DSH FY 12-13 LIUR Formula 11-20-2012

LOW INCOME PERCENT FORMULA FOR FISCAL YEAR 2012/13
Low Income Percent = (Medicaid Fraction) + (Charity Fraction)
Page 1 of 5
Safety Net Financing Division
DSH Unit
Revised on November 20, 2012

Medicaid 2
Fraction
= 100 *
Medicaid Fraction 1
Medi-Cal Paid
Patient Revenue
+
Total Cash Subsidies from
State and Local Governments
Total Paid Patient Revenue
Where,
Medi-Cal
Paid
Patient
Revenue
=
Medi-Cal Net
Patient Revenue
(L1246005)
―
QAF Fee-for-
Service Payments
–Selected Privates 3 +
Medi-Cal
Short-Doyle
Net Patient
Revenue 4
Disproportionate
― Absolute Share Payments
Value (L1242605 or
L1242613)
+
Medi-Cal Managed
Care Net
Patient Revenue
(L1246007)
―
QAF Managed
Care Payments –
Selected Privates 3
Total Cash Subsidies
from State and
Local Governments
=
Absolute UC Gross Clinical
Value Teaching Support
(L1244523)
+
County Indigent Program
Net Patient Revenue
(L1246009 + L1246010)
+
County Indigent Program
Managed Care
Net Patient Revenue
(L1246011)
Total Paid
Patient Revenue
=
Total Net
Patient Revenue
(L0811001)
―
QAF Fee-for-Service
Payments – Selected
Privates 3
―
QAF Managed Care
Payments – Selected
Privates 3
―
Disproportionate
Absolute Share Payments
Value (L1242605 or
L1242613)
1. Unless otherwise noted, all data are derived from the OSHPD Annual Financial Disclosure Report (AFDR) for the hospital’s fiscal year ending (FYE)
in 2010.
2. 0 ≤ Medicaid Fraction ≤ 100.
3. Pursuant to the OSHPD Technical Letter, private hospitals with FYE in Dec. were required to report the Quality Assurance Fee (QAF) Program
payments in the CY 2010 AFDR. As such, the QAF payments made to private hospitals with FYE in Dec. will be accounted for in the FY 2012-13
LIUR calculation.
4. Medi-Cal Short-Doyle paid claims for calendar year of service 2010 with dates of payment through February 2012.
Page 2 of 5
Safety Net Financing Division
DSH Unit
Revised on November 20, 2012

Charity Fraction 1
Charity 2
Fraction
= 100 *
Total Other
Inpatient Charity
―
Inpatient Portion of Total Cash Subsidies
from State and Local Governments
Gross Inpatient Revenue
(L1241521)
Where,
1. Unless otherwise noted, all data are derived from the OSHPD Annual Financial Disclosure Report (AFDR) for the hospital’s fiscal year ending in
2010.
2. 0 ≤ Charity Fraction ≤ 100.
Page 3 of 5
Safety Net Financing Division
DSH Unit
Revised on November 20, 2012

Total Other
Inpatient
Charity
=
County Indigent
Program Gross
Inpatient Revenue
(L1241509)
+
County Indigent Program
Managed Care Gross
Inpatient Revenue
(L1241511)
―
County Indigent
Program Gross
Inpatient Charity
(L1243009)
―
Inpatient County
Indigent Program
Managed Care
Patient Charity
(L1243011 x B)
+
Gross
Inpatient
Charity
―
Gross Inpatient
Charity
Gross Patient
Charity
(L1243023)
*
Hill-Burton Gross
Patient Charity
(L0835001)
+
UC Gross Inpatient
Teaching Allowances
(L1244017)
+
UC Gross Inpatient
Absolute Clinical Teaching
Value Support
(L1244517)
Where,
Gross
Inpatient
Charity
=
Non-Medi-Cal Gross Inpatient
Charity
(L1243001 + L1243009 +
L1243013 + L1243019)
+
Inpatient Non-Medi-Cal Managed
Care Gross Inpatient Charity
(L1243003 x A*
+ L1243011 x B*
+ L1243015 x C*)
+
Other Indigent
Gross Inpatient
Charity
(L1243017)
+
Medi-Cal Gross
Inpatient Revenue
(L1241505)
Medi-Cal Gross
Patient Revenue
(L1241505 +L1241506)
*
Medi-Cal Gross
Patient Charity
(L1243005)
+
Inpatient Medi-Cal Managed Care
Gross Patient Charity
(L1243007 x D*)
Page 4 of 5
Safety Net Financing Division
DSH Unit
Revised on November 20, 2012

Inpatient Portion of Total
Cash Subsidies from State
and Local Governments
= Absolute
Value
UC Gross Inpatient
Clinical Teaching
Support
(L1244517)
+
County Indigent
Program Inpatient
Net Patient Revenue
(L1246009)
+
Inpatient County Indigent
Program Managed Care Net
Patient Revenue
(L1246011 x B*)
*Inpatient ratio as follows:
Medicare Managed Care
A = L1241503 / (L1241503 [Inpatient] + L1241504 [Outpatient])
County Indigent Managed Care
B = L1241511 / (L1241511 [Inpatient] + L1241512 [Outpatient])
Other Third Party Managed Care
C = L1241515 / (L1241515 [Inpatient] + L1241516 [Outpatient])
Medi-Cal Managed Care
D = L1241507 / (L1241507 [Inpatient] + L1241508 [Outpatient])
Page 5 of 5
Safety Net Financing Division
DSH Unit
Revised on November 20, 2012