PP, Federal Register Notice dated October 22, 2003
(68 FR 60396)
Applicable to the following application forms: HRSA-99-2
Section
X
Special Calculation Instructions for Hospitals that Have
Not Completed a Medicare Cost Reporting Period
Hospitals eligible to begin receiving CHGME PP funding without
having completed a MCR period, must use the following methodology
to convert a partial MCR period to a full one. To calculate the
variables that follow below, the participating children’s hospitals
must first determine the number of days in which the hospital has
been eligible to receive CHGME PP funding (its period of eligibility
for CHGME PP funding).
Determining the Period of Eligibility
For the initial application process, the period of eligibility
is equal to the number of days from the date the hospital became
eligible to participate in the CHGME PP to the CHGME PP initial
application deadline date. The start date for hospitals that are
training residents from an existent program is the effective date
of the affiliation agreement for the aggregate cap, established
for purposes of the CHGME PP. For new hospitals starting a new
residency program, the start date is the date on which the hospital
first trains residents.
For the reconciliation application process, the hospital will report
the actual resident FTE count from the most recently filed (or most
recently completed) MCR. If the hospital has not filed (or completed)
an MCR period by the CHGME PP reconciliation application deadline,
the period of eligibility is equal to the number of days from the
beginning of the FY for which payments are being made (October 1)
to the CHGME PP reconciliation application deadline date.
Example:
CACC became a freestanding children’s hospital when it received
its own Medicare provider number (55-3300) on January 1, 2003.
CACC has a June 30th MCR year-end. On July 1, 2003
CACC began training residents previously trained at a hospital
that has never received funding from the CHGME PP. The FY 2004
CHGME PP application deadline is August 1, 2003. CACC’s period
of eligibility for the initial application is July 1, 2003 to
July 30, 2003. Hence, the resident FTE counts and all other data
reported in CACC’s CHGME PP initial application will be based
on this period (7/1/03 through 7/30/03). CACC will follow the
instructions provided herein to calculate its resident FTE counts,
CMI, etc. for an incomplete cost reporting period. CACC’s CHGME
PP funding will not be based upon a rolling-average until three
(3) MCR periods have been completed.
The reconciliation application deadline is May 1, 2004. CACC
will not complete its first MCR period until June 30, 2004. Consequently,
CACC’s period of eligibility for the reconciliation application
will be October 1, 2003 through May 1, 2004.
The following methodology should be used to convert relevant data
from a partial MCR period to a full MCR period.
Calculating the Resident FTE Count for an Incomplete Cost
Reporting Period
To convert the resident FTE count from a partial MCR period to
a full MCR period:
- Determine the hospital’s period of eligibility.
- Count the actual (“raw”) number of unweighted allopathic and
osteopathic resident FTEs during the hospital’s period of eligibility.
- Divide the unweighted resident FTE count for allopathic and
osteopathic residents (number 2 above) by the number of days in
during the hospital’s period of eligibility (number 1 above).
This number is the average number of unweighted resident FTEs
per day.
- Multiply the average number of unweighted resident FTEs (number
3 above) by the number of days that your hospital will be training
residents during the FY in which payments are being made. This
number is the estimated number of unweighted allopathic and osteopathic
resident FTEs trained per year.
- Use the same methodology (steps 1-4 above) to determine the
weighted resident FTE count of allopathic and osteopathic residents.
The example below includes the calculation of the weighted resident
FTE count.
- Use the same methodology (steps 1-4 above) to determine the
unweighted and weighted resident FTE count for dental and podiatric
residents.
The concept of converting a partial MCR period into a full MCR
period is consistent with Medicare regulations. Since the CHGME
PP is paying hospitals for training residents during the FY for
which payments are being made, the Program will convert a partial
training period to reflect the amount of time the hospital will
training residents during the FY for which payments are being made.
Although this methodology delineates the method by which partial
year residents are counted, it is important to note that all counts
are subjected to the cap set by the affiliation agreement.
Example:
CACC received its unique Medicare provider number (in the
3300 series) classifying it as a children’s hospital on January
1, 2003. CACC did not begin training residents until Shirley
Temple Medical Center transferred its pediatric residents to CACC
on July 1, 2003 at which time it met all CHGME PP hospital eligibility
criteria. CACC has an affiliation agreement with Shirley Temple
Medical Center giving it an aggregate cap of 100 FTEs. Based
upon its eligibility, CACC will apply for FY 2004 CHGME PP funding.
- The number of days in which CACC was eligible to participate
in the CHGME PP is 30 days (the number of days from July 1,
2003 to July 30, 2003). CACC chose to use July 30 as its
“end date” to allow time for completing and validating its CHGME
PP application and to ensure that the application was postmarked
by the CHGME PP application deadline. CACC was not eligible
to receive CHGME PP funding prior to July 1, 2003 because it
was not training residents.
- From July 1st to July 30th CACC trained
a total of 10 unweighted resident FTEs and 8.5 weighted resident
FTEs. This resident FTE count reflects the actual “raw” number
of resident FTEs that CACC trained during July. [e.g., The
normal workweek for a pediatric resident is 6 days. During
the week of July 1 through July 7 CACC had one full-time resident
in his IRP that worked 6/6 days (6/6 = 1 FTE) and one part-time
FTE in her IRP that worked 4/6 days (4/6 = 0.67 FTE). Hence,
the actual “raw” number of weighted and unweighted residents
that CACC trained during the first week of July is 1.67 (1 +
.67 = 1.67).]
- The average unweighted resident FTE count per day is 0.3333
(10 resident FTEs/30 days = 0.3333) and the average weighted
resident FTE count per day is 0.2833 (8.5 FTE residents/30 days
= 0.2833).
- Since CACC will be eligible for the CHGME PP and training
residents every day of FY 2004 for which it is applying for
CHGME PP funding (October 1, 2003 to September 30, 2004), CACC
will report an “estimated annualized” unweighted FTE resident
count of 121.65 [365 x 0.3333 = 121.65 (rounded from 121.6545)]
and an “estimated annualized” weighted FTE count of 103.40 [
365 x 0.2833= 103.40 (rounded from 103.4045]. Since CACC's
unweighted FTE count is more than its FTE cap (of 100), CACC
will have to reduce its FTE count using the methodology described
under “Exceeding the Cap”.
Additional references:
- 42 CFR 413.77 (CMS)
- CHGME PP, Federal Register Notice dated March 1, 2001 (66
FR 12940)
Applicable to the following application forms: HRSA-99-1,
HRSA-99-2, and HRSA-99-4
Calculating the Case Mix Index (CMI) for an Incomplete Cost
Reporting Period
Hospitals that have not completed a MCR period will report a CMI
to the CHGME PP based upon the discharges during the hospital’s
period of eligibility.
Example:
CACC received its unique Medicare provider (3300 series) number
on January 1, 2003. CACC did not begin training residents until
Shirley Temple Medical Center transferred its pediatric residents
to CACC on July 1, 2003 at which time it met all CHGME PP hospital
eligibility criteria. The number of days in which CACC was eligible
to participate in the CHGME PP is 30 days (the number of days
from July 1, 2003 to July 30, 2003). CACC chose to use July
30 as its “end date” to allow time for completing and validating
its CHGME PP application and to ensure that the application was
postmarked by the CHGME PP application deadline. CACC was not
eligible to receive CHGME PP funding prior to July 1, 2003 because
it was not training residents. Hence, CACC’s CMI will be
based upon all discharges from July 1 to July 30 using the CMS
DRG-version specified by the CHGME PP.
Additional references:
- 42 CFR 413.77 (CMS)
- CHGME PP, Federal Register Notice dated July 20, 2001 (66
FR 37980)
Applicable to the following application forms: HRSA
99-2
Calculating Discharges for an Incomplete Cost Reporting Period
Hospitals that have not completed a MCR period will report discharge
data to the CHGME PP based upon discharges during the hospital’s
period of eligibility using the following methodology:
- Calculate the number of discharges during the hospital’s period
of eligibility. This number represents the total number of
discharges during the hospital’s period of eligibility.
- Divide the total number of discharges by the number of days
in during the hospital’s period of eligibility. This represents
the average number of discharges per day.
- Multiply the average number of discharges per day by the number
of days in which the hospital is eligible to receive CHGME PP
funding during the FY for which it is applying for funding.
Example:
The number of days in which CACC was eligible to participate
in the CHGME PP is 30 days (the number of days from July 1, 2003
to July 30, 2003). CACC chose to use July 30 as its “end date”
to allow time for completing and validating its CHGME PP application
and to ensure that the application was postmarked by the CHGME
PP application deadline. CACC was not eligible to receive CHGME
PP funding prior to July 1, 2003 because it was not training residents.
- CACC had 752 discharges from July 1 to July 30.
- CACC’s average number of discharges per day is 25.07 (752
discharges/30 days = 25.0666).
- Since CACC will be caring for patients as a freestanding
children’s teaching hospital during the entire FY 2004 (October
1, 2003 – September 30, 2004) for which it is applying for CGGME
PP funding, CACC will report 9,150 discharges on HRSA-99-2 [365
days x 25.07 discharges per day = 9,150.55 discharges (whole
numbers only)].
Additional references:
- 42 CFR 413.77(e)(2) (CMS)
- CHGME PP, Federal Register Notice dated July 20, 2001 (66
FR 37980)
Applicable to the following application forms: HRSA
99-2
Calculating the Number of Available Beds for an Incomplete
Cost Reporting Period
Hospitals that have not completed a MCR period will calculate their
bed count by summing the total available bed count during the hospital’s
period of eligibility.
Example:
The number of days in which CACC was eligible to participate
in the CHGME PP is 30 days (the number of days from July 1, 2003
to July 30, 2003). CACC chose to use July 30 as its “end date”
to allow time for completing and validating its CHGME PP application
and to ensure that the application was postmarked by the CHGME
PP application deadline. CACC was not eligible to receive CHGME
PP funding prior to July 1, 2003 because it was not training residents.
During the period July 1 to July 30, 2003
CACC had 2,730 beds available to house pediatric inpatients and
910 bassinets available for healthy newborn babies. Therefore,
the bed count is 91 beds per day (2,730 beds/30 days=91) as healthy
newborn babies should be excluded from the reported available
bed count.
Additional references:
- 42 CFR 413.77(e)(2) (CMS)
- CHGME PP, Federal Register Notice dated July 20, 2001 (66
FR 37980)
Applicable to the following application forms: HRSA
99-2
Calculating Inpatient Days for an Incomplete Cost Reporting
Period
Hospitals that have not completed a MCR period will calculate their
inpatient days by summing the daily midnight census during the hospital’s
period of eligibility. Then the hospital divides that sum by the
number of days in that period, resulting in the average midnight
census. The hospital should then multiply the average midnight
census with the number of days that the hospital is eligible for
the CHGME PP during the FY in which payments are to be made.
Example:
The number of days in which CACC was eligible to participate
in the CHGME PP is 30 days (the number of days from July 1, 2003
to July 30, 2003). CACC chose to use July 30 as its “end date”
to allow time for completing and validating its CHGME PP application
and to ensure that the application was postmarked by the CHGME
PP application deadline. CACC was not eligible to receive CHGME
PP funding prior to July 1, 2003 because it was not training residents.
From July 1 to July 30, the CACC had a total of 1,911 inpatient
days, resulting in an average of 63.70 inpatients per day (1,911
inpatient days/30 days). Their inpatient day total for the FY
would be 365 days x 64 inpatients per day = 23,360 inpatient days
(must also use whole numbers).
Additional references:
- 42 CFR 413.77 (CMS)
- CHGME PP, Federal Register Notice dated July 20, 2001 (66
FR 37980)
Applicable to the following application forms: HRSA
99-2
Calculating Outpatient Services for an Incomplete Cost Reporting
Period
Hospitals will not complete this section until a MCR period has
been completed.
Additional references:
- CHGME PP, Federal Register Notice dated July 20, 2001 (66
FR 37980)
Section
XI
CHGME PP Application
Form Instructions
Instructions
for Completing HRSA 99
Hospital
Demographic and Contact Information
The HRSA 99
must be completed in its entirety. All sections of this form must
be completed unless otherwise specified. The form must contain
original signatures. Faxed or photocopied signatures will not be
accepted. Specific line item instructions are provided below.
Section |
Instructions |
1 |
Provide
the official name, physical address, tax identification number,
county where the hospital is physically located, Medicare
provider number, D&B D-U-N-S number, and website of the
applicant children’s hospital. Information regarding D&B
D-U-N-S numbers can be obtained at 1-800-234-3867 or www.dnb.com.
|
2 |
Provide
the complete name, title, mailing address, telephone number
and email address of the person to be notified if the application
is funded. All future correspondence will be mailed
to this individual only (e.g., notice of award
letters). |
3 |
Provide
the complete name, title, mailing address, telephone number,
email address, and signature of the person authorized to sign
for the applicant hospital. An original signature and date
are required. This individual must be the same individual
that signs form HRSA 99-3. |
4 |
Provide
the complete name, title, mailing address, telephone number,
email address, and signature of the hospital’s Director of
Graduate Medical Education. An original signature and date
are required. If the hospital does not have a Director of
GME, the individual who has oversight responsibility for residents
participating in GME programs at the hospital should be identified. |
5 |
Provide
the complete name, title, mailing address, telephone number
and email address of the person who can provide documentation
in support of the information reported in the CHGME PP application
for funding. Like all Federal programs, information submitted
is subject to audit. All Resident FTE Assessment inquiries
and related communications will be directed to this individual. |
6 |
Provide
the complete name, title, mailing address, telephone number,
and email address of the person who prepared and/or completed
this application package for the applicant hospital. This
individual will be the person contacted if there are questions
or issues related to the information submitted in the CHGME
PP application for funding. |
Instructions
for Completing HRSA 99-1
Determination
of Weighted and Unweighted Resident FTE Counts
All values
entered on HRSA 99-1 must be taken to the hundredth place [two decimal
points (e.g. 38.00 or 12.43)] and the standard rounding rules applied
[if the number is .5 or greater then round up to the next number
(e.g., 38.189 would be rounded to 38.19)].
Instructions
for the Initial Application Cycle
GUIDE
TO INSTRUCTIONS |
The
Section and Line Number that the instruct-ions apply to are
identified in this area in the following table. |
Hospitals
that filed a full MCR for the subject cost reporting period
must follow the instructions provided in this (left) column
for each section. Where specified, hospitals must report
the data as stated in the hospital’s CMS 2552-96 Worksheets
E-3, Part IV and E-3, Part VI from the subject cost reporting
period. Deviation from what is stated on Worksheets E-3,
Part IV and E-3, Part VI must be supported and attested to
by the FI prior to submission of this application in order
to be accepted by the CHGME PP. In some instances, the instructions
are the same for all hospitals irrespective of the type of
MCR the hospital filed for the subject cost reporting period.
In those cases, only one set (i.e., one column) of instructions
is provided. |
Hospitals
that filed a Low or No-Utilization MCR for the subject
recent cost reporting period must follow the instructions
provided in this (right) column for each section. In some
instances, the instructions are the same for all hospitals
irrespective of the type of MCR the hospital filed for the
subject cost reporting period. In those cases, only one set
(i.e., one column) of instructions is provided. |
Hospitals
that have not completed at least three (3) MCR periods
must follow the instructions provided in italics, where provided
below. |
Section
1 |
DETERMINATION
OF RESIDENT FTE CAP FOR THE HOSPITAL’S MOST RECENT COST
REPORTING
PERIOD ENDING ON OR BEFORE DECEMBER 31, 1996 |
Hospitals
that did not train residents during the most recent cost reporting
period ending on or before December 31, 1996 should enter
“N/A” on lines 1.01 through 1.03. |
1.01 |
Enter
the inclusive dates of the subject cost reporting period.
The following format must be used: (From:) mm/dd/yyyy
(To:) mm/dd/yyyy. |
1.02 |
Enter
the status of the subject MCR using the codes below: |
Enter
the status of the subject MCR using the codes below: |
Code |
Definition |
Code |
Definition |
S |
Settled.
This status
refers to cost reports that have been settled [a notice of
program reimbursement (NPR) issued] by the Medicare FI. |
L |
Low-utilization
MCR.
This status
refers to resident FTE counts submitted by the hospital in
their initial application that have not been assessed by the
CHGME FI. |
S/R/P |
Settled/Reopened/Preliminary
FI.
This status
refers to cost reports that have been settled (an NPR issued
by the Medicare FI), then re-opened by the Medicare FI and
any changes (to the resident FTE counts during the reopening)
have been assessed by the CHGME (or Medicare) FI. |
N |
No-utilization
MCR.
This status
refers to resident FTE counts submitted by the hospital in
their initial application that have not been assessed by the
CHGME FI. |
S/R/RS |
Settled/Reopened/Resettled.
This status
refers to cost reports that have been settled (an NPR issued
by the Medicare FI), re-opened by the Medicare FI, and then
re-settled by the Medicare FI. |
C |
Complete.
This status
refers to resident FTE counts that have been assessed by the
CHGME FI and reported to the hospital and the CHGME PP in
the CHGME FI’s final assessment report. |
R |
Re-issue.
This status
refers to resident FTE counts reported in a CHGME FI’s final
assessment report that have been re-assessed based on a request
from the children’s hospital or the CHGME FI and the results
of the reassessment reported to the hospital and the CHGME
PP in the CHGME FI’s final re-assessment report. |
1.03 |
Enter
the unweighted resident FTE count for allopathic and osteopathic
programs for the most recent cost reporting period ending
on or before December 31, 1996. (Worksheet E-3, Part IV Line
3.01 on the hospital’s MCR beginning on or after October 1,
1997.) |
Enter
the unweighted resident FTE count for allopathic and osteopathic
programs for the most recent cost reporting period ending
on or before December 31, 1996. |
Hospitals
must complete Sections 4 through 6 of Form HRSA-99-1 prior
to completing Sections 2 and 3. |
Section
2 |
AVERAGE
UNWEIGHTED RESIDENT FTE COUNT |
2.01 |
Enter
the amount from line 4.19 of the 1996 Cap Year column. |
2.02 |
Enter
the amount from line 5.19 of the 1996 Cap Year column. Hospitals
that have not completed three (3) MCR periods should enter
“N/A”. |
2.03 |
Enter
the amount from line 6.19 of the 1996 Cap Year column. Hospitals
that have not completed three (3) MCR periods should enter
“N/A”. |
2.04 |
Enter
the sum of lines 2.01, 2.02 and 2.03 from above divided by
3. Hospitals that have not completed three (3) MCR periods
should enter the amount from line 2.01 above. |
2.05 |
Enter
the unweighted number of resident FTEs in the initial years
of all programs that meet the rolling average exception criteria
in 42 CFR 413.79(d). |
2.06 |
Enter
the sum of lines 2.04 and 2.05 from above. |
2.07 |
Enter
the amount from line 4.19 of the 422 of the MMA column. |
2.08 |
Enter
the sum of lines 2.06 and 2.07 from above. |
Section
3 |
AVERAGE
WEIGHTED RESIDENT FTE COUNT |
3.01 |
Enter
the amount from line 4.20 of the 1996 Cap Year column. |
3.02 |
Enter
the amount from line 5.20 of the 1996 Cap Year column. Hospitals
that have not completed three (3) MCR periods should enter
“N/A”. |
3.03 |
Enter
the amount from line 6.20 of the 1996 Cap Year column. Hospitals
that have not completed three (3) MCR periods should enter
“N/A”. |
3.04 |
Hospitals
that have not completed three (3) MCR periods should enter
the amount from line 3.01 above. |
Enter
the sum of lines 3.15 and 3.21 from CMS 2552-96 Worksheet
E-3, Part IV from your most recently filed MCR which is equivalent
to the sum of lines 3.01, 3.02 and 3.03 from above divided
by 3. If the sum of lines 3.01 through 3.03 divided by 3
does not equal the sum of lines 3.15 and 3.21 from CMS 2552-96
on your most recently filed MCR, please contact your regional
manager immediately. |
Enter
the sum of lines 3.01, 3.02 and 3.03 from above divided by
3. |
3.05 |
Hospitals
that have not completed three (3) MCR periods should enter
the weighted number of resident FTEs in the initial years
of all programs that meet the rolling average exception criteria
in 42 CFR 413.79(d). |
Enter
the weighted number of resident FTEs in the initial years
of all programs that meet the rolling average exception criteria
in 42 CFR 413.79(d) . |
Enter
the weighted number of resident FTEs in the initial years
of all programs that meet the rolling average exception criteria
in 42 CFR 413.79(d) . |
3.06 |
Hospitals
that have not completed three (3) MCR should enter the sum
of lines 3.04 and 3.05 from above. This is the weighted resident
FTE count. |
Enter
the sum of lines 3.04 and 3.05 from above. |
3.07 |
Enter
the amount from line 4.20 of the 422 of the MMA column. |
3.08 |
Enter
the sum of lines 3.06 and 3.07 from above. |
Section
4 |
DETERMINATION
OF RESIDENT FTE COUNT FOR THE HOSPITAL’S
MOST
RECENTLY COMPLETED COST REPORTING PERIOD |
Hospitals
that have not completed a MCR period must use the methodology
described in the application guidance section titled “Special
Calculation Instructions for Hospitals that Have Not Completed
a Medicare Cost Reporting Period” to determine their weighted
and unweighted resident FTE counts based upon an incomplete
cost reporting period. |
4.01 |
Enter
the inclusive dates of the subject cost reporting period.
The following format must be used: (From:) mm/dd/yyyy
(To:) mm/dd/yyyy. |
Hospitals
that have not completed a full MCR period must enter the date
in which the hospital became eligible to participate (i.e.
date that the hospital obtained a Medicare provider number
and began training residents) and the CHGME PP application
deadline. This is the hospital’s period of eligibility. |
4.02 |
Enter
the status of the subject MCR using the codes below: |
Enter
the status of the subject MCR using the codes below: |
Code |
Definition |
Code |
Definition |
AF |
As
Filed.
This status
refers to cost reports that have been submitted by the children’s
hospital to the Medicare FI, but have not yet been reviewed
by the CHGME (or Medicare) FI. |
L |
Low-utilization
MCR.
This status
refers to resident FTE counts submitted by the hospital in
their initial application that have not been assessed by the
CHGME FI. |
AM |
Amended.
This status
refers to cost reports that have been amended and submitted
by the children’s hospital to the Medicare FI, but have not
yet been reviewed by the CHGME (or Medicare) FI. |
N |
No-utilization
MCR.
This status
refers to resident FTE counts submitted by the hospital in
their initial application that have not been assessed by the
CHGME FI. |
P |
Preliminary.
This status
refers to resident FTE counts that have been assessed by the
CHGME (or Medicare) FI where the cost report has not yet been
settled (notice of program reimbursement has not been issued). |
C |
Complete.
This status
refers to resident FTE counts that have been assessed by the
CHGME FI and reported to the hospital and the CHGME PP in
the CHGME FI’s final assessment report. |
S |
Settled.
This status
refers to cost reports that have been settled [an NPR issued]
by the Medicare FI. |
R |
Re-issue.
This status
refers to resident FTE counts reported in a CHGME FI’s final
assessment report that have been re-assessed based on a request
from the children’s hospital or the CHGME FI and the results
of the reassessment reported to the hospital and the CHGME
PP in the CHGME FI’s final re-assessment report. |
S/R/P |
Settled/Reopened/Preliminary
FI.
This status
refers to cost reports that have been settled (an NPR issued
by the Medicare FI), then re-opened by the Medicare FI and
any changes (to the resident FTE counts during the reopening)
have been assessed by the CHGME (or Medicare) FI. |
S/R/RS |
Settled/Reopened/Resettled.
This status
refers to cost reports that have been settled (an NPR issued
by the Medicare FI), re-opened by the Medicare FI, and then
re-settled by the Medicare FI. |
4.03 |
1996
cap year column: Enter the unweighted resident FTE count for
allopathic and osteopathic programs for the most recent cost
reporting period ending on or before December 31, 1996 which
is equivalent to Line 3.01 Line 3.01 from CMS 2552-96 Worksheet
E-3, Part IV from the subject MCR. For hospitals whose MCR
did not contain an entry on line 3.01, enter “0”. If Line
3.01 from Worksheet E-3, Part IV does not equal line 1.03
from above, line 3.01 from Worksheet E-3, part IV must be
supported and attested to by the FI prior to submission of
this application in order to be accepted by the CHGME PP. |
1996
cap year column: Enter the unweighted resident FTE count
for allopathic and osteopathic programs for the most recent
cost reporting period ending on or before December 31, 1996
which is equivalent to Line 1.03 from above. |
4.04 |
Enter
the unweighted resident FTE count for allopathic and osteopathic
programs which meet the criteria for an adjustment to the
cap for new programs in accordance with 42 CFR 413.79(e) which
is equivalent to Line 3.02 from CMS 2552-96 Worksheet E-3,
Part IV from the subject MCR. |
Enter
the unweighted resident FTE count for allopathic and osteopathic
programs which meet the criteria for an add-on to the cap
for new programs in accordance with 42 CFR 413.79(e) for the
subject cost reporting period. |
4.05 |
Enter
the adjustment (increase or decrease) for the unweighted resident
FTE count for allopathic or osteopathic programs for affiliated
programs in accordance with 42 CFR 413.75(b), 413.79(c)(2)(iv),
and 63 FR 26336 of May 12, 1998 which is equivalent to Line
3.03 from CMS 2552-96 Worksheet E-3, Part IV from the subject
MCR. |
Enter
the adjustment (increase or decrease) for the unweighted resident
FTE count for allopathic or osteopathic programs for affiliated
programs in accordance with 42 CFR 413.75(b), 413.79(c)(2)(iv),
and 63 FR 26336 of May 12, 1998 for the subject cost reporting
period. |
4.06 |
1996
cap year column: Enter the sum of lines 4.03 through 4.05.
This is the FTE adjusted cap which is equivalent to Line 3.04
from CMS 2552-96 Worksheet E-3, Part IV from the subject MCR.
If the hospital’s 1996 Base Year Cap is reduced under 42 CFR
413.79(c)(3) due to unused resident slots, effective for cost
reporting periods ending on or after July 1, 2005, Line 3.04
from CMS 2552-96 Worksheet E-3, Part IV from the subject MCR
is equivalent to the sum of Line 3.03 from CMS 2552-96 Worksheet
E-3, Part IV and Line 4 from Worksheet E-3, Part VI from the
subject MCR. |
1996
cap year column: Enter the sum of lines 4.03 through 4.05
from above. This is the FTE adjusted cap. If the hospital’s
1996 Base Year Cap is reduced under 42 CFR 413.79(c)(3) due
to unused resident slots, effective for cost reporting periods
ending on or after July 1, 2005, enter Line 3.04 from CMS
2552-96 Worksheet E-3, Part IV from the subject MCR which
is equivalent to the sum of Line 3.03 from CMS 2552-96 Worksheet
E-3, Part IV and Line 4 from Worksheet E-3, Part VI from the
subject MCR. If the hospital was not required to file CMS
2552-96 Worksheets E-3, Part IV or E-3, Part VI following
the 1996 Base Year Cap reduction under 42 CFR 413.79(c)(3)
for the subject cost reporting period contact your regional
manager. |
§422
of the MMA column: Enter the number of unweighted allopathic
and osteopathic GME FTE resident cap slots the hospital received
under 42 CFR 413.79(c)(4) which is equivalent to Line 5 (or
line 5.01 for cost reporting periods that overlap July 1,
2005) from CMS 2552-96 Worksheet E-3, Part VI from the subject
MCR. If the hospital received GME FTE resident cap slots
under 42 CFR 413.79(c)(4), but was not required to file CMS
2552-96 Worksheets E-3, Part VI for the subject cost reporting
period contact your regional manager. If the hospital did
not receive GME FTE resident cap slots under 42 CFR 413.79(c)
enter “zero” on Lines 4.06 through 4.13, 4.19 and 4.20 of
this column. |
4.07 |
1996
cap year column: Enter the unweighted resident FTE count for
allopathic or osteopathic programs for the current year from
your records, other than those in the initial years of the
program that meet the criteria for an exception to the rolling
average rules (42 CFR 413.79(d) and/or (e)). This is equivalent
to Line 3.05 from CMS 2552-96 Worksheet E-3, Part IV from
the subject MCR. |
1996
cap year column: Enter the unweighted resident FTE count
for allopathic or osteopathic programs for the current year
from your records, other than those in the initial years of
the program that meet the criteria for an exception to the
rolling average rules (42 CFR 413.79(d) and/or (e)). |
§422
of the MMA column: Enter the sum of Lines 4.07 minus 4.08
from the 1996 Cap Year Column. |
4.08 |
1996
cap year column: Enter line 3.06 from CMS 2552-96 Worksheet
E-3, Part IV from the subject MCR. |
1996
cap year column: Enter the lesser of lines 4.06 or 4.07 from
above (lesser of lines 5.06 or 5.07 for Section 5 and lines
6.06 or 6.07 for Section 6). |
§422
of the MMA column: enter the lesser of Lines 4.06 or 4.07
from above. |
4.09 |
1996
cap year column: Enter the unweighted FTE resident count
for allopathic and osteopathic residents in their initial
residency period. |
§422
of the MMA column: Enter the unweighted FTE resident count
for allopathic and osteopathic residents in their initial
residency period. |
4.10 |
1996
cap year column: Enter the hospital’s unweighted FTE resident
count for allopathic and osteopathic residents beyond their
initial residency period. The sum of lines 4.09 and 4.10
should equal line 4.07 from above (the sum of lines 5.09 and
5.10 should equal line 5.07 for Section 5 and the sum of lines
6.09 and 6.10 should equal line 6.07 for Section 6). |
§422
of the MMA column: Enter the hospital’s unweighted FTE resident
count for allopathic and osteopathic residents beyond their
initial residency period. The sum of lines 4.09 and 4.10
should equal line 4.07 from above. |
4.11 |
1996
cap year column: Multiply line 4.10 from above (line 5.10
for Section 5 and line 6.10 for Section 6) by 0.5 and enter
the product. This is the weighted FTE resident count for
allopathic and osteopathic residents beyond their initial
residency period. |
§422
of the MMA column: Multiply line 4.10 from above by 0.5 and
enter the product. This is the weighted FTE resident count
for allopathic and osteopathic residents beyond their initial
residency period. |
4.12 |
1996
cap year column: Enter line 3.09 from CMS 2552-96 Worksheet
E-3, Part IV. This should equal the sum of lines 4.09 and
4.11 from above. |
1996
cap year column: Enter the sum of lines 4.09 and 4.11 from
above (sum of lines 5.09 and 5.11 for Section 5 and lines
6.09 and 6.11 for Section 6). This is the total weighted resident
FTE count for allopathic and osteopathic programs. |
§422
of the MMA column: Enter the sum of lines 4.09 and 4.11 from
above. |
4.13 |
1996
cap year column: Enter line 3.10 from CMS 2552-96 Worksheet
E-3, Part IV. |
1996
cap year column: For Section 4: If line 4.07 is less than
or equal to line 4.06 enter the amount from line 4.12 above.
If line 4.07 is greater than line 4.06, multiply line 4.12
by (line 4.06 divided by line 4.07) and enter the product.
For Section
5: If line 5.07 is less than or equal to line 5.06 enter
the amount from line 5.12 above. If line 5.07 is greater
than line 5.06, multiply line 5.12 by (line 5.06 divided by
line 5.07) and enter the product.
For Section
6: If line 6.07 is less than or equal to line 6.06 enter
the amount from line 6.12 above. If line 6.07 is greater
than line 6.06, multiply line 6.12 by (line 6.06 divided by
line 6.07) and enter the product. |
§422
of the MMA column: If line 4.07 is less than or equal to
line 4.06, enter the amount from line 4.12 above. If line
4.07 is greater than line 4.06, multiply line 4.12 by (line
4.06 divided by line 4.07) and enter the product. |
4.14 |
1996
cap year column: Enter the unweighted resident FTE count
for dental and podiatric programs. |
4.15 |
1996
cap year column: Enter the unweighted resident FTE count
for dental and podiatric residents in their initial residency
period. |
4.16 |
1996
cap year column: Enter the unweighted resident FTE count
for dental and podiatric residents beyond their initial residency
period. |
4.17 |
1996
cap year column: Multiply line 4.16 from above (line 5.16
for Section 5 and line 6.16 for Section 6) by 0.5 and enter
the product. |
4.18 |
1996
cap year column: Enter line 3.11 from CMS 2552-96 Worksheet
E-3, Part IV. This should equal the sum of lines 4.15 and
4.17. For hospitals who’s MCR did not contain an entry on
line 3.11 on Worksheet E-3, Part IV enter the sum of lines
4.15 and 4.17 from above (the sum of lines 5.15 and 5.17 for
Section 5 and lines 6.15 and 6.17 for Section 6). This is
the total weighted resident FTE count for dental and podiatric
programs. |
1996
cap year column: Enter the sum of lines 4.15 and 4.17 from
above (the sum of lines 5.15 and 5.17 for Section 5 and lines
6.15 and 6.17 for Section 6). This is the total weighted
resident FTE count for dental and podiatric programs. |
4.19 |
1996
cap year column: Enter the sum of lines 4.08, 4.15 and 4.16
from above (the sum of lines 5.08, 5.15 and 5.16 for Section
5 and the sum of lines 6.08, 6.15 and 6.16 for Section 6).
This is the hospital’s total unweighted FTE resident count. |
§422
of the MMA column: Enter line 4.08 from above. |
4.20 |
1996
cap year column: Enter the sum of lines 3.10 and 3.11 from
CMS 2552-96 Worksheet E-3, Part IV. This should equal the
sum of lines 4.13 and 4.18 (sum of lines 5.13 and 5.18 for
Section 5 and the sum of lines 6.13 and 6.18 for Section 6). |
1996
cap year column: Enter the sum of lines 4.13 and 4.18 from
above (sum of lines 5.13 and 5.18 for Section 5 and the sum
of lines 6.13 and 6.18 for Section 6). This is the hospital’s
total weighted FTE resident count. |
§422
of the MMA column: Enter line 4.13 from above. |
Section
5 |
DETERMINATION
OF RESIDENT FTE COUNT FOR THE HOSPITAL’S
PRIOR
COST REPORTING PERIOD |
The
direct GME FTE resident cap slots hospitals received under
42 CFR 413.79(c)(4) are not subject to the three year rolling
average; therefore, Section 5 does not include a §422 of
the MMA column and related guidance is not applicable this
section. |
Hospitals
that have not completed three (3) MCR periods should enter
“N/A” on lines 5.01 through 5.20. |
Section
6 |
DETERMINATION
OF FTE RESIDENT COUNT FOR THE HOSPITAL’S
PENULTIMATE
COST REPORTING PERIOD |
The
direct GME FTE resident cap slots hospitals received under
42 CFR 413.79(c)(4) are not subject to the three year rolling
average; therefore, Section 6 does not include a §422 of
the MMA column and related guidance is not applicable this
section. |
Hospitals
that have not completed three (3) MCR periods should enter
“N/A” on lines 6.01 through 6.20. |
Instructions
for the Reconciliation Application Cycle
All children’s
hospitals, regardless of their filing status, will use the resident
FTE counts as reported by their CHGME FI in his/her final Resident
FTE Assessment Report to complete their reconciliation application
which includes an updated and revised, as needed, HRSA 99-1. For
additional information regarding the Resident FTE Assessment Program
see Section II.
Instructions for Completing HRSA 99-2
Determination
of Indirect Medical Education Data
Related to
the Teaching of Residents
Inpatient
Data for the Current Medicare Cost Report (MCR) Period
The “current”
MCR period is defined as the hospital’s most recently filed
MCR for hospitals that file full MCRs (report residents to
Medicare on CMS 2552-96, Worksheet E-3, Part IV) or the most
recently completed MCR period for hospitals that file low
or no-utilization MCRs.
Hospitals
that have not completed a full MCR period must
use the methodology described in the application guidance
section titled “Special Calculation Instructions for Hospitals
that Have Not Completed a Medicare Cost Reporting Period”
to complete the below. |
1.01 |
Inclusive
dates of the current MCR period. Enter the inclusive dates
of the MCR period reported on line 4.01 of HRSA 99-1. |
1.02 |
Number
of Inpatient Days. The sum of the entire midnight census
counts including nursery days for the MCR period reported
on line 1.01 above. [Value must be taken to two decimal
points (i.e., 38.00 or 12.43).] |
1.03 |
Number
of Inpatient Discharges. The sum of all inpatient discharges
including healthy newborns for the MCR period reported on
line 1.01 above. [Value must be taken to two decimal points
(i.e., 38.00 or 12.43).] |
1.04 |
Case
Mix Index (CMI). The CMI is the sum of the diagnosis-related
group (DRG) weights for all discharges during the MCR period
identified on line 1.01 above divided by the number of discharges.
The CMI represents the average DRG relative weight for the
hospital. All hospitals must submit a CMI on all patient
discharges using the appropriate CMS DRG version, excluding
healthy newborns. [Value must be taken to 4 decimal
points (i.e., 1.2105).]
The CMI
is utilized in the IME formula to determine IME payments.
Hospitals that do not submit a CMI are not eligible for IME
payments. These hospitals are required to initial the appropriate
box on line 1.04 of HRSA 99-2 acknowledging their ineligibility
for IME payments. The initials on HRSA 99-2 must be consistent
with the signature on HRSA 99-3. |
|
Calculate
the IRB Ratio for the Current MCR Period
The “current”
MCR period is defined as the hospital’s most recently filed
MCR for hospitals that file full MCRs (report residents to
Medicare on CMS 2552-96, Worksheet E-3, Part IV) or the most
recently completed MCR period for hospitals that file low
or no-utilization MCRs.
Hospitals
that meet the criteria for an exception or adjustment to the
cap should refer to the Centers for Medicare and Medicaid
Services August 1, 2001 Federal Register Notice (66 FR 39878)
which provides additional information and guidance in calculating
the IRB ratio. |
1.05 |
Enter
the 3-year adjusted unweighted FTE rolling average for the
current MCR period. The 3-year unweighted FTE rolling average
for the current MCR period is equal to line 2.06 of HRSA 99-1.
Enter the data reported on line 2.06 of HRSA 99-1. [Value
must be taken to two decimal points (i.e., 38.00 or 12.43).] |
1.06 |
|
1.07 |
Enter
the IRB ratio for the current MCR period. The IRB ratio is
equal to the 3-year unweighted rolling average (line 1.05
above) divided by the bed count (line 1.06 above). [Value
must be taken to six decimal points (i.e. 34.567800).] |
Calculate
the IRB Ratio for the Previous MCR Period
The “previous”
MCR period refers to the annual cost reporting period that
ended one year prior to the cost reporting period identified
on line 1.01 above. The previous MCR period should equal
line 5.01 of HRSA 99-1
Hospitals
that were not required to complete section 5 of HRSA 99-1
should contact their regional manager for additional information
and guidance for lines 1.08 through 1.11 below.
Hospitals
that meet the criteria for an exception or adjustment to the
cap should refer to the Centers for Medicare and Medicaid
Services August 1, 2001 Federal Register Notice (66 FR 39878)
which provides additional information and guidance in calculating
the IRB ratio. |
1.08 |
Inclusive
dates of the previous MCR period. Enter the inclusive dates
of the MCR period reported on line 5.01 of HRSA 99-1. |
1.09 |
Unweighted
FTE count for the previous MCR period. Enter the unweighted
FTE count for the previous MCR period which is equal to line
5.19 of HRSA 99-1. [Value must be taken to two decimal
points (i.e., 38.00 or 12.43).] |
1.10 |
|
1.11 |
IRB
ratio for the previous MCR period. Calculate the IRB ratio
for the previous MCR period. The IRB ratio is equal to the
unweighted FTE count for the previous MCR period (line 1.09
above) divided by the bed count (line 1.10 above). [Value
must be taken to six decimal points (i.e. 34.567890 or 12.540000).] |
IRB
Cap |
1.12 |
IRB
Cap. Enter the lesser of 1.07 or 1.11. [Value must be
taken to six decimal points (i.e. 34.567890.] |
§422
of the MMA IRB Ratio for the Current MCR Period |
1.13 |
§422
of the MMA unweighted resident FTE count for the current MCR
period. The unweighted resident FTE count for the current
MCR period is equal to line 4.19 of the §422 of the MMA column
of the HRSA 99-1. Enter the data reported on line 4.19 from
the §422 of the MMA column of HRSA 99-1. [Value must
be taken to two decimal points (i.e., 38.00 or 12.43).] |
1.14 |
Bed
count for the current MCR period. Enter the available bed
count for the current MCR period. This should be consistent
with the data reported in line 1.06 above. [Value must
be taken to two decimal points (i.e., 38.00 or 12.43).] |
1.15 |
§422
of the MMA IRB ratio for the current MCR period. Calculate
the §422 of the MMA IRB ratio for the current MCR period.
The §422 of the MMA IRB ratio is equal to the increase in
the unweighted FTE count (line 1.13 above) divided by the
bed count (line 1.14 above). [Value must be taken to six
decimal points (i.e., 34.567890 or 12.540000).] |
Outpatient
Data |
1.16 |
Number
of Ambulatory Surgery Visits. Total number of scheduled outpatient
ambulatory surgical visit provided to patients who do not
remain in the hospital overnight. The surgery may be performed
in operating suites also used for inpatient surgery specifically
designed surgical suites for outpatient surgery, or procedure
rooms within an outpatient care facility. |
1.17 |
Number
of Radiology Visits. Total number of diagnostic radiology
visits provided to patients in the outpatient setting such
as computed tomographic scanner (CT scan), magnetic resonance
imaging (MRI), position emission tomography (PET), Single
photon emission computerized tomography (SPECT), and ultrasound.
(Do not include inpatient testing) |
1.18 |
Number
of Urgent Care Visits. Total number of urgent care visits
that provide care and treatment for problems that are not
life threatening but require attention over the short term. |
1.19 |
Number
of Emergency Department Visits. Total number of emergency
room visits for patients whose condition requires immediate
care. |
1.20 |
Number
of Clinic Visits. Total number of clinic visits to each specialized
medical unit responsible for the diagnosis and treatment of
patients on an outpatient, non-emergency basis. Visits to
the satellite clinics and primary group practices should be
included if revenue is received by the hospital. |
Instructions
for Completing HRSA 99-3
Hospital
Certification
A certification
statement must be completed and signed by the applicant hospital’s
certifying official attesting to the legitimacy of the application
for funds under the CHGME PP. By signing the certification statement,
the applicant hospital agrees to adhere to all the conditions listed
and is aware that the applicant hospital may be denied entry to
or revoked from the program if any conditions are violated.
The certification
statement must contain an original signature. Faxed or photocopied
signatures will not be accepted. The HRSA 99-3 should be signed
by the individual authorized to sign for the application hospital
on HRSA 99 (number 3).
As a part of
the first certification statement, the required Assurances, Certifications
and Other Requirements are included. The certifying
official is certifying the applicant hospital has met the requirements
and the necessary forms have been filed (see attached Assurances,
Certifications and Other Requirements). If one or more
of the following assurances, certifications and other requirements
are not met, attach an explanation on plain white paper.
For assurances
addressed in paragraphs A through D, contact the Voluntary Compliance
and Outreach Division at (202) 619-2595, to obtain information and/or
confirm the applicant hospital’s submission and acceptance by the
Department of Health and Human Services (DHHS) Office for Civil
Rights an Assurance of Compliance Form HHS 690.
Instructions
for Completing HRSA 99-4
Government
Performance and Results Act Tables
Hospitals
must report data from the cost reporting period reflected on line
4.01 of HRSA 99-1
Table 1.
Number of FTE Residents Supported by the Children’s
Hospitals
in Approved Residency Training Programs
Note:
Applicants requesting funding must submit the required data in the
following format. This data is for residents rotating through both
the inpatient and outpatient settings of the hospital. Resident
FTE counts reported below should be unweighted and line 1.04 (below)
should be consistent with the unweighted resident FTE counts reflected
in Form HRSA 99-1 Section 4.
Line |
Instructions |
1.01 |
Sponsored*
by the Children’s Hospital and Rotating at the Children’s
Hospital. Provide the number of FTE residents (general
pediatric, subspecialty pediatric & fellows, and non-pediatric)
training in your hospital and sponsored by your hospital during
the cost reporting period. |
1.02 |
Sponsored
by the Children’s Hospital and Rotating at Non-provider Sites.
Provide the number of FTE residents (general pediatric,
subspecialty pediatric & fellows, and non-pediatric) sponsored
by your hospital but are rotating to non-provider sites during
the cost reporting period. |
1.03 |
Sponsored
by Other Hospitals and Rotating at the Children’s Hospital.
Provide the number of FTE residents (general pediatric,
subspecialty pediatric and fellows, and non-pediatric) sponsored
by another hospital but are rotating to your hospital during
the cost reporting period. |
1.04 |
Total
Number of FTE Residents. Provide the total number of
FTE Residents from the sum of Lines 1.01 through 1.03 (above) |
1.05 |
Sponsored
by the Children’s Hospital and Rotating at Other Hospitals.
Provide the number of FTE residents (general pediatric,
subspecialty pediatric & fellows, and non-pediatric) sponsored
by your hospital but are rotating to other hospitals during
the cost reporting period. |
Definitions |
Sponsoring
Institution |
*CHGME
PP defines a sponsoring institution as an institution, which
assumes the ultimate responsibility for a graduate medical
education program. According to the Accreditation Council
for Graduate Medical Education (ACGME), the following are
the institutional requirements for a Sponsoring Institution:
1) A residency program must operate under the authority and
control of a sponsoring institution. 2) There must be a written
statement of institutional commitment to GME that is supported
by the governing authority, the administration, and the teaching
staff. 3) Sponsoring institutions must be in substantial
compliance with the Institutional Requirements and must ensure
that their ACGME-accredited programs are in substantial compliance
with the Program Requirements and the applicable Institutional
Requirements. 4) An institution’s failure to comply substantially
with the Institutional Requirements may jeopardize the accreditation
of all of its sponsored residency programs. |
General
Pediatric Resident |
Residents
training in their initial residency period of a pediatric
residency program |
Subspecialty
Pediatric Resident |
Residents
training beyond their initial residency period (i.e., fellows) |
Non-Pediatric
Resident |
Residents
training in their initial residency period not specifically
in pediatrics (i.e., radiology, pathology, general surgery,
dental) |
Table 2.
Hospital's Total and Operating Margins
Margin
Types |
Hospitals
Filing Low or No-Utilization Medicare Cost Reports |
Hospitals
Filing Full Medicare Cost Reports |
Total
Margins |
Total
margin is defined as the net income from all sources [(net
patient revenue + all other income)-[(total operating expenses
+ other expenses)] divided by total hospital revenues (net
patient revenues + total other income) multiplied by 100 |
To
calculate the total margin take Worksheet G-3 Line 31 and
divide it by Line 3 + Line 25. |
Operating
Margins |
The
operating margin is defined as the net income from service
to patients (net patient revenues – total operating expenses)
divided by net patient revenues (total patient revenues –
contractual allowances) multiplied by 100 |
To
calculate the operating margin, take the number from Worksheet
G-3 line 3, subtract the number from worksheet A Column 3
line 95, divide by the number from worksheet G-3, line 3 and
multiply it by 100. |
Margin
Types |
Hospitals
Filing Low or No-Utilization Medicare Cost Reports |
Hospitals
Filing Full Medicare Cost Reports |
Total
Allowable Operating Expenses |
Contact
the hospital’s fiscal intermediary to clarify what Medicare
accepts as allowable operating expenses, if mechanism is not
already identified in the hospital’s financial statements |
The
total allowable operating expenses can identified on the hospital’s
Medicare cost report - Worksheet G-2 Part II Line 26 |
Table 4.
Hospital’s Revenue and Expenses Attributed to Patient Care
Revenue/Expense
Type |
Inpatient |
Outpatient |
Hospital’s
gross revenue attributed to Medicaid and SCHIP (Medicaid refers
to any funding provided by Title XIX including that from Medicaid
HMOs and DSH payments. SCHIP-State Children’s Health Insurance
Program refers to funding provided under Title XXI). |
Revenue
received by the hospital from the Medicaid and SCHIP programs
for inpatient care. Report as dollar amounts rather than percentages |
Revenue
received by the hospital from the Medicaid and SCHIP programs
for outpatient care. Report as dollar amounts rather than
percentages |
Hospital’s
gross revenue attributed to Medicare |
Revenue
received by the hospital from the Medicare for inpatient care.
Report as dollar amounts rather than percentages |
Revenue
received by the hospital from the Medicare for outpatient
care. Report as dollar amounts rather than percentages |
Hospital’s
gross revenue attributed to self-pay |
Revenue
received by the hospital directly from patients for inpatient
care. Report as dollar amounts rather than percentages |
Revenue
received by the hospital directly from patients for outpatient
care. Report as dollar amounts rather than percentages |
Hospital
‘s gross revenue attributed to other sources |
Revenue
received by the hospital from other sources for inpatient
care not listed above. Report as dollar amounts rather than
percentages |
Revenue
received by the hospital from other sources for outpatient
care not listed above. Report as dollar amounts rather than
percentages |
Hospital’s
total gross revenue attributed to patient care |
Total
gross revenue received by the hospital for inpatient care
(sum of inpatient columns 1-4). Report as dollar amounts rather
than percentages. |
Total
gross revenue received by the hospital for outpatient care
(sum of outpatient columns 1-4). Report as dollar amounts
rather than percentages. |
Hospital’s
total expenses attributed to uncompensated care |
Total
expenses that the hospital attributes to uncompensated inpatient
care. Report as dollar amounts rather than percentages. |
Total
expenses that the hospital attributes to uncompensated outpatient
care. Report as dollar amounts rather than percentages. |
Hospital’s
total expenses attributed to charity care |
Total
expenses that the hospital attributes to charity care in the
inpatient setting. Report as dollar amounts rather than percentages. |
Total
expenses that the hospital attributes to charity care in the
outpatient setting. Report as dollar amounts rather than percentages. |
Instructions
for Completing HRSA 99-5
Application
Checklist
The application
checklist must be completed following the instructions provided
on the checklist itself. All required forms and supporting documentation
should be included in the application package mailed to the CHGME
PP in the order that the forms and supporting documentation are
listed on the checklist.
Section
XII
References
Commonly Used
Acronyms
ACGME |
ACCREDITATION
COUNCIL FOR GRADUATE MEDICAL EDUCATION |
AF |
AS
FILED |
CH |
CHILDREN'S
HOSPITAL |
CHGME
PP |
CHILDREN'S
HOSPITALS GRADUATE MEDICAL EDUCATION PAYMENT PROGRAM |
CMI |
CASE
MIX INDEX |
CMS |
CENTERS
FOR MEDICARE AND MEDICAID SERVICES |
D(G)ME |
DIRECT
(GRADUATE) MEDICAL EDUCATION |
FEL |
FELLOW |
FI |
FISCAL
INTERMEDIARY |
FY |
|
FRN |
FEDERAL
REGISTER NOTICE |
FTE |
FULL-TIME
EQUIVALENT |
GME |
GRADUATE
MEDICAL EDUCATION |
GPRA |
|
HRSA |
HEALTH
RESOURCES AND SERVICES ADMINISTRATION |
IME |
INDIRECT
MEDICAL EDUCATION |
INT |
INTERN |
IRB |
INTERN
RESIDENT BED COUNT |
IRP |
INITIAL
RESIDENCY PERIOD |
MCR |
MEDICARE
COST REPORT |
NBME |
NATIONAL
BOARD OF MEDICAL EXAMINERS |
PGY1 |
POST-GRADUATE
YEAR (1,2,….) |
PPS |
PROSPECTIVE
PAYMENT SYSTEM |
RES
(R) |
RESIDENT
(1,2,…) |
USMLE |
UNITED
STATES MEDICAL LICENSING EXAMINATION |
WI |
WAGE
INDEX |
|