[Code of Federal Regulations]

[Title 42, Volume 2]

[Revised as of October 1, 2005]

From the U.S. Government Printing Office via GPO Access

[CITE: 42CFR403.321]



[Page 50]

 

                         TITLE 42--PUBLIC HEALTH

 

                    CHAPTER IV--CENTERS FOR MEDICARE

                          & MEDICAID SERVICES,

                        DEPARTMENT OF HEALTH AND

                             HUMAN SERVICES

 

PART 403_SPECIAL PROGRAMS AND PROJECTS--Table of Contents

 

      Subpart C_Recognition of State Reimbursement Control Systems

 

Sec. 403.321  State systems for hospital outpatient services.



    CMS may approve a State's application for approval of an outpatient 

system if the following conditions are met:

    (a) The State's inpatient system is approved.

    (b) The State's outpatient application meets the requirements and 

assurances for an inpatient system described in Sec. 403.304 (b) and 

(c), and Sec. 403.306 (b)(1) and (b)(2)(ii).

    (c) The State submits a separate application that provides separate 

assurances and estimates and data in further support of its assurance 

submitted under paragraph (b)(1) of Sec. 403.320, as follows:

    (1) Upon application for approval, the State must submit estimates 

and data that include, but are not limited to, projections for the first 

12-month period covered by the assurance for each hospital, in both the 

aggregate and on an average cost per service and payment basis, of 

Medicare outpatient expenditures under Medicare principles of 

reimbursement; parallel projections of Medicare outpatient expenditures 

under the State system; and the resulting cost or savings to Medicare 

independent of the State system for hospital inpatient services.

    (2) The State must submit separate statewide projections for each 

year of the 36-month period of the aggregate outpatient expenditures for 

each system. The projections submitted under this paragraph must--

    (i) Comply with the requirements of paragraphs (b) (3) and (5) of 

Sec. 403.320 regarding a detailed description of the methodology used 

to derive the expenditure amounts:

    (ii) Include the data and assumptions set forth in paragraphs (b)(3) 

(i), (ii), (iii), (iv), and (v) of Sec. 403.320; and

    (iii) Include any assumption the State has adopted for establishing 

the number of Medicare and total base year outpatient services for each 

hospital.

    (3) The State must provide a detailed explanation of the reasons for 

any difference between the data or assumptions used for the separate 

projections.