Medicare and Medicaid GME Funding

Presentation to GME Program CoordinatorsApril 2014

What are Medicare and Medicaid?

• Medicare – Medicare is the federal health insurance program for people who are 64 or

older, certain younger people with disabilities, and people with End-Stage Renal Disease (permanent kidney failure requiring dialysis or a transplant, sometimes called ESRD).

• Medicaid– Medicaid is a state/federal program that pays for medical services for low-

income pregnant women, children, individuals who are elderly or have a disability, parents and women with breast or cervical cancer.

Program oversight

• Medicare– Medicare requires a cost report be submitted by all participating providers.– Determines a facility’s cost of providing patient care.– Annual audit of the report by a Medicare Administrative Contractor.– Adjustments can be made based on audit findings.

• Medicaid– Managed by the state.– State of Utah does not require submission of a cost report.– State plan is developed by the Utah Department of Health.

• Payments to hospitals are governed by the state plan.• The state plan reflects the legislative and executive branch positions on health care funding

for Medicaid participants. • State plan is approved by the federal government.

UUHC Medicare Funds

• UUHC Medicare– Direct Med Ed

• Intended to cover a portion of salary and benefit costs of residency training programs.

• Per resident amount used to determine funds.

– Indirect Med Ed• Intended to cover the higher patient care costs of teaching hospitals

relative to non-teaching hospitals.• Resident to bed ratio and complex formula used to determine funds.• Regulations are complex regarding resident rotations that can be counted

on the Medicare cost report.• Rules are different for IME and DME.

Medicare DME

• UUHC Medicare GME – FY2013– DME (Direct Medical Education)

• UUHC funds more than 750 residents in training.• The un-weighted FTE count per the cost report is approximately 350 residents.• Count for DME is reduced for those residents over their allowed initial residency

program years.• Weighted FTE count is approximately 311 residents.• Medicare caps our allowable DME count of residents at 278.41.• We were approved for 25 additional slots based upon Section 422 of the Medicare

Modernization Act (MMA).• Dental and Podiatry residents are outside of the cap – no limit.• UUHC’s Per Resident Amount is currently $79,376.14; Medicare utilization at the

hospital is 26.5%; payment is subject to a 3-year rolling average. • Medicare cap of residents – DME and IME – global, not program-specific nor resident-

specific.• Paid as a pass through and final settled on the Medicare cost report.

Medicare IME

• UUHC Medicare GME – FY2013– IME (Indirect Medical Education)

• Based upon formula of Interns and Residents to Bed ratio raised to the 0.405 power, subject to 3-year rolling average, multiplied by “C-factor”, multiplied by Federal Specific Base Payment Amounts.

• Current FTE count for IME is 264.5.• Medicare caps our allowable IME count of residents at 250.5.• We were approved for 25 additional slots based upon Section 422 of the Medicare

Modernization Act (MMA).• Covers impact on UUHC operations.• Paid on the interim as part of the patient DRG payment and final settled on the

Medicare cost report.

Changes to GME - Medicare

• Changes Specific to UUHC from ACA - Medicare– Sec 5503 Resident Redistribution for Unused Resident Slots

• Specific priority and criteria must be met. UUHC submitted but did not receive any slots.– Sec 5504 Counting residents in Non-Provider Settings

• prior to reform-incur “all or substantially all” of the costs (90%). Included supervisory costs.• After reform-incur costs of stipends and benefits of resident time spent in non-provider setting.

– Sec 5505 Didactic, Research and Other Time-• Didactic time spent at hospital AND non hospital sites for DME can be counted. For IME, can

only count time spent in hospital site. UUHC clinics are considered part of hospital site.• Research time in hospital setting not associated with patient care can be counted for DME

(bench research). Research for IME only if patient care. Can’t be counted in non provider setting. • Vacation, sick leave and other approved leave can be counted as long as it does not prolong time

spent in the program.– Sec 5506 Redistribution of Residency Slots for Closed Hospitals

• Process in which a hospital with an approved residency program closes on or after March 1, 2008. CMS will permanently redistribute resident slots. Specific priority and criteria must be met.– UUHC has submitted a request for additional slots for those available due to closing hospitals. We have

not received any additional slots.

UUHC Medicaid Funds

• UUHC – Medicaid

– GME funding – Utah Medicaid funds $1.8 million – Federal share is $4.3 million for a total Utah pool of $6.1 million. UUHC receives approx. $4.6 million of the pool based upon the historical count of residents trained and the volumes of Medicaid days.

– Upper Payment Limit (UPL) Funding • Formerly called Medicaid IME, but re-structured as UPL in 2010.• UPL represents the difference between that which Medicaid paid and that

which Medicare would have paid for the same service. • Previously retrospective reconciliation; now no retrospective settlement. • Does not relate to DGME.

Program Coordinators

• UUHC Residency FTE Count – Reimbursed rotations from affiliated hospitals– Medicare audit adjustment impact of data– E*Value – data input and activity set-up– Reporting vacations and locations– Changes in scheduled locations– GME Office reconciles errors in the rotations reported in E*Value– Counting Fellows – reduced for years beyond residency program– Counting Dental and Podiatry residents.

Wrap-up

Questions?