 |
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(1) Cost reporting forms provided by the office.
(2) Substitute forms that have received prior written approval by the office.
(1) Dietary services and supplies.
(2) Raw food.
(3) Patient laundry services and supplies.
(4) Patient housekeeping services and supplies.
(5) Plant operations services and supplies.
(6) Utilities.
(7) Social services.
(8) Activities supplies and services.
(9) Recreational supplies and services.
(10) Repairs and maintenance.
(1) is associated or affiliated with; or
(2) has the ability to control or be controlled by;
the organization furnishing the service, facilities, or supplies, whether or not such control is actually exercised.
(hh) "Tentative profit add-on payment" means the profit add-on payment calculated under this rule before considering a facility's nursing home report card score.
(1) are not supported according to the MDS supporting documentation guidelines as set forth in
(2) result in the assessment being classified into a different RUG-III category.
(1) A significant change MDS assessment, as defined by CMS' Resident Assessment Instrument (RAI) Manual, that is not completed within fourteen (14) days of determining that a nursing facility resident's condition has changed significantly.
(2) A full or quarterly MDS assessment that is not completed as required by
(A) physical therapy;
(B) speech therapy; and
(C) occupational therapy.
SECTION 2.
Authority: |
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| Effective Date | Threshold Percent | Administrative Component Corrective Remedy Percent |
| (A) | (B) | (C) |
| October 1, 2002 | 40% | 5% |
| January 1, 2004 | 30% | 10% |
| April 1, 2005 | 20% | 15% |
(l) Based on findings from the MDS audit, beginning on the effective date of this rule, the office or its contractor shall make adjustments or revisions to all MDS data items that are required to classify a resident pursuant to the RUG-III resident classification system that are not supported according to the MDS supporting documentation guidelines as set forth in 405 IAC 1-15 . Such adjustments or revisions to MDS data transmitted by the nursing facility will be made in order to reflect the resident's highest functioning level that is supported according to the MDS supporting documentation guidelines as set forth in 405 IAC 1-15 . The resident assessment will then be used to reclassify the resident pursuant to the RUG-III resident classification system by incorporating any adjustments or revisions made by the office or its contractor.
(m) Beginning on the effective date of this rule, Upon conclusion of an MDS audit, the office or its contractor shall recalculate the facility's CMI. If the recalculated CMI results in a change to the established Medicaid rate:
(Office of the Secretary of Family and Social Services;
(1) the rate shall be recalculated; and
(2) any payment adjustment shall be made.
SECTION 3. 405 IAC 1-14.6-7 IS AMENDED TO READ AS FOLLOWS:
405 IAC 1-14.6-7 Inflation adjustment; minimum occupancy level; case mix indices
Authority: Affected: IC 12-13-7-3 ; IC 12-15-13-6
Sec. 7. (a) For purposes of determining the average allowable cost of the median patient day and a provider's annual rate review, each provider's cost from the most recent completed year will be adjusted for inflation by the office using the methodology in this subsection. All allowable costs of the provider, except for mortgage interest on facilities and equipment, depreciation on facilities and equipment, rent or lease costs for facilities and equipment, and working capital interest shall be adjusted for inflation using the CMS Nursing Home without Capital Market Basket index as published by DRI/WEFA. The inflation adjustment shall apply from the midpoint of the annual financial report period to the midpoint prescribed as follows:
| Effective Date | Midpoint Quarter |
| January 1, Year 1 | July 1, Year 1 |
| April 1, Year 1 | October 1, Year 1 |
| July 1, Year 1 | January 1, Year 2 |
| October 1, Year 1 | April 1, Year 2 |
(b) Notwithstanding subsection (a), beginning July 1, 2007, 2011, the inflation adjustment determined as prescribed in subsection (a) shall be reduced by an inflation reduction factor equal to three and three-tenths percent (3.3%). The resulting inflation adjustment shall not be less than zero (0). Any reduction or elimination of the inflation reduction factor shall be made effective no earlier than permitted under IC 12-15-13-6 (a).
(c) In determining prospective allowable costs for a new provider that has undergone a change of provider ownership or control through an arm's-length transaction between unrelated parties, when the first fiscal year end following the change of provider ownership or control is less than six (6) full calendar months, the previous provider's most recently completed annual financial report used to establish a Medicaid rate for the previous provider shall be utilized to calculate the new provider's first annual rate review. The inflation adjustment for the new provider's first annual rate review shall be applied from the midpoint of the previous provider's most recently completed annual financial report period to the midpoint prescribed under subsection (a).
(d) Allowable fixed costs per patient day for direct care, indirect care, and administrative costs shall be computed based on the following minimum occupancy levels:
(1) For nursing facilities with less than fifty-one (51) beds, an occupancy rate equal to the greater of eighty-five percent (85%), or the provider's actual occupancy rate from the most recently completed historical period.
(2) For nursing facilities with greater than fifty (50) beds, an occupancy rate equal to the greater of ninety percent (90%) or the provider's actual occupancy rate from the most recently completed historical period.
(e) Notwithstanding subsection (d), the office or its contractor shall reestablish a provider's Medicaid rate effective on the first day of the quarter following the date that the conditions specified in this subsection are met, by applying all provisions of this rule, except for the eighty-five percent (85%) applicable minimum occupancy requirement described in subsection (d), if both of the following conditions can be established to the satisfaction of the office:
(1) The provider demonstrates that its current resident census has:
(A) increased to eighty-five percent (85%) the applicable minimum occupancy level described in subsection (d), or greater since the facility's fiscal year end of the most recently completed and desk reviewed cost report utilizing total nursing facility licensed beds as of the most recently completed desk reviewed cost report period; and
(B) remained at such level for not fewer than ninety (90) days.
(2) The provider demonstrates that its resident census has:
(A) increased by a minimum of fifteen percent (15%) since the facility's fiscal year end of the most recently completed and desk reviewed cost report; and
(B) remained at such level for not fewer than ninety (90) days.
(f) Allowable fixed costs per patient day for capital-related costs shall be computed based on an occupancy rate equal to the greater of ninety-five percent (95%) or the provider's actual occupancy rate from the most recently completed historical period.
(g) Except as provided for in subsection (h), the CMIs contained in this subsection shall be used for purposes of determining each resident's CMI used to calculate the facility-average CMI for all residents and the facility-average CMI for Medicaid residents.
| RUG-III Group | RUG-III Code | CMI Table |
| Rehabilitation | RAD | 2.02 |
| Rehabilitation | RAC | 1.69 |
| Rehabilitation | RAB | 1.50 |
| Rehabilitation | RAA | 1.24 |
| Extensive Services | SE3 | 2.69 |
| Extensive Services | SE2 | 2.23 |
| Extensive Services | SE1 | 1.85 |
| Special Care | SSC | 1.75 |
| Special Care | SSB | 1.60 |
| Special Care | SSA | 1.51 |
| Clinically Complex | CC2 | 1.33 |
| Clinically Complex | CC1 | 1.27 |
| Clinically Complex | CB2 | 1.14 |
| Clinically Complex | CB1 | 1.07 |
| Clinically Complex | CA2 | 0.95 |
| Clinically Complex | CA1 | 0.87 |
| Impaired Cognition | IB2 | 0.93 |
| Impaired Cognition | IB1 | 0.82 |
| Impaired Cognition | IA2 | 0.68 |
| Impaired Cognition | IA1 | 0.62 |
| Behavior Problems | BB2 | 0.89 |
| Behavior Problems | BB1 | 0.77 |
| Behavior Problems | BA2 | 0.67 |
| Behavior Problems | BA1 | 0.54 |
| Reduced Physical Functions | PE2 | 1.06 |
| Reduced Physical Functions | PE1 | 0.96 |
| Reduced Physical Functions | PD2 | 0.97 |
| Reduced Physical Functions | PD1 | 0.87 |
| Reduced Physical Functions | PC2 | 0.83 |
| Reduced Physical Functions | PC1 | 0.76 |
| Reduced Physical Functions | PB2 | 0.73 |
| Reduced Physical Functions | PB1 | 0.66 |
| Reduced Physical Functions | PA2 | 0.56 |
| Reduced Physical Functions | PA1 | 0.50 |
| Unclassifiable | BC1 | 0.48 |
| Delinquent | BC2 | 0.48 |
(h) In place of the CMIs contained in subsection (g), beginning on the effective date of this rule amendment and continuing thereafter, the CMIs contained in this subsection shall be used for purposes of determining the facility-average CMI for Medicaid residents that meet all the following conditions:
(1) The resident classifies into one (1) of the following RUG-III groups:
(A) PB2.
(B) PB1.
(C) PA2.
(D) PA1.
(2) The resident has a cognitive performance score (CPS) of:
(A) zero (0) – Intact;
(B) one (1) – Borderline Intact; or
(C) two (2) – Mild Impairment.
(3) Based on an assessment of the resident's continence control as reported on the MDS, the resident is not experiencing occasional, frequent, or complete incontinence control.
(4) The resident has not been admitted to any Medicaid-certified nursing facility before the effective date of this rule amendment.
| CMIs effective for the period following the effective date of this rule amendment | |||||
| RUG-III Group | RUG-III Code | The first calendar quarter through the fourth calendar quarter | The fifth calendar quarter through the eighth calendar quarter | The ninth calendar quarter and thereafter | |
| Reduced Physical Functions | PB2 | 0.48 | 0.41 | 0.30 | |
| Reduced Physical Functions | PB1 | 0.44 | 0.38 | 0.28 | |
| Reduced Physical Functions | PA2 | 0.38 | 0.32 | 0.24 | |
| Reduced Physical Functions | PA1 | 0.33 | 0.28 | 0.21 | |
(1) Two (2) preliminary CMI reports. These preliminary CMI reports:
(A) serve as confirmation of the MDS assessments transmitted by the nursing facility; and
(B) provide an opportunity for the nursing facility to correct and transmit any missing or incorrect MDS assessments.
The first preliminary report will be provided by the seventh day of the first month following the end of a calendar quarter. The second preliminary report will be provided by the seventh day of the second month following the end of a calendar quarter.
(2) Final CMI reports utilizing MDS assessments received by the fifteenth day of the second month following the end of a calendar quarter. These assessments received by the fifteenth day of the second month following the end of a calendar quarter will be utilized to establish the facility-average CMI and facility-average CMI for Medicaid residents utilized in establishing the nursing facility's Medicaid rate.
(1) be effective on the day the nursing facility provides inpatient services to more than eight (8) ventilator-dependent residents; and
(2) remain in effect until the first day of the calendar quarter following the date the nursing facility provides inpatient services to eight (8) or fewer ventilator-dependent residents.
For purposes of determining the nursing home report card score rate add-on effective with this rule amendment and each July 1 thereafter, the office or its contractor shall determine each nursing facility's report card score based on the latest published data as of the end of each state fiscal year. The nursing home report card score rate add-on shall be computed as described in the following table:
| Nursing Home Report Card Score | Nursing Home Report Card Score Rate Add-On |
| 0 – 82 | $5.75 |
| 83 – 265 | $5.75 – ((Nursing Home Report Card Score – 82) × $0.03125) |
| 266 and above | $0 |
Facilities that did not have a nursing home report card score published as of July 4, 2003, the most recently completed state fiscal year may receive a per patient day rate add-on equal to two dollars ($2).
(1) Twenty-five percent (25%) or more of its residents as of December 31, 2006, were under the chronological age of twenty-one (21) years of age.
(2) According to the last health facility survey conducted by Indiana state department of health on or before December 31, 2006, the facility was not in compliance with 42 CFR 483.70(d)(1)(i).
(3) The facility bedrooms accommodate no more than four (4) residents.
(4) The facility bedrooms measure at least eighty (80) square feet per resident in multiple resident bedrooms and at least one hundred (100) square feet in single resident rooms.
SECTION 4. 405 IAC 1-14.6-9 IS AMENDED TO READ AS FOLLOWS:
405 IAC 1-14.6-9 Rate components; rate limitations; profit add-on
Authority: Affected: IC 12-13-7-3 ; IC 12-15-13-6
Sec. 9. (a) The Medicaid reimbursement system is based on recognition of the provider's allowable costs for the direct care, therapy, indirect care, administrative, and capital components, plus a potential profit add-on payment as defined below. The direct care, therapy, indirect care, administrative, and capital rate components are calculated as follows:
(1) The indirect care administrative, and capital components are equal to the provider's allowable per patient day costs for each component, plus the allowed profit add-on payment as determined by the methodology in subsection (b).
(2) The therapy component is equal to the provider's allowable Medicaid per patient day direct therapy costs.
(3) The direct care component is equal to the provider's normalized allowable per patient day direct care costs times the facility-average CMI for Medicaid residents, plus the allowed profit add-on payment as determined by the methodology in subsection (b).
(4) The administrative component shall be equal to one hundred percent (100%) of the average allowable cost of the median patient day.
(b) The profit add-on payment will be calculated as follows:
(4) The administrative component profit add-on is equal to sixty percent (60%) times the difference (if greater than zero (0)) between:
(A) the average allowable cost of the median patient day times the profit ceiling percentage contained in Table 4; minus
(B) a provider's allowable per patient day cost.
(5) (4) The tentative capital component profit add-on payment is equal to sixty percent (60%) times the difference (if greater than zero (0)) between:
(6) (5) The therapy component profit add-on is equal to zero (0).
(1) For nursing facilities designated by the office as children's nursing facilities, the allowed direct care component profit add-on is equal to the profit add-on percentage contained in Table 1, times the difference (if greater than zero (0)) between:
(A) the normalized average allowable cost of the median patient day for direct care costs times the facility average CMI for Medicaid residents times the profit ceiling percentage contained in Table 1; minus
(B) the provider's normalized allowable per patient day costs times the facility average CMI for Medicaid residents.
| Table 1 | ||||
| Children's Nursing Facilities | ||||
| Direct Care Profit Add-on Percentage | Direct Care Profit Ceiling Percentage | |||
| Effective Date | July 1, 2003, through June 30, | July 1, | July 1, 2003, through June 30, | July 1, |
| Percentage | 30% | 52% | 110% | 105% |
(2) For nursing facilities that are not designated by the office as children's nursing facilities, the tentative direct care component profit add-on payment is equal to the profit add-on percentage contained in Table 2, times the difference (if greater than zero (0)) between:
(A) the normalized average allowable cost of the median patient day for direct care costs times the facility average CMI for Medicaid residents times the profit ceiling percentage contained in Table 2; minus
(B) the provider's normalized allowable per patient day costs times the facility average CMI for Medicaid residents.
| Table 2 | ||||
| Non-Children's Nursing Facilities | ||||
| Direct Care Profit Add-on Percentage | Direct Care Profit Ceiling Percentage | |||
| Effective Date | July 1, 2003, through June 30, | July 1, | July 1, 2003, through June 30, | July 1, |
| Percentage | 30% | 0% | 110% | 105% |
(C) For nursing facilities not designated by the office as children's nursing facilities, the allowed direct care component profit add-on payment is equal to the facility's tentative direct care component profit add-on payment times the applicable percentage contained in Table 3, based on the facility's nursing home report card score as determined by the office or its contractor using the latest published data as of the end of each state fiscal year.
| Table 3 – Allowed Direct Care Profit Add-On Percentage | ||
| Nursing Home Report Card Score | Effective Dates | |
| First Full Calendar Quarter through Fourth Full Calendar Quarter Following Rule Effective Date | Fifth Full Calendar Quarter Following Rule Effective Date and Thereafter | |
| 0 – 82 | 100% | 100% |
| 83 – 357 | 100% - ((Nursing Home Report Card Score – 82) × 0.36232%) | N/A |
| 358 and greater | 0% | N/A |
| 83 – 279 | N/A | 100% - ((Nursing Home Report Card Score - 82) × 0.50505%) |
| 280 and greater | N/A | 0% |
(D) In no event shall the allowed direct care profit add-on payment exceed ten percent (10%) of the average allowable cost of the median patient day.
(3) The tentative indirect care component profit add-on payment is equal to the profit add-on percentage contained in Table 3. 4, times the difference (if greater than zero (0)) between:
(A) the average allowable cost of the median patient day times the profit ceiling percentage contained in Table 3, 4; minus
(B) a provider's allowable per patient day cost.
| Table | ||||
| Indirect Care Profit Add-on Percentage | Indirect Care Profit Ceiling Percentage | |||
| Effective Date | July 1, 2003, through June 30, | July 1, | July 1, 2003, through June 30, | July 1, |
| Percentage | 60% | 52% | 105% | 100% |
(C) The allowed indirect care component profit add-on payment is equal to the facility's tentative indirect care component profit add-on payment times the applicable percentage contained in Table 5, based on the facility's nursing home report card score as determined by the office or its contractor using the latest published data as of the end of each state fiscal year.
| Table 5 – Allowed Indirect Care Profit Add-On Percentage | ||
| Nursing Home Report Card Score | Effective Dates | |
| First Full Calendar Quarter through Fourth Full Calendar Quarter Following Rule Effective Date | Fifth Full Calendar Quarter Following Rule Effective Date and Thereafter | |
| 0 – 82 | 100% | 100% |
| 83 – 357 | 100% - ((Nursing Home Report Card Score – 82) × 0.36232%) | N/A |
| 358 and greater | 0% | N/A |
| 83 – 279 | N/A | 100% - ((Nursing Home Report Card Score - 82) × 0.50505%) |
| 280 and greater | N/A | 0% |
(A) the average allowable cost of the median patient day times the profit ceiling percentage contained in Table 5; 6; minus
(B) a provider's allowable per patient day cost.
| Table | ||
| Capital Component Profit Ceiling Percentage | ||
| Effective Date | July 1, 2003, through June 30, | July 1, |
| Percentage | 100% | 80% |
(C) The allowed capital component profit add-on payment is equal to the facility's tentative capital component profit add-on payment times the applicable percentage contained in Table 7, based on the facility's nursing home report card score as determined by the office or its contractor using the latest published data as of the end of each state fiscal year.
| Table 7 – Allowed Capital Profit Add-On Percentage | ||
| Nursing Home Report Card Score | Effective Dates | |
| First Full Calendar Quarter through Fourth Full Calendar Quarter Following Rule Effective Date | Fifth Full Calendar Quarter Following Rule Effective Date and Thereafter | |
| 0 – 82 | 100% | 100% |
| 83 – 357 | 100% - ((Nursing Home Report Card Score – 82) x 0.36232%) | N/A |
| 358 and greater | 0% | N/A |
| 83 – 279 | N/A | 100% - ((Nursing Home Report Card Score - 82) × 0.50505%) |
| 280 and greater | N/A | 0% |
(c) Notwithstanding subsections (a) and (b), in no instance shall a rate component exceed the overall rate ceiling defined as follows:
(3) The average allowable cost of the median patient day for administrative costs times the overall rate ceiling percentage in Table 8.
(4) (3) The average allowable cost of the median patient day for capital-related costs times the overall rate ceiling percentage in Table 9. 10.
(5) (4) For the therapy component, no overall rate component limit shall apply.
(1) The normalized average allowable cost of the median patient day for direct care costs times the facility-average CMI for Medicaid residents times the overall rate ceiling percentage in Table 6. 8.
| Table | ||
| Direct Care Component Overall Rate Ceiling Percentage | ||
| Effective Date | July 1, 2003, through June 30, | July 1, |
| Percentage | 120% | 110% |
(2) The average allowable cost of the median patient day for indirect care costs times the overall rate ceiling percentage in Table 7. 9.
| Table | ||
| Indirect Care Component Overall Rate Ceiling Percentage | ||
| Effective Date | July 1, 2003, through June 30, | July 1, |
| Percentage | 115% | 100% |
| Table | ||
| Capital Component Overall Rate Ceiling Percentage | ||
| Effective Date | July 1, 2003, through June 30, | July 1, |
| Percentage | 100% | 80% |
(d) In order to determine the normalized allowable direct care costs from each facility's Financial Report for Nursing Facilities, the office or its contractor shall determine each facility's CMI for all residents on a time-weighted basis.
(e) The office shall publish guidelines for use in determining the time-weighted CMI. These guidelines:
(Office of the Secretary of Family and Social Services; (1) shall be published as a provider bulletin; and
(2) may be updated by the office as needed.
Any such updates shall be made effective no earlier than permitted under IC 12-15-13-6 (a).
SECTION 5. 405 IAC 1-14.6-18 IS AMENDED TO READ AS FOLLOWS:
405 IAC 1-14.6-18 Allowable costs; calculation of allowable owner or related party compensation; wages; salaries; fees
Authority: Affected: IC 12-13-7-3 ; IC 12-15
Sec. 18. (a) Compensation for:
(1) owner, related party, management, general line personnel, and consultants who perform management functions; or
(2) any individual or entity rendering services above the department head level;
shall be subject to the annual limitations described in this section. All compensation received by the parties as described in this subsection shall be reported and separately identified on the financial report form even though such payment may exceed the limitations. This compensation is allowed to cover costs for all administrative, policymaking, decision making, and other management functions above the department head level. Beginning effective July 1, 2003, through June 30, 2007, 2011, compensation subject to this limitation includes wages, salaries, and fees for owner, management, contractors, and consultants who actually perform management functions as well as any other individual or entity performing such tasks. Beginning effective July 1, 2007, 2011, and thereafter, wages, salaries, and fees paid for owner, administrator, assistant administrator, management, contractors, and consultants who actually perform management functions as well as any other individual or entity performing such tasks are subject to this limitation.
(b) Beginning effective July 1, 2003, through June 30, 2007, 2011, the maximum allowable amount for owner, related party, and management compensation shall be the average allowable cost of the median patient day for owner, related party, and management compensation subject to this limitation as defined in subjection (a). The average allowable cost of the median patient day shall be updated four (4) times per year effective January 1, April 1, July 1, and October 1.
(c) Beginning effective July 1, 2007, 2011, the maximum amount of owner, related party, and management compensation for the parties identified in subsection (a) shall be the lesser of the amount:
(1) under subsection (d), as updated by the office on July 1 of each year based on the average rate of change of the most recent twelve (12) quarters of the Gross National Product Implicit Price Deflator; or
(2) of patient-related wages, salaries, or fees actually paid or withdrawn that were properly reported to the federal Internal Revenue Service as wages, salaries, fringe benefits, or fees.
If liabilities are established, they shall be paid within seventy-five (75) days after the end of the accounting period or the costs shall be disallowed.
(d) The owner, related party, and management compensation limitation per operation effective July 1, 1995, shall be as follows:
(Office of the Secretary of Family and Social Services; | Owner and Management Compensation | |
| Beds | Allowance |
| 10 | $21,542 |
| 20 | $28,741 |
| 30 | $35,915 |
| 40 | $43,081 |
| 50 | $50,281 |
| 60 | $54,590 |
| 70 | $58,904 |
| 80 | $63,211 |
| 90 | $67,507 |
| 100 | $71,818 |
| 110 | $77,594 |
| 120 | $83,330 |
| 130 | $89,103 |
| 140 | $94,822 |
| 150 | $100,578 |
| 160 | $106,311 |
| 170 | $112,068 |
| 180 | $117,807 |
| 190 | $123,562 |
| 200 | $129,298 |
| 200 and over | $129,298 + $262/bed over 200 |
This subsection applies to each provider of a Medicaid-certified operation. The unused portions of the allowance for one (1) operation shall not be carried over to other operations.
SECTION 6. 405 IAC 1-14.6-21 IS AMENDED TO READ AS FOLLOWS:
405 IAC 1-14.6-21 Allocation of expenses
Authority: Affected: IC 12-13-7-3 ; IC 12-15
Sec. 21. (a) Except as provided in subsection (b), the detailed basis for allocation of expenses between nursing facility services and other services in a facility shall remain a prerogative of the provider as long as the basis is reasonable and consistent between accounting periods.
(b) The following relationships shall be followed:
(Office of the Secretary of Family and Social Services; (1) Reported expenses and patient census information must be for the same reporting period.
(2) Nursing salary allocations must be on the basis of nursing hours worked and must be for the reporting period except when specific identification is used based on the actual salaries paid for the reporting period.
(3) Nothing in this rule is intended to alter the appropriate classification of costs on the annual financial report from the appropriate classification of costs under 405 IAC 1-14.1 . No allocation of costs between annual financial report line items shall be permitted.
(4) Any changes in the allocation or classification of costs must be approved by the office prior to the changes being implemented. Proposed changes in allocation or classification methods must be submitted to the office for approval at least ninety (90) days prior to the provider's reporting year end.
SECTION 7. 405 IAC 1-14.6-23 IS AMENDED TO READ AS FOLLOWS:
405 IAC 1-14.6-23 Limitation to Medicaid rate increases for nursing facilities
Authority: Affected: IC 12-13-7-3 ; IC 12-15
Sec. 23. Notwithstanding all other provisions of this rule, for the period October 1, 2007, through June 30, 2011, nursing facility rates that have been calculated under this rule shall be limited to a maximum allowable increase as follows:
(6) (7) A provider's annual Medicaid rate may be in effect for longer or shorter than twelve (12) months. In such cases, the maximum allowable increase percent shall be proportionately increased or decreased to cover the actual time frame their previous annual rate was in effect, using a twelve (12) month period as the basis.
(7) Subsequent to each annual rate review, the direct care component of the Medicaid rate will be adjusted quarterly to reflect changes in the provider's case mix index as described in section 6(d) of this rule. These rate adjustments are not limited to the maximum allowable increase.
(Office of the Secretary of Family and Social Services; (1) For annual rate reviews effective October 1, 2007, the maximum allowable increase of seven percent (7%) per annum shall be applied to a provider's latest annual Medicaid rate with an effective date prior to March 31, 2007.
(2) For annual rate reviews effective July 1, 2008, the maximum allowable increase of seven percent (7%) per annum shall be applied to a provider's annual Medicaid rate with an effective date of October 1, 2007.
(3) For annual rate reviews effective July 1, 2009, the maximum allowable increase of three percent (3%) per annum shall be applied to a provider's annual Medicaid rate with an effective date of July 1, 2008.
(4) For annual rate reviews effective July 1, 2010, the maximum allowable increase of three percent (3%) per annum shall be applied to a provider's annual Medicaid rate with an effective date of July 1, 2009.
(5) The therapy rate component shall be excluded for purposes of calculating the maximum allowable increase pursuant to under subdivisions (1) through (4). of this section.
(6) Beginning on the first full calendar quarter following the effective date of this rule amendment, the direct care component shall be excluded for purposes of calculating the maximum allowable increase under subdivisions (1) through (4).
(8) Should a provider's quality assessment rate change subsequent to the effective date of their annual Medicaid rate, the office shall restate the provider's Medicaid quality assessment rate add-on and the maximum allowable increase using the new quality assessment rate, applying all provisions of this rule. A provider's Medicaid rate restated under this provision shall be used to calculate their subsequent maximum allowable increase as determined in subdivisions (1) through (4). of this section.
(9) The additional reimbursement authorized by section 7(i) of this rule shall be excluded for purposes of calculating the maximum allowable increase pursuant to under subdivisions (1) through (4) of this section when the nursing facility's prior annual Medicaid rate does not include this additional reimbursement.
SECTION 8. 405 IAC 1-14.6-24 IS AMENDED TO READ AS FOLLOWS:
405 IAC 1-14.6-24 Nursing facility quality assessment
Authority: Sec. 24. (a) Effective August 1, 2003 through June 30, 2007, 2011, the office shall collect a quality assessment from each nursing facility licensed under IC 16-28 as a comprehensive care facility based on the most recently completed annual financial report or quality assessment data collection form, as follows:
(1) If the total annual nursing facility census days are fewer than seventy thousand (70,000), ten dollars ($10) per non-Medicare day.
(2) If the total annual nursing facility census days are equal to or greater than seventy thousand (70,000), two dollars and fifty cents ($2.50) per non-Medicare day.
(3) If the nursing facility is nonstate government owned or operated, two dollars and fifty cents ($2.50) per non-Medicare day.
(b) The following nursing facilities shall be exempt from the quality assessment described in subsection (a):
(1) A continuing care retirement community registered with the securities commissioner of the office of the secretary of state under IC 23-2-4 .
(2) A hospital-based nursing facility licensed under IC 16-21 .
(3) The Indiana Veterans' Home.
(c) For nursing facilities certified for participation in the Medicaid program under Title XIX of the federal Social Security Act (42 U.S.C. 1396 et seq.), the quality assessment shall be an allowable cost for cost reporting and auditing purposes. The quality assessment shall be included in Medicaid reimbursement as an add-on to the Medicaid rate. The add-on is determined by dividing the product of the assessment rate times total non-Medicare patient days by total patient days from the most recently completed desk reviewed annual financial report.
(d) For nursing facilities that are not certified for participation in the Medicaid program under Title XIX of the federal Social Security Act (42 U.S.C. 1396 et seq.), the department of state revenue shall collect the quality assessment under 45 IAC 20 . facility shall remit the quality assessment to the state of Indiana within ten (10) days after the due date. If a nursing facility fails to pay the quality assessment under this subsection within ten (10) days after the date the payment is due, the nursing facility shall pay interest on the quality assessment at the same rate as determined under IC 12-15-21-3 (6)(A).
(e) The office or its contractor shall notify each nursing facility of the amount of the facility's assessment after the amount of the assessment has been computed. If the facility disagrees with the computation of the assessment, the facility shall request an administrative reconsideration by the Medicaid rate-setting contractor. The reconsideration request shall be as follows:
(1) In writing.
(2) Contain the following:
(A) Specific issues to be reconsidered.
(B) The rationale for the facility's position.
(3) Signed by the authorized representative of the facility and must be received by the contractor within forty-five (45) days after the notice of the assessment is mailed.
Upon receipt of the request for reconsideration, the Medicaid rate-setting contractor shall evaluate the data. After review, the Medicaid rate-setting contractor may amend the assessment or affirm the original decision. The Medicaid rate-setting contractor shall thereafter notify the facility of its final decision in writing, within forty-five (45) days of the Medicaid rate-setting contractor's receipt of the request for reconsideration. In the event that a timely response is not made by the rate-setting contractor to the facility's reconsideration request, the request shall be deemed denied and the provider may initiate an appeal under IC 4-21.5-3 .
(f) The assessment shall be calculated on an annual basis with equal monthly amounts due on or before the tenth day of each calendar month.
(g) A facility may file a request to pay the quality assessment on an installment plan. The request shall be as follows:
(1) In writing setting forth the facility's rationale for the request.
(2) Submitted to the office or its designee.
An installment plan established under this section shall not exceed a period of six (6) months from the date of execution of the agreement. The agreement shall set forth the amount of the assessment that shall be paid in installments and include provisions for the collection of interest. The interest shall not exceed the percentage set out in IC 12-15-21-3 (6)(A).
(h) A facility that fails to pay the quality assessment due under this section within ten (10) days after the date the payment is due shall pay interest on the quality assessment at the same rate as determined under IC 12-15-21-3 (6)(A).
(i) The office may withhold Medicaid payments to a facility that fails to pay an assessment within thirty (30) days after the due date. The amount withheld may not exceed the amount of the assessment and any interest due under subsection (h).
(j) Not later than one hundred twenty (120) days after payment of the quality assessment was due, the office shall report each facility that has failed to pay the quality assessment by the due date to the state department of health to initiate license revocation proceedings.
(Office of the Secretary of Family and Social Services;
SECTION 9. 405 IAC 1-14.6-25 IS AMENDED TO READ AS FOLLOWS:
405 IAC 1-14.6-25 Additional reimbursement for closing or converting nursing facilities
Authority: Affected: IC 12-13-7-3 ; IC 12-15
Sec. 25. (a) Beginning on the first full calendar quarter following the effective July 1, 2003, date of this rule amendment and continuing through June 30, 2007, 2011, nursing facility operators that were licensed and certified to participate in the Medicaid program under Title XIX of the federal Social Security Act (42 U.S.C. 1396 et seq.) as of July 1, 2003, on the effective date of this rule amendment may be eligible to receive additional Medicaid reimbursement if they:
(1) close their nursing facility; or
(2) convert their nursing facility to alternative uses.
(b) The amount of additional reimbursement available under this section shall be determined by the office taking into consideration the following factors:
(1) The location of the nursing facility.
(2) The number of beds proposed to be closed or converted.
(3) The current and historical census of the facility.
(4) The financial condition of the nursing facility operator.
(5) The proposed time frame for closing or converting the facility.
(6) The availability of other facilities and services to meet the needs of residents.
(c) In order to receive additional reimbursement available under this section, the nursing facility provider shall submit a proposal to the office or its designee that fully describes the operator's proposed plan to close or convert the nursing facility. The office or its designee shall specify procedures and time frames that facilities shall follow in preparing and submitting proposals.
(d) The office shall review all proposals submitted under subsection (c) and shall notify the proposing nursing facility provider in writing of its response to their proposal. Based on its review of any proposal, the office may, in its sole discretion, do any of the following:
(1) Accept and approve the proposal for additional reimbursement as submitted.
(2) Request additional information it deems necessary to complete its review.
(3) Request modifications of the proposal as submitted.
(4) Accept and approve the proposal for additional reimbursement as revised.
(5) Reject and disapprove the proposal for additional reimbursement with or without requesting additional information or modifications from the proposing nursing facility provider.
(e) In the event the office accepts and approves a proposal for additional reimbursement, the office and nursing facility provider shall negotiate in good faith to execute a written agreement that specifies all terms and conditions that shall govern the proposing nursing facility provider's efforts to close or convert the nursing facility. The agreement between the office and the nursing facility provider shall be finalized and executed by all appropriate parties before any additional reimbursement available under this section shall be paid.
(f) The office shall pay any additional reimbursement available under this section into an escrow account, which will be established for the sole purpose to retain and disburse these funds. The funds shall be disbursed to the provider following the provider's successful completion of all conditions specified in the agreement referenced in subsection (e).
(g) The additional reimbursement available under this section shall
(1) consist of an enhanced capital reimbursement rate add-on. and
(2) be used to fund debt service termination and related closing costs as delineated in the agreement referenced in subsection (e).
(Office of the Secretary of Family and Social Services; The enhanced capital reimbursement rate add-on shall be computed by dividing the total amount determined in subsection (b) by the facility's actual occupancy from the most recently completed desk reviewed annual financial report and shall be reimbursed for a period not to exceed twelve (12) months.
SECTION 10. All provisions of this rule amendment shall be implemented effective on the first day of the first calendar quarter following the effective date of this rule amendment.
Posted: 05/27/2009 by Legislative Services Agency
DIN: 20090527-IR-405090215PRA
Composed: Apr 19,2024 6:37:40AM EDT
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