DSH Hospitals May Now Request SSI Realignment At Any Time, For Any Year Past

Until just recently, hospitals could only request a cost report reopening three years from issuance of the NPR. But now, “per 42 CFR 412.106(b)(3), providers are entitled to request a realignment of their SSI ratio to the provider’s cost reporting period at any time…If the SSI Realignment is received more than three years after the NPR, a Notice of Realignment will be issued for the SSI Realignment request.” This represents a great opportunity for incremental DSH reimbursements.


A hospital’s Supplemental Security Income (SSI) percentage, is an important factor in calculating DSH reimbursements. The SSI ratio, also known as the Medicare fraction, represents the percentage of patient days for beneficiaries who are eligible for both Medicare Part A and SSI. Because SSI days reside in the numerator of the Medicare fraction – the greater number of SSI days, the greater the DSH payment.

SSI ratios are calculated based on the Federal Fiscal Year (FFY) which runs from 10/1 through 9/30. So, for hospitals with a 9/30 Fiscal Year, the FFY and hospital’s fiscal year are in perfect alignment when CMS publishes SSI ratios for all DSH hospitals. But for 12/31, 3/31, and 6/30 fiscal year hospitals, the CMS report is calculating SSI ratios for the FFY, and not including several months within the hospital’s fiscal year-end cost report.

Hospitals can review two years of MedPAR data. This allows non-9/30 hospitals to eliminate eligible days in the second year, for months outside the hospital’s fiscal, and add days from the first MedPAR year that complete SSI ratios for the given fiscal year. This “patient detail data” brings SSI ratios in alignment with the hospital’s fiscal year.

But there is no guarantee that SSI Realignment will result in greater DSH reimbursements. It all depends on whether the “patient detail data” yields a greater (or lesser) SSI ratio for the hospital. If a hospital requests an SSI recalculation that results in a lesser DSH amount than was included in the original NPR, the difference would have to be paid back to CMS. So, hospitals should always work-up the “patient detail data” before requesting a reopening and a corresponding SSI recalculation.

What to do now

Many hospitals look at SSI Realignment every year in order to optimize Medicare reimbursements. But, if there are gap years in your hospital’s realignment process – now is the time to take advantage of the new cost report reopening freedom, to examine realignment for years past.

QRS is eager to work with you to optimize your SSI ratios. We have created a report that tracks SSI percentages for all DSH hospitals going back to the early ‘80s and can detect SSI% trends year-over-year, to identify the cost reports that promise positive results for SSI Realignment and then provide “rough” estimates of impact on your DSH for those years.

By filling-out the form below, you can request a “Patient Detail Data” SSI Realignment Report, which will provide a firm estimate of incremental DSH revenue for your hospital. This “firm” estimate is used to determine which years will be selected for reopening, and the impact amount expected for each year. However, for hospitals that appealed CMS-1498R (aka Allina v. Sebelius), years receiving a settlement are not eligible for SSI Realignment.

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