Disproportionate Share Hospital (DSH)

Medicare DSH Eligibility Data

CMS has developed a limited view of the HIPAA Eligibility Transaction System (HETS) to allow hospitals that receive Medicare DSH payments to view Medicare enrollment information for their hospital inpatients.

The data available for viewing via HETS 270/271 DSH will allow hospitals to verify that patients eligible for Medicaid are not also entitled to Medicare Part A benefits. In addition, hospitals can verify Medicare enrollment for their hospital inpatients, including whether a patient is entitled to Medicare Part A benefits, enrolled in a Medicare managed care plan, or has Medicare as a secondary insurance.

HETS 270/271 is an electronic data interchange (EDI) system that uses current ANSI X12 formatting standards. Submitters must connect to HETS 270/271 via the Medicare Data Communication Network (MDCN). Additional information about the HETS 270/271 system, including connectivity and file formatting requirements, is available online at: http://www.cms.hhs.gov/hetshelp.

Applicants interested in receiving the HETS 270/271 DSH view can contact the MCARE Help Desk Monday – Friday 7:00 A.M. to 9:00 P.M. EST at 1-866-324-7315, or send an email to mcare@cms.hhs.gov for additional information. The MCARE Help Desk will work with you and provide you with all documentation necessary to obtain access to the Medicare DSH view.

The Medicare DSH Adjustment (42 CFR 412.106)

The Medicare DSH adjustment provision under section 1886(d) (5) (F) of the Act was enacted by section 9105 of the Consolidated Omnibus Budget Reconciliation Act (COBRA) of 1985 and became effective for discharges occurring on or after May 1, 1986. According to section 1886(d) (5) (F) of the Act, there are two methods for a hospital to qualify for the Medicare DSH adjustment. The primary method is for a hospital to qualify based on a statutory formula that results in the DSH patient percentage. The DSH patient percentage is equal to the sum of the percentage of Medicare inpatient days attributable to patients eligible for both Medicare Part A and Supplemental Security Income (SSI), and the percentage of total inpatient days attributable to patients eligible for Medicaid by not Medicare Part A. The DSH patients percentage is defined as:

DSH Patient Percent = (Medicare SSI Days / Total Medicare Days) + (Medicaid, Non-Medicare Days / Total Patient Days)

The alternate special exception method is for large urban hospitals that can demonstrate that more than 30 percent of their total net inpatient care revenues come from State and local governments for indigent care (other than Medicare or Medicaid)

Under the primary method to qualify for DSH adjustments, the first computation includes the number of hospital patient days used by patients who, for those days, were entitled to both Medicare Part A and SSI (excluding State supplementation). This number is divided by the number of patient days used by patients under Medicare Part A for that same period. The second computation includes hospital patient days used by patients who, for those days, were eligible for medical assistance under a state plan approved under title XIX (Medicaid), but who were not entitled to Medicare Part A. This number is divided by the total number of hospital patient days for that same period.

Hospitals whose DSH patient percentage exceeds 15 percent are eligible for a DSH payment adjustment based on another statutory formula. The formula varies for urban hospitals with 100 or more beds and rural hospitals with 500 or more beds, hospital that qualify as rural referral centers or sole community hospitals, and other hospitals.

Note to Providers:

May 3, 2010: CMS published CMS Ruling "CMS-1498-R" pertaining to three Medicare Disproportionate Share Hospital (DSH) issues. Specifically, the Ruling addresses jurisdictionally proper pending appeals and open cost reports on the issues of Medicare non-covered days (such as exhausted benefit days and Medicare secondary payer days), the data matching process for Supplemental Security Income "SSI" fractions, and "labor and delivery" days. The Ruling became effective on April 28, 2010. To view the Ruling, please visit the link below in the downloads section.

Note to Providers on the FY 2006, 2007, 2008, 2009 and 2010 SSI Ratios

March 16, 2012:  CMS issued Change Request 5647 on July 20, 2007 instructing applicable hospitals to submit no pay bills for their Medicare Advantage (MA) patients for FY 2007 forward.  CMS later issued Change Request 6329 instructing applicable hospitals to also submit their FY 2006 MA data. 

Revised SSI ratios for the Medicare DSH calculation for FY 2006 through FY 2009 are available at the hyperlinks below.  In addition to including MA patient days in the ratios for FY 2006, 2007, 2008, and 2009 CMS has also calculated the SSI ratios in the manner proscribed by CMS-1498-R.  To view these ratios, please visit the link below in the downloads section.  Information regarding the MedPAR claims run out and the SSI eligibility file used to calculate ratios can be found within the excel files below. 

Providers who are interested in obtaining the data used to calculate their FY 2006–FY 2009 ratios are encouraged to submit a Letter of Request along with a DSH Data Use Agreement.  For additional information, please visit the link below in the related links section.

October 17,2012:  SSI ratios for the Medicare DSH calculation for FY 2010 are available at the hyperlink below. The methodology for calculating FY 2010 SSI ratios is the same method used for FY 2006 – FY 2009 described above.  The data request process for FY 2010 is also the same as the process outlined above for FY 2006 – FY 2009.   ***Please note, this file replaces the file originally posted on September 11, 2012 which contained erroneous data.  Hospitals are to use the data contained in this file and disregard data from the September 11, 2012 posting.***