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Medicaid Disproportionate Share Hospital (DSH) Payments

Federal law requires that state Medicaid programs make Disproportionate Share Hospital (DSH) payments to qualifying hospitals that serve a large number of Medicaid and uninsured individuals.

Federal law establishes an annual DSH allotment for each state that limits Federal Financial Participation (FFP) for total statewide DSH payments made to hospitals. Federal law also limits FFP for DSH payments through the hospital-specific DSH limit. Under the hospital-specific DSH limit, FFP is not available for state DSH payments that are more than the hospital's eligible uncompensated care cost, which is the cost of providing inpatient hospital and outpatient hospital services to Medicaid patients and the uninsured, minus payments received by the hospital on or on the behalf of those patients.

DSH Audit and Reporting Requirements

For states to receive FFP for DSH payments, federal law requires states to submit an independent certified audit and an annual report to the Secretary describing DSH payments made to each DSH hospital.

The report must identify each disproportionate share hospital that got a DSH payment adjustment, and provide any other information the Secretary needs to ensure the appropriateness of the payment amount. The annual certified independent audit includes specific verifications to make sure all DSH payments are appropriate.

Final Rule on DSH Audit and Reporting Requirements

On December 19, 2008, the Centers for Medicare & Medicaid Services (CMS) published a final rule to implement federal law, specifying the elements for the required DSH report and the verifications required for the audit. CMS also developed additional guidance, including the General DSH Audit and Reporting Protocol  and the  DSH Report Format to help states meet statutory and regulatory requirements.

As of December 30, 2018, and in light of four recent appellate court decisions, CMS withdrew FAQs 33 & 34 from the Medicaid DSH guidance that was issued in January 2010 titled "Additional Information on the DSH Reporting and Audit Requirements ."

As a result, FAQs 33 and 34 are no longer operative, and CMS will accept revised DSH audits that cover hospitals services furnished before June 2, 2017. Ultimately, whether or not a state submits revised DSH audits, CMS expects states to comply with 42 C.F.R. § 433.312(a), and expects that any overpayments identified in the audits will either be redistributed to other DSH-eligible hospitals in accordance with the applicable state plan, see 73 Fed. Reg. 77904 (Dec. 19, 2008), or that the federal portion will be refunded to CMS in accordance with the regulation. At this time, CMS does not intend to provide additional guidance regarding whether individual states should submit revised DSH audits. States are encouraged to review any applicable district court or appellate court decisions. See, e.g., Tenn. Hosp. Ass’n v. Azar, 908 F.3d 1029 (6th Cir. Nov. 14, 2018); Children’s Health Care v. CMS, 900 F.3d 1022 (8th Cir. Aug. 20, 2018); Children’s Hosp. of the King’s Daughters, Inc. v. Azar, 896 F.3d 615 (4th Cir. July 23, 2018); New Hampshire Hosp. Ass’n v. Azar, 887 F.3d 62 (1st Cir. Apr. 4, 2018).

As discussed further below, hospital services furnished on or after June 2, 2017 are covered by a final rule issued by CMS on April 3, 2017 (Medicaid Program: Disproportionate Share Hospital Payments-Treatment of Third Party Payers in Calculating Uncompensated Care Costs), clarifying the treatment of third party payers in determining the hospital-specific Medicaid DSH payment limit.

For any questions and concerns, please contact Wendy Harrison (wendy.harrison@cms.hhs.gov).

Final DSH Rule: Treatment of Third Party Payers in Calculating Uncompensated Care Costs

On April 30, 2017, CMS issued a final rule regarding Medicaid DSH payments. This rule (published at 82 Fed. Reg. 16114 and codified at 42 C.F.R. § 447.299(c)(10)) clarifies federal requirements regarding the treatment of third party payers in determining the hospital-specific Medicaid DSH payment limit, which is set by statute as a hospital’s “uncompensated costs” incurred in providing hospital services to Medicaid and uninsured patients.

The final rule makes clearer our existing policy that uncompensated costs include only those costs for Medicaid eligible individuals that remain after accounting for all payments received by or on behalf of Medicaid eligible individuals, including Medicare and other third party payments. This is consistent with the statutory requirements governing Medicaid DSH and applicable limits.

Following the district court decision in Children’s Hosp. Ass’n of Texas v. Azar, No. 17-cv-844 (D.D.C. Mar. 2, 2018), which vacated the 2017 rule, CMS previously advised that it would not be enforcing the 2017 rule as long as that district court decision remained operative. Additionally, CMS withdrew FAQs 33 & 34 from the Medicaid DSH guidance that was issued in January 2010 titled “Additional Information on the DSH Reporting and Audit Requirements,” which provided instructions to states for offsetting third party payers (TPP) payments for services provided prior to June 2, 2017. On August 13, 2019, the United States Court of Appeals for the D.C. Circuit issued an opinion reversing the district court judgment, reinstating the final rule, and remanding the case for further proceedings. Children’s Hosp. Ass’n of Texas v. Azar, No. 18-5135 (D.C. Cir. Aug. 13, 2019). Additionally, we have received favorable rulings from two other appellate courts—namely, the Fifth and Eighth Circuits. See Baptist Mem’l Hosp.-Golden-Triangle, Inc. v. Azar, 18-60592 (5th Cir. Apr. 20, 2020); Missouri Hosp. Ass’n v. Azar, No. 18-1778 (8th Cir. Nov. 4, 2019).

Based on these court rulings, CMS will be enforcing the 2017 rule as it applies to all hospital services furnished on or after June 2, 2017. In order to assist states in complying with the applicable requirements, CMS released a CMCS Information Bulletin on August 18, 2020 entitled, “Treatment of Third Party Payers (TPP) in Calculating Uncompensated Care Costs (UCC).” This bulletin provides states with guidance on how to properly report UCC for 2017 if states decide not to include TPP payments as an offset for purposes of calculating the hospital-specific DSH limit for periods before the June 2, 2017 effective date of the 2017 final rule.

Notice of Proposed Rulemaking: State Disproportionate Share Hospital Allotment Reductions

On July 27, 2017, CMS issued a notice of proposed rulemaking (NPRM) regarding Medicaid Disproportionate Share Hospital allotment reductions. This NPRM proposes a methodology to implement the annual reductions to state Medicaid DSH allotments for FY 2018 through FY 2025 as required by the Affordable Care Act. The proposed methodology relies on five factors identified in statute. Taking these factors into account for each state, the proposed methodology will generate a state-specific DSH allotment reduction amount for each fiscal year.

Final Rule: State Disproportionate Share Hospital Allotment Reductions

On September 23, 2019, CMS released a final rule to implement statutorily required disproportionate share hospital (DSH) allotment reductions that are scheduled to begin in FY2020. The rule finalizes a methodology to calculate the annual reductions for FY2020 through FY2025. The methodology includes five factors outlined in 1923(f) of the Social Security Act, which include the uninsured factor (UPF), Medicaid volume factor (HMF), uncompensated care factor (HUF), low DSH state factor (LDF), and budget neutrality factor (BNF). CMS will calculate individual state’s DSH reductions using each respective year’s preliminary DSH allotment as currently calculated under statue.

Consolidated Appropriations Act, 2021:  Hospital-Specific Medicaid Disproportionate Share Hospital Limit Calculations

On December 27, 2020, the Consolidated Appropriations Act, 2021 (CAA) was signed into law. Section 203 of the CAA relates to the treatment of Medicaid shortfall and third-party payers (TPP) in the calculation of hospital specific DSH limits. Prior to the passage of the CAA, payments made by all TPP, such as Medicare, other insurers, and cost sharing, would all be included in the calculation of hospital specific DSH limits. Effective October 1, 2021, the CAA changes the methodology at section 1923(g) the Social Security Act (the Act) for calculating the hospital-specific DSH limit to include only costs and payments associated with Medicaid-eligible individuals where Medicaid is the primary payer. Costs and payments associated with the services provided to Medicaid-eligible individuals are otherwise excluded from the calculation of the hospital-specific DSH limit when Medicaid is not the primary payer for those services.

The change in methodology in the CAA, section 1923(g)(2) of the Act provides an exception for certain hospitals that are in the 97th percentile or above of all hospitals with respect to the number of Medicare supplemental security income (SSI) days or percentage of Medicare SSI days to total inpatient days. Hospitals meeting this exception will calculate their hospital-specific DSH limit using the higher value of either the hospital-specific DSH limit calculation resulting from the methodology in effect prior to the passage of the CAA or the methodology in effect as of October 1, 2021, per the CAA.

On December 10, 2021, CMS released a State Medicaid Director Letter (SMDL) titled "New Supplemental Payment Reporting and Medicaid Disproportionate Share Hospital Requirements under the Consolidated Appropriations Act, 2021.” In this SMDL, CMS indicates that it intends to release additional guidance and engage in future rulemaking as necessary to address the provisions of section 203 of the CAA. We will update this page as necessary to reflect the release of additional guidance and other related materials.

2024 Final Rule:  Medicaid Program Disproportionate Share Hospital Third-Party Payer Rule

On February 23, 2024, CMS issued a final rule (2024 TPP rule) addressing legislative changes to the Social Security Act (the Act), which govern the hospital-specific limit on Medicaid disproportionate share hospital (DSH) payments, as a result of the Consolidated Appropriations Act, 2021. This final rule clarifies how hospital-specific DSH limits will be calculated, effective October 1, 2021 and codifies changes that enhance administrative efficiency by making technical changes and clarifications to the DSH program.

97th Percentile Hospital Exception List

Section 1923(g)(2)(B) of the Act provides an exception for hospitals that, for the most recent cost reporting period, are in the 97th percentile or above of all hospitals with respect to either (1) the number of Medicare Supplemental Security Income (SSI) days or (2) the percentage of Medicare-SSI days to total inpatient days. This exception provides qualifying hospitals with a hospital-specific limit that is the higher of that calculated under the methodology in which costs and payments for Medicaid patients are counted only for beneficiaries for whom Medicaid is the primary payer, or the methodology in effect on January 1, 2020.  On an annual basis, CMS will release a list of hospitals that qualify for an exception in advance of October 1st of each year, applicable to the upcoming State Plan Rate Year (SPRY) starting between October 1st and September 30th. Because the Final Rule changed how the hospital-specific DSH limits were calculated effective October 1, 2021, we are releasing the exception lists for the past three fiscal years (FY2022, FY2023, and FY2024) at this time. An overview of the methodology used to determine hospitals that qualify for the exception for 97th percentile hospitals, as codified in the 2024 TPP rule, can be found in the Technical Specifications document.

The 2024 TPP rule allows for a revised list to be published only to correct a mathematical or other similar technical error that is identified by states, hospitals, CMS, or other interested parties during the one-year period, beginning on the date the list is published for each year.  Any dispute over the underlying Medicare cost report and claims data is outside of this process.  During the one-year period, comments regarding mathematical or technical errors can be submitted to MedicaidDSH@cms.hhs.gov for CMS consideration.

Annual DSH Exception Lists

Year Title Published
Year Title Published

State-specific Annual DSH Reports and Independent Certified Audits

State-specific annual DSH reports are posted as submitted by states based on their availability and are arranged alphabetically by state under the corresponding State Plan Rate Year (SPRY) heading.

Due to the size of the files and issues associated with electronic formatting, state-specific independent certified audits will be available only upon request. Interested parties should contact Richard Cuno (Richard.Cuno@cms.hhs.gov) to request copies. In order to facilitate requests, the subject line should read "DSH Independent Certified Audit Request". In the body of the email, please provide specifics regarding the state and SPRY that you are requesting. Please be advised that the provision of the audits is subject to availability and does not constitute approval of their contents.

Annual DSH Reports

SPRY 2019 DSH Reports

SPRY 2018 DSH Reports 

SPRY 2017 DSH Reports 

SPRY 2016 DSH Reports 

SPRY 2015 DSH Reports 

SPRY 2014 DSH Reports 

SPRY 2013 DSH Reports 

SPRY 2012 DSH Reports 

SPRY 2011 DSH Reports 

SPRY 2010 DSH Reports 

SPRY 2009 DSH Reports 

SPRY 2008 DSH Reports 

SPRY 2007 DSH Reports 

SPRY 2006 DSH Reports 

SPRY 2005 DSH Reports