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Children's
Hospitals Graduate Medical Education Payment Program
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Dictionary |
Definitions on this page: A - E
Cap | Cap (Establishing & Adjusting) | Cap (Exceeding) | Cap (Year) | Direct Medical Education (Formula) | Eligibility & Funding Criteria | Eligibility (Changes)
Cap
The “cap” is the number of unweighted resident FTEs enrolled in a hospital’s
allopathic and osteopathic residency programs during the “cap year” (the most
recent cost reporting period ending on or before December 31, 1996). The
cap (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.
Example:
CACC had 75 residents enrolled in its allopathic programs, 25 residents enrolled
in its osteopathic programs and 7 residents enrolled in its dental and podiatric
programs for its 6/30/96 MCR (its most recent cost reporting period ending
on or before December 31, 1996). Hence, CACC’s cap for Medicare and CHGME
Payment Program purposes is 100 (75+25=100).
Additional references:
Social Security Act, Section 1886
42 CFR 413.86 (Centers for Medicaid and Medicare Services, formerly the Health
Care Financing Administration)
CHGME Payment Program, Federal Register Notice dated March 1, 2001 (66 FR 12940)
CHGME Payment Program, Federal Register Notice dated July 20, 2001 (66 FR 37980)
Applicable to the following application forms:
HRSA-99-1 and HRSA-99-2
Cap (Establishing
and Adjusting a Hospital’s 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 cap and are, therefore,
limited “capped” to a resident FTE count of zero “0”. Hence, hospitals
must obtain (or adjust) their cap in order to receive CHGME Payment Program
funding.
To provide an adjustment to a cap, the CHGME Payment Program will allow hospitals
to add resident FTEs to their cap based on the following Medicare and CHGME
Payment Program regulations:
1. The formation of a new residency program within the first 3 years after
the first program in a hospital begins training residents as described in 42
CFR 413.86(g)(6); or
2. The execution of an affiliation agreement for an aggregate cap, as set forth
in 42 CFR 413.86(g)(4) and 63 FR 26338, published in the Federal Register on
May 12, 1998, with the following exceptions:
a. ``new children's teaching hospital'' participating in the CHGME Payment
Program for the first year must establish an effective date of the agreement
for purposes of the CHGME Payment Program. For the first year, unless otherwise
specified, the Department will use as the effective date of the affiliation
agreement for an aggregate cap the date that the hospital becomes eligible
for the CHGME Payment Program. This effective date will only apply to the CHGME
Payment Program. A hospital must also have an effective date of July 1 for
the Medicare Program. Subsequent to the first year of the affiliation agreement,
the effective date must comply with the above-cited Federal Register final
rule, which specifies an effective date of July 1 for all affiliation agreements.
The CHGME Payment Program allows this exception because hospitals must meet
eligibility criteria and have their caps determined prior to the CHGME application
deadline. If the CHGME Payment Program application deadline occurs before July
1, 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 Payment
Program 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 Payment Program, the CHGME Payment Program will
not prorate the cap based on the effective date of the cap. Instead, the full
value of the cap as determined by the affiliation agreement will be used. For
purposes of the CHGME Payment Program 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 Payment Program
will be allowed to use the cap agreed upon in the 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.
Example:
CACC opened as a freestanding children’s hospital on January 1, 2001 and would
like to apply for funds from the CHGME Payment Program, which has an application
deadline of August 1, 2001 for the 2002 Federal fiscal year. Since CACC
did not train residents in 1996, it has a cap of zero, but was able to arrange
an 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 Payment Program funding:
1. Established their cap by forming an affiliation
agreement with Shirley Temple Medical Center for an aggregate cap.
2. The agreement will have an effective date of January 1, 2001 for purposes
of the CHGME Payment Program but an effective date of July 1, 2001 and expiration
date of June 30, 2002 for and in accordance with Medicare rules and regulations.
3. CACC and Shirley Temple Medical Center filed the agreement with CMS fiscal
intermediaries on or before June 30, 2001 (in accordance with Medicare rules
and regulations) and provided a signed copy to the CHGME Payment Program following
acceptance by the fiscal intermediary.
Hospitals that report residents to Medicare and are part of an affiliated
group may elect to apply the FTE limit on an aggregate basis under Medicare
rules and regulations. If the combined FTE counts for the individual
members of the group exceed the aggregate limit, each hospital’s 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 Payment Program.
Hospitals should refer to 42 CFR 413.86 for additional information on adjustments
to the cap.
Additional references:
Social Security Act, Section 1886
42 CFR 413.86 (Centers for Medicaid and Medicare Services, formerly the Health
Care Financing Administration)
CHGME Payment Program, Federal Register Notice dated March 1, 2001 (66 FR 12940)
CHGME Payment Program, 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
Cap (Exceeding the)
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 FTE limit to the actual unweighted
FTE count for the subject cost reporting period.
Example:
CACC, per its affiliation agreement, has a cap of 100. For its 6/30/01
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].
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.
Example:CACC, per its affiliation agreement, has a cap of 100. For
its 6/30/01 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 [the lesser of the unweighted
allopathic and osteopathic resident FTE count (150) or the cap (100)].
Additional references:
42 CFR 413.86 (Centers for Medicaid and Medicare Services, formerly the Health
Care Financing Administration)
CHGME Payment Program, Federal Register Notice dated March 1, 2001 (66 FR 12940)
Applicable to the following application forms:
HRSA 99-1and HRSA 99-2
Cap
(Year)
The “cap year” is the most recent cost reporting period ending on or before
December 31, 1996.
Additional references:
Social Security Act, Section
1886
42 CFR 413.86 (Centers for Medicaid and Medicare Services, formerly the Health
Care Financing Administration)
CHGME Payment Program, Federal Register Notice dated March 1, 2001 (66 FR 12940)
CHGME Payment Program, Federal Register Notice dated July 20, 2001 (66 FR 37980)
Applicable to the following application forms:
HRSA-99-1 and HRSA-99-2
Direct
Medical Education (DME) Formula
DME
payments to individual hospitals are based upon a hospital’s
rolling average of the weighted resident FTE count
for DME payments.
The rolling average is the average of the resident FTE counts reported by the
hospital for the:
DME Payi = ZDME * FTEi (.711*WIi +
.289)
n
' FTE i*(.711*WIi+.289)
i=1
Where
DME Payi = Direct
CHGME payment to the individual hospital
i = Indicates
individual hospital
Z = Total
dollars available for CHGME Program for DME payment
WI = Area wage index for hospital
FTE = Number
of weighted FTE residents working at the hospital
.711 =
Labor related share of hospital expenses
.289 =
Non-labor related share of hospital expenses
Eligibility
and Funding Criteria
By statute (Public Law 106-310), an eligible children’s
hospital must meet the following criteria:
1. participates in an approved graduate medical education (GME) program;
2. has a Medicare Provider Agreement;
3. is 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
4. is a “freestanding” hospital.(2)
(1) A hospital with a 3300 series Medicare provider number would meet
this criteria (i.e., 55-3300).
(2)For purposes of eligibility in the CHGME Payment Program, children’s
hospitals that operate under a Medicare hospital provider number assigned to
a larger health care entity that would allow the children’s hospital to receive
Medicare GME payments as part of the larger health care entity are excluded.
Additional references:
Social Security Act, Section
1886
CHGME Payment Program, Federal Register Notice dated March 1, 2001 (66 FR 12940)
Eligibility
(Changes in)
A hospital remains eligible for CHGME Payment Program funding as long as it
trains residents as a “freestanding” children’s hospital during the FY for
which CHGME Payment Program payments are made.
Hospitals which become ineligible for payments:
1. must notify the Health Resources and Services Administration (CHGME Payment
Program) immediately of the change in status and the date it became ineligible;
and
2. will be liable for the reimbursement, with interest, of any funds received
during the period after it became ineligible.
Additional references:
CHGME Payment Program, Federal Register Notice dated March 1, 2001 (66 FR 12940)
