Section 16.03.09.415 - OUTPATIENT HOSPITAL SERVICES: PROVIDER REIMBURSEMENT01.Outpatient Hospital. The Department will not pay more than the combined payments the provider is allowed to receive from the participants and carriers or intermediaries for providing comparable services under comparable circumstances under Medicare. For those providers subject to cost settlement, outpatient hospital services identified below that are not listed in the Department's fee schedules will be reimbursed reasonable costs based on a year-end cost settlement. a. Maximum payment for hospital outpatient diagnostic laboratory services will be limited to the Department's established fee schedule.b. Maximum payment for hospital outpatient partial care services will be limited to the Department's established fee schedule.c. Hospital-based ambulance services will be reimbursed at the lower of either the provider's actual charge for the service or the maximum allowable charge for the service as established by the Department in its pricing file.d. Hospital Outpatient Surgery. Those items furnished by a hospital to an outpatient in connection with Ambulatory Surgical Center must be surgical procedures covered by Idaho Medicaid. The aggregate amount of payments for related facility services, furnished in a hospital on an outpatient basis, is equal to the lesser of:i. The hospital's reasonable costs as reduced by federal mandates for certain operating costs, capital costs, customary hospital charges; orii. The blended payment amount that is based on hospital specific cost and charge data and Medicaid rates paid to free-standing Ambulatory Surgical Centers (ASC); oriii. The blended rate of costs and the Department's fee schedule for ambulatory surgical centers at the time of cost settlement; oriv. The blended rate for outpatient surgical procedures is equal to the sum of forty-two percent (42%) of the hospital specific amount and fifty-eight percent (58%) of the ASC amount.e. Hospital Outpatient Radiology Services include diagnostic and therapeutic radiology, CAT scan procedures, magnetic resonance imaging, ultrasound and other imaging services. The aggregate payment for hospital outpatient radiology services furnished will be equal to the lesser of:i. The hospital's reasonable costs; orii. The hospital's customary charges; oriii. The blended payment amount for hospital outpatient radiology equal to the sum of forty-two percent (42%) of the hospital specific amount and fifty-eight percent (58%) of the Department's fee schedule amount.02.Reduction to Outpatient Hospital Costs. For services dates through June 30, 2021, outpatient costs not paid according to the Department's established fee schedule, including the hospital specific component used in the blended rates, will be reduced by five and eight-tenths percent (5.8%) of operating costs and ten percent (10%) of each hospital's capital costs component. This reduction will only apply to the following provider classes:a. In-state hospitals specified in Section 56-1408(2), Idaho Code, that are not a Medicare-designated sole community hospital or rural primary care hospital.b. Out-of-state hospitals that are not a Medicare-designated sole community hospital or rural primary care hospital.Idaho Admin. Code r. 16.03.09.415