Medicare Disproportionate Share Adjustment Procedures (CMS-R-194)

A hospital's disproportionate share adjustment is determined by its fiscal intermediary (FI) using a combination of Medicare Part A and SSI data provided by CMS, and Medicare date calculated from the hospital's cost report. The data provided through these calculations are then compared to the qualifying criteria located in 42 CFR 412.106 to determine the final adjustment. If these calculations, based on the Federal fiscal year, do not allow the hospital to qualify for a disproportionate share adjustment, the hospital may request that they be performed using its cost reporting period.

The latest form for Medicare Disproportionate Share Adjustment Procedures (CMS-R-194) expires 2021-12-31 and can be found here.