Court Rejects Secretary’s Denial of Exhausted Benefit Days in the DSH Medicaid Proxy


As part of the ongoing battle between the Secretary of Health and Human Services and the hospital community, the United States District Court for the District of Columbia has sided with the hospitals. At issue was whether days attributable to a patient who was eligible for both Medicare and Medicaid (dual-eligible) but who had exhausted all of his Medicare hospital coverage (exhausted benefit days) should be counted in the Medicare or the Medicaid fraction of the disproportionate share (DSH) adjustment. The provider maintained that for the days in question the patient had not been entitled to benefits under Medicare Part A and that the days, therefore, were properly included in the Medicaid fraction. The Secretary, however, acting through CMS, took the position that it is the status of the patients, as opposed to the payment for the specific days, that determines whether a patient day is included in the numerator of the Medicaid proxy. The court sided with the provider. Columbia St. Mary’s Hosp. Milwaukee, Inc. v. Sebelius, Case No. 09- 2031 (DDC, Oct. 4, 2012)...

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