Current through Register Vol. 50, No. 9, September 20, 2024
A.
Resident per diem rates are calculated based on information reported on the
cost report. ICFs/IID will receive a rate for each resident. The rates are
based on cost components appropriate for an economic and efficient ICF/IID
providing quality service. The resident per diem rates represent the best
judgment of the state to provide reasonable and adequate reimbursement required
to cover the costs of economic and efficient ICF/IID.
B. The cost data used in setting base rates
will be from the latest available audited or desk reviewed cost reports. The
initial rates will be adjusted to maintain budget neutrality upon transition to
the ICAP reimbursement methodology. For rate periods between rebasing, the
rates will be trended forward using the index factor contingent upon
appropriation by the legislature.
C. A resident's per diem rate will be the sum
of:
1. direct care per diem rate;
2. care related per diem rate;
3. administrative and operating per diem
rate;
4. capital rate;
5. provider fee; and
6. dental pass-through/add-on per diem rate
(effective for dates of service on or after May 1, 2023).
D. Determination of Rate Components
1. The direct care per diem rate shall be a
set percentage over the median adjusted for the acuity of the resident based on
the ICAP, tier based on peer group. The direct care per diem rate shall be
determined as follows.
a. Median Cost. The
direct care per diem median cost for each ICF/IID is determined by dividing the
facility's total direct care costs reported on the cost report by the
facility's total days during the cost reporting period. Direct care costs for
providers in each peer group are arrayed from low to high and the median (50th
percentile) cost is determined for each peer group.
b. Median Adjustment. The direct care
component shall be adjusted to 105 percent of the direct care per diem median
cost in order to achieve reasonable access to care.
c. Inflationary Factor. These costs shall be
trended forward from the midpoint of the cost report period to the midpoint of
the rate year using the index factor.
d. Acuity Factor. Each of the ICAP levels
will have a corresponding acuity factor. The median cost by peer group, after
adjustments, shall be further adjusted by the acuity factor (or multiplier) as
follows.
|
ICAP
Support Level
|
Acuity Factor
(Multiplier)
|
|
Pervasive
|
1.35
|
|
Extensive
|
1.17
|
|
Limited
|
1.00
|
|
Intermittent
|
.90
|
e. Direct Service Provider Wage Enhancement.
For dates of service on or after February 9, 2007, the direct care
reimbursement in the amount of $2 per hour to ICF/IDD providers shall include a
direct care service worker wage enhancement incentive. It is the intent that
this wage enhancement be paid to the direct care staff. Non-compliance with the
wage enhancement shall be subject to recoupment.
i. At least 75 percent of the wage
enhancement shall be paid to the direct support professional and 25 percent
shall be used to pay employer-related taxes, insurance and employee
benefits.
ii. The wage enhancement
will be added on to the current ICAP rate methodology as follows:
(a). Per diem rates for recipients residing
in 1-8 bed facilities will increase $16.00;
(b). Per diem rates for recipients residing
in 9-16 bed facilities will increase $14.93; and
(c). Per diem rates for recipients residing
in 16+ bed facilities will increase $8.
2. The care related per
diem rate shall be a statewide price at a set percentage over the median and
shall be determined as follows.
a. Median
Cost. The care related per diem median cost for each ICF/IID is determined by
dividing the facility's total care related costs reported on the cost report by
the facility's actual total resident days during the cost reporting period.
Care related costs for all providers are arrayed from low to high and the
median (50th percentile) cost is determined.
b. Median Adjustment. The care related
component shall be adjusted to 105 percent of the care related per diem median
cost in order to achieve reasonable access to care.
c. Inflationary Factor. These costs shall be
trended forward from the midpoint of the cost report period to the midpoint of
the rate year using the index factor.
3. The administrative and operating per diem
rate shall be a statewide price at a set percentage over the median, tier based
on peer group. The administrative and operating component shall be determined
as follows.
a. Median Cost. The administrative
and operating per diem median cost for each ICF/IID is determined by dividing
the facility's total administrative and operating costs reported on the cost
report by the facility's actual total resident days during the cost reporting
period. Administrative and operating costs for all providers are arrayed from
low to high and the median (50th percentile) cost is determined.
b. Median Adjustment. The administrative and
operating component shall be adjusted to 103 percent of the administrative and
operating per diem median cost in order to achieve reasonable access to
care.
c. Inflationary Factor. These
costs shall be trended forward from the midpoint of the cost report period to
the midpoint of the rate year using the index factor.
4. The capital per diem rate shall be a
statewide price at a set percentage over the median, tier based on peer group.
The capital per diem rate shall be determined as follows.
a. Median Cost. The capital per diem median
cost for each ICF/IID is determined by dividing the facility's total capital
costs reported on the cost report by the facility's actual total resident days
during the cost reporting period. Capital costs for providers of each peer
group are arrayed from low to high and the median (50th percentile) cost is
determined for each peer group.
b.
Median Adjustment. The capital cost component shall be adjusted to 103 percent
of the capital per diem median cost in order to achieve reasonable access to
care.
c. Inflationary Factor.
Capital costs shall not be trended forward.
d. The provider fee shall be calculated by
the department in accordance with state and federal rules.
i. Effective for dates of service on or after
April 1, 2014, the add-on amount to each ICF/IDs per diem rate for the provider
fee shall be increased to $16.15 per day.
5. The dental add-on per diem rate shall be a
statewide price, and the pass-through, once calculated, will be facility
specific. This pass-through/add-on may be adjusted annually and will not follow
the rebasing and inflationary adjustment schedule. The dental
pass-through/add-on per diem rate shall be determined as follows:
a. Prior to inclusion of these costs on
facility cost reports, a per diem add on will be created based on estimates
provided by the state's actuary and should reflect the costs associated with
those basic dental services that are excluded from the dental PMPMs paid to the
Louisiana Medicaid dental managed care entity(ies).
b. The above dental add-on per-diem, but not
the pass-through rate, paid to each facility will be subject to a wholly
separate and distinct floor calculation for each cost report year that the
per-diem is in effect, beginning July 1, 2023. The total sum of the per-diem
add-on paid to each facility will be compared to each facilities costs
associated with basic dental services that are excluded from the dental PMPMs
paid to the Louisiana Medicaid dental managed care entity(ies). Should 95
percent of the total per-diem add-on paid exceed the facilities noted cost, the
facility shall remit to the bureau the difference between these two
amounts.
c. Once these dental
expenses have been recognized in a facility cost report with a year ended on or
after June 30, 2024 that is utilized in a rate rebase period, the add-on will
no longer be paid to that facility and a facility specific pass-through
per-diem rate will be calculated as the total dental cost reported on the cost
report divided by total cost report patient days. These per-diem rates and
costs will follow the same oversight procedures as noted at
Section
32909 The facility specific
pass-through per-diem may be reviewed and adjusted annually, at the discretion
of the department.
E. The rates for the 1-8 bed peer group shall
be set based on costs in accordance with
§32903 BD.4.d. The reimbursement rates
for peer groups of larger facilities will also be set in accordance with
§32903 BD.4.d; however, the rates,
excluding any dental pass-through/add-on will be limited as follows.
1. The 9-15 peer group reimbursement rates
will be limited to 95 percent of the 1-8 bed peer group reimbursement
rates.
2. The 16-32 bed peer group
reimbursement rates will be limited to 95 percent of the 9-15 bed peer group
reimbursement rates.
3. The 33 and
greater bed peer group reimbursement rates will be set in accordance with
§32903 BD.4.d, limited to 95 percent of
the 16-32 bed peer group reimbursement rates.
F. Rebasing of rates will occur at least
every three years utilizing the most recent audited and/or desk reviewed cost
reports.
G. Adjustments to the
Medicaid daily rate may be made when changes occur that eventually will be
recognized in updated cost report data (such as a change in the minimum wage or
FICA rates). These adjustments would be effective until such time as the data
base used to calculate rates fully reflect the change. Adjustments to rates may
also be made when legislative appropriations would increase or decrease the
rates calculated in accordance with this rule. The secretary of the Department
of Health and Hospitals makes the final determination as to the amount and when
adjustments to rates are warranted.
H. A facility requesting a pervasive plus
rate supplement shall bear the burden of proof in establishing the facts and
circumstances necessary to support the supplement in a format and with
supporting documentation specified by the LDH ICAP Review Committee.
1. The LDH ICAP Review Committee shall make a
determination of the most appropriate staff required to provide requested
supplemental services.
2. The
amount of the Pervasive Plus supplement shall be calculated using the Louisiana
Civil Service pay grid for the appropriate position as determined by the LDH
ICAP Review Committee and shall be the 25th percentile salary level plus 20
percent for related benefits times the number of hours
approved.
I. Other Client
Specific Adjustments to the Rate. A facility may request a client specific rate
supplement for reimbursement of the costs for enteral nutrition, ostomy or
tracheotomy medical supplies or a vagus nerve stimulator.
1. The provider must submit sufficient
medical supportive documentation to the LDH ICAP Review Committee to establish
medical need for enteral nutrition, ostomy or tracheotomy medical supplies.
a. The amount of reimbursement determined by
the ICAP Review Committee shall be based on the average daily cost for the
provision of the medical supplies.
b. The provider must submit annual
documentation to support the need for the adjustment to the
rate.
2. Prior
authorization for implementation for the Vagus nerve stimulator shall be
requested after the evaluation has been completed but prior to stimulator
implantation. The request to initiate implantation shall come from the
multi-disciplinary team as a packet with the team's written decision regarding
the recipient's candidacy for the implant and the results of all pre-operative
testing. The PA-01 form for the device and surgeon shall be included in the
packet forwarded to Unisys.
a. The amount of
reimbursement shall be the established fee on the Medicaid Fee Schedule for
medical equipment and supplies.
J. Effective for dates of service on or after
September 1, 2009, the reimbursement rate for non-state intermediate care
facilities for persons with developmental disabilities shall be increased by
1.59 percent of the per diem rate on file as of August 31, 2009.
K. Effective for dates of service on or after
August 1, 2010, the per diem rates for non-state intermediate care facilities
for persons with developmental disabilities (ICFs/IID) shall be reduced by 2
percent of the per diem rates on file as of July 31, 2010.
1. Effective for dates of service on or after
December 20, 2010, non-state ICFs/IID which have downsized from over 100 beds
to less than 35 beds prior to December 31, 2010 shall be excluded from the
August 1, 2010 rate reduction.
L. Effective for dates of service on or after
August 1, 2010, the per diem rates for ICFs/IID which have downsized from over
100 beds to less than 35 beds prior to December 31, 2010 shall be restored to
the rates in effect on January 1, 2009.
M. Effective for dates of service on or after
July 1, 2012, the per diem rates for non-state intermediate care facilities for
persons with developmental disabilities (ICFs/IID) shall be reduced by 1.5
percent of the per diem rates on file as of June 30, 2012.
N. Pursuant to the provisions of Act 1 of the
2020 First Extraordinary Session of the Louisiana Legislature, effective for
dates of service on or after July 1, 2020, private ICF/IID facilities that
downsized from over 100 beds to less than 35 beds prior to December 31, 2010
without the benefit of a cooperative endeavor agreement (CEA) or transitional
rate and who incurred excessive capital costs, shall have their per diem rates
(excluding provider fees) increased by a percent equal to the percent
difference of per diem rates (excluding provider fees and dental pass through)
they were paid as of June 30, 2019. See chart below with the applicable
percentages:
|
Intermittent
|
Limited
|
Extensive
|
Pervasive
|
|
1-8 beds
|
6.2 percent
|
6.2 percent
|
6.2 percent
|
6.1 percent
|
|
9-15 beds
|
3.2 percent
|
6.2 percent
|
6.2 percent
|
6.1 percent
|
|
16-32 beds
|
N/A
|
N/A
|
N/A
|
|
|
33+ beds
|
N/A
|
N/A
|
N/A
|
|
1. The
applicable differential shall be applied anytime there is a change to the per
diem rates (for example, during rebase, rate reductions, inflationary changes,
or special legislative appropriations). This differential shall not extend
beyond December 31, 2024.
AUTHORITY
NOTE: Promulgated in accordance with
R.S.
36:254 and Title XIX of the Social Security
Act.
