Indiana Administrative Code
Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES
Article 1 - MEDICAID PROVIDERS AND SERVICES
Rule 12 - Rate-Setting Criteria for Nonstate-Owned Intermediate Care Facilities for the Mentally Retarded and Community Residential Facilities for the Developmentally Disabled
Section 12-9 - Criteria limiting rate adjustment granted by office
Current through March 20, 2024
Authority: IC 12-15-1-10; IC 12-15-21-2
Affected: IC 12-13-7-3; IC 12-15
Sec. 9.
During rebasing years and for base rate reviews, the Medicaid reimbursement system is based on recognition of the provider's allowable costs plus a potential profit add-on payment. The payment rate established during rebasing years and for base rate reviews is subject to the following limitations:
(1) In no instance shall the approved Medicaid rate be higher than the rate paid to that provider by the general public for the same type of services. For purposes of this rule, the rates paid by the general public shall not include rates paid by the DDRS.
(2) Should the rate calculations produce a rate higher than the reimbursement rate requested by the provider, the approved rate shall be the rate requested by the provider.
(3) Inflated allowable per patient or per resident day costs plus the allowed profit add-on payment as determined by the methodology in Table I.
(4) In no instance shall the approved Medicaid rate exceed the overall rate limit percent (Column A) in Table II, times the average inflated allowable cost of the median patient or resident day.
TABLE I
Profit Add-On
The profit add-on is equal to the percent (Column A) of the difference (if greater than zero (0)) between a provider's inflated allowable per patient or resident day cost, and the ceiling (Column B) times the average inflated allowable per patient or resident day cost of the median patient or resident day. Under no circumstances shall a provider's per patient or resident day profit add-on exceed the cap (Column C) times the average inflated allowable per patient or resident day cost of the median patient or resident day.
|
Level of Care |
(A) Percent |
(B) Ceiling |
(C) Cap |
|
Sheltered living Intensive training Child rearing Nonstate-operated ICF/IID |
40% 40% 40% 40% |
105% 120% 130% 125% |
10% 10% 12% 12% |
|
Developmental training Child rearing with a specialized program Small behavior management residences for children Basic developmental Small extensive medical needs residences for adults Extensive support needs residences for adults |
40% 40% 40% 40% 40% 40% |
110% 120% 120% 110% 110% 110% |
10% 12% 12% 10% 10% 10% |
TABLE II
Overall Rate Limit
|
Level of Care |
(A) Percent |
|
Sheltered living Intensive training Child rearing |
115% 120% 130% |
|
Developmental training Child rearing with a specialized program Small behavior management residences for children Basic developmental |
120% 120% 120% 120% |
|
Small extensive medical needs residences for adults Extensive support needs residences for adults Nonstate-operated ICF/IID |
120% 120% 107% |
