; and (iv) other relevant factors, as determined by the State (subject to the approval of the Secretary). (C) Consideration of financial circumstances of high tier hospitals (i) In general The State shall certify that the State methodology adequately considers the unique financial circumstances of tier 1 hospitals and tier 2 hospitals, and takes necessary steps to mitigate net operating losses by such hospitals. (ii) Guidance (I) In general Not later than 18 months after the date of enactment of the SAFE Hospitals Act of 2018 , the Secretary shall issue guidance to States outlining methods that States may use to satisfy the requirement of this subparagraph. (II) State alternatives Subject to the approval of the Secretary, a State may develop an alternative method for satisfying the requirement of this subparagraph. (D) Treatment of IMDs and CAHs The State shall specify how the methodology prioritizes institutions for mental diseases and critical access hospitals (as defined in section 1861(mm)(1)), but in no case shall institutions for mental diseases or critical access hospitals receive a higher priority than tier 1 hospitals. (E) State authority to reclassify hospitals Subject to the approval of the Secretary, for purposes of prioritizing disproportionate share payments under a State methodology under this subsection, a State may treat up to 15 percent of all disproportionate share hospitals in the State, excluding institutions for mental diseases, as belonging to a different disproportionate share hospital tier than the tier in which the hospitals are described under paragraph (2). (F) Rule of construction Nothing in this subsection shall be construed as requiring a State to apply a uniform payment methodology to all hospitals within a disproportionate share hospital tier. (4) Methodology for States with fewer than 15 disproportionate share hospitals (A) In general In the case of a State that has fewer than 15 disproportionate share hospitals, the State shall use the methodology for identifying and making