Current through Reg. 50, No. 187; September 24, 2024
(1) This rule
applies to participating intermediate care facilities for individuals with
intellectual disabilities (ICF/IID) not publicly owned and not publicly
operated rendering Florida Medicaid services to recipients in accordance with
Rule 59G 4.170, Florida Administrative Code (F.A.C.).
(2) Definitions.
(a) Acceptable cost report - A completed,
accurate and legible cost report that contains all relevant schedules,
worksheets and supporting documents in accordance with cost reporting
instructions.
(b) AHCA - Agency for
Health Care Administration.
(c)
Eligibility Factor - The percentage of days that a provider is in compliance
with all conditions of participation during the rate period in effect one year
prior to the rate period being set.
(d) Filing due date (cost report) - No later
than five calendar months after the close of the ICF/IID's cost reporting
year.
(e) Incentive - An amount
paid to providers whose annual rates of cost increase for operating costs or
resident care costs from one cost reporting period to the next are less than
1.4 times the average cost increase for the applicable period documented by the
ICF/IID Cost Inflation Index.
(f)
Interim cost per diem - A reimbursement rate or a portion of an overall
reimbursement rate that is calculated from budgeted cost data divided by the
total resident days.
(g) Medicaid
Trend Adjustment (MTA) - The MTA is a percentage reduction that is uniformly
applied to all Florida Medicaid providers each rate period when the rate
setting unit cost is greater than the legislative unit cost and all quality
assessment funds have been exhausted.
(h) Operating cost per diem - Those costs not
directly related to resident care, property costs, or Return on Equity (ROE).
Operating costs include administrative, plant operation, laundry, and
housekeeping costs divided by the total resident days.
(i) Patient Responsibility - The amount a
recipient is required to pay the ICF/IID, as determined by the Department of
Children and Families (DCF), based upon the recipient's monthly
income.
(j) Property cost per diem
- A calculation based upon those costs related to the ownership or leasing of
an ICF/IID. Such costs may include property taxes, insurance, interest and
depreciation, or rent divided by the total resident days.
(k) Quality Assessment - Pursuant to section
409.9083, Florida Statutes
(F.S.), a per-resident-day basis assessment is imposed upon each
ICF/IID.
(l) Rate setting due date
- February 1 of each year shall be the rate setting due date. All cost reports
received by AHCA on or before February 1 shall be used to establish the
reimbursement rates for the upcoming rate period. If February 1 falls on the
weekend, the due date shall be the first business day following February
1.
(m) Reimbursement Class -
Designated provider reimbursement level for the provision of services to
recipients residing in an ICF/IID, as follows:
1. Developmental Residential and
Developmental Institutional - A reimbursement level for recipients who are
ambulatory or self-mobile using mechanical devices and who can transfer
themselves without human assistance but may require assistance and oversight to
ensure safe evacuation.
2.
Developmental Non-ambulatory and Developmental Medical - A reimbursement level
for recipients who are capable of mobility only with human assistance or
require human assistance to transfer to or from a mobility device or require
continuous medical and nursing supervision.
(n) Resident care cost per diem - Those costs
directly attributed to nursing services, dietary costs, and other costs
directly related to resident care such as activity costs, social services, and
all medically-ordered therapies divided by the total resident days.
(o) Return on Equity (ROE) or use allowance
cost per diem - Net Income or Profits or Shareholder's Equity divided by the
total resident days.
(p) Target
Rate Factor - 1.4 times the simple average of the monthly Florida ICF/IID Cost
Inflation Indices associated with the most recent cost reporting period divided
by the simple average of the monthly indices associated with the prior cost
reporting period.
(3)
Reimbursement. Each July 1, AHCA will reimburse for Florida Medicaid services
rendered by facilities not publicly owned and not publicly operated in
accordance with Section
409.906, F.S.
(4) Reimbursement Methodology.
(a) Rate setting method.
1. Determine Inflated Prior Period Costs of
Operating and Resident Care components
Prior Period Inflated Costs Per Diem = (Prior Period Base
*Target Rate of Inflation)/Resident Days
2. Current Period Costs Per Diem = Total
Allowable Cost of Component/Resident Days
3. Determine the Incentive Basis for
Operating and Resident Care component per diems
If Prior Period Inflated Costs Per Diem > Current Period
Costs Per Diem,
Incentive Basis = Prior Period Inflated Costs Per Diem -
Current Period Costs Per Diem
4. Final Incentive Per Diem
a. For Operating component = Eligibility
Factor *Minimum of:
(I) Incentive Basis for
Operating Component *50%
(II)
Incentive Basis for Operating Component - Current Period Costs Per Diem
*10%
b. For Resident Care
component = Eligibility Factor *Minimum of:
(I) Incentive Basis for Resident Care
Component *50%
(II) Incentive Basis
for Resident Care Component - Current Period Costs Per Diem
*3%
5. Current
Period Base Per Diem = Current Period Costs Per Diem + Final Incentive Per
Diem
6. Prospective Rate Per Diem =
Current Period Base Per Diem *(Simple average of the monthly cost inflation
indices for the prospective rate period/Simple average of the monthly cost
inflation indices for the cost report period used to calculate current base per
diems)
7. Total Prospective per
diem = Prospective Rate of Operating per diem + Prospective Rate of Resident
Care per diem + Property per diem + ROE or use allowance + Interim Components +
MTA + Quality Assessment.
(b) Base Year ceilings for new providers in
facilities with six beds or less.
1. Property
costs per diems shall not be in excess of the established ceiling
limitations.
2. Operating costs per
diems shall not be in excess of the 90th percentile of per resident day costs
of all currently participating ICF/IID providers that have prospective rates.
This ceiling shall be recalculated for every rate period beginning July 1 of
each year.
3. Resident care costs
per diems shall not exceed the highest per resident day cost for the respective
reimbursement class of any other currently participating provider having a
prospective rate. The ceiling shall be recalculated for every rate period
beginning July 1 of each year.
4.
Total costs per diem ceilings (including ROE) shall not exceed the total costs
per diem ceilings for interim cost per diems multiplied times 4% (l.04). When a
provider is limited to the total ceiling in the base year, the total ceiling
shall be allocated to each component to cost settle interim rates and to
calculate prospective rates based on the percentage that each component's
actual allowable cost is to the total actual allowable cost for all components,
including ROE, in the base year.
(5) Intermediate Care Facility Quality
Assessment Fee (QAF). In accordance with Section
409.9083, F.S., there is imposed
upon each ICF/IID, a quality assessment. The aggregate amount of assessments
for all ICF/IIDs in a given year shall be an amount not exceeding the maximum
percentage allowed under federal law of the total aggregate net patient
services revenue of assessed facilities.
(a)
Participating ICF/IIDs shall use the Facility Quality Assessment form (only
accepted electronically), AHCA Form 5000-3548, October 2013, incorporated by
reference, for the submission of its monthly quality assessment. This form can
be accessed at
https://apps.ahca.myflorida.com/nfqa/,
and at
http://www.flrules.org/Gateway/reference.asp?No=Ref-13532.
(b) Each facility shall report monthly to the
Agency its total number of resident days and remit an amount equal to the
assessment rate times the reported number of days. Facilities are required to
submit their full quality assessment payment by the 15th day of the next
succeeding calendar month.
(6) Sanctions. Providers are subject to the
following monetary fines pursuant to Section
409.9083(6),
F.S., for failure to timely pay a quality assessment:
(a) For a facility's first offense, a fine of
$500 per day shall be imposed until the quality assessment is paid in full, but
in no event shall the fine exceed the amount of the quality
assessment.
(b) For any offense
subsequent to a first offense, a fine of $1, 000 per day shall be imposed until
the quality assessment is paid in full, but in no event shall the fine exceed
the amount of the quality assessment. A subsequent offense is defined as any
offense within a period of five years preceding the most recent quality
assessment due date.
(c) An offense
is defined as one month's quality assessment payment not received by the 20th
day of the next succeeding calendar month.
(d) In the event that a provider fails to
report their total number of resident days as defined in Section
409.9083(1)(c),
F.S., by the 20th day of the next succeeding calendar month, the fines in
paragraphs (a)-(b) apply and the maximum amount of the fines shall be equal to
their last submitted quality assessment amount, but no greater than $1000 per
day, and in no event shall the total fine exceed the amount of the quality
assessment.
(e) In addition to the
aforementioned fines, providers are also subject to the non-monetary remedies
enumerated in Section
409.9083(6),
F.S. Imposition of the non-monetary remedies by the Agency will be as follows:
1. For a third subsequent offense, the Agency
will withhold any medical assistance reimbursement payments until the
assessment is recovered.
2. For a
fourth or greater subsequent offense, the Agency will seek suspension or
revocation of the facility's license.
(7) Sanctions for failure to timely submit a
quality assessment are non-allowable costs for reimbursement purposes and shall
not be included in the provider's Medicaid per diem rate.
(8) The facility may amend any previously
submitted quality assessment data, but in no event may an amendment occur more
than twelve months after the due date of the assessment. The deadline for
submitting an amended assessment shall not relieve the facility from their
obligation to pay any amount previously underpaid and shall not waive the
Agency's right to recoup any underpaid assessments.
(9) This rule is effective for 5 years after
its effective date.
Rulemaking Authority 409.919, 409.9083 FS. Law Implemented
409.908, 409.9083 FS.
New 3-14-99, Amended 10-12-04, 2-22-06, 4-12-09, 3-3-10,
2-23-11, 7-16-12, 2-13-14, 2-4-15, 6-15-15, 7-11-16, 6-27-17, 3-11-18,
10-24-21.
