Code of Maryland Regulations
Title 10 - MARYLAND DEPARTMENT OF HEALTH
Part 2
Subtitle 09 - MEDICAL CARE PROGRAMS
Chapter 10.09.10 - Nursing Facility Services
Section 10.09.10.01 - Definitions
Universal Citation: MD Code Reg 10.09.10.01
Current through Register Vol. 51, No. 19, September 20, 2024
A. In this chapter, the following terms have the meanings indicated.
B. Terms Defined.
(1) "Accrual basis" means recording revenue
in the period when earned, regardless of when collected, and recording expenses
in the period when incurred, regardless of when paid.
(2) "Administrative day" means a day of care
rendered to a recipient who no longer requires the level of care being
provided.
(3) "Allowable cost"
means costs that are includable in the per diem rate and that represent the
provider's actual cost as verified by the Department or the Department's
designee.
(4) "Appropriate
facility" means a facility located within a 25-mile radius of the location of
the facility currently rendering care to the recipient or a more distant
facility if acceptable to the recipient, which facility is licensed and
certified to render the recipient's required level of care.
(5) "Bad debts" means amounts considered to
be uncollectible from accounts and notes receivable that were created or
acquired in providing services. "Accounts receivable" and "notes receivable"
are designations for claims arising from rendering services which, when made or
entered, were considered collectible in money in the relatively near
future.
(6) "Case mix index (CMI)"
means a numeric score that identifies the average relative nursing resource
needs for the residents classified under the Resource Utilization Group (RUG)
based on the assessed nursing needs of the resident, whose values are set forth
as CMI Set F01, located at
https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-
Instruments/NursingHomeQualityInits/NHQMDS30TechnicalInform ation.html.
(7) "Centers for Medicare and
Medicaid Services (CMS) " means the federal agency that is located in the U.S.
Department of Health and Human Services that administers the Medicare and
Medicaid programs.
(8) "Change of
ownership" means:
(a) One of the following
occurs:
(i) The merger of the provider into
the acquiring entity and the acquiring entity's tax identification number
remains;
(ii) The assignment,
transfer, disposition, lease, or sale of all or substantially all of a
provider's assets to another entity;
(iii) The consolidation of two or more
providers, resulting in the creation of a new entity; or
(iv) The merger of the provider into another
entity, or the consolidation of two or more entities, resulting in the creation
of a new entity;
(b) A
provider's Medical Assistance participating provider number dissolves or will
no longer be utilized for purposes of billing the Program for covered services;
and
(c) A new Medical Assistance
participating provider number or tax identification number is used
instead.
(9) "Cost
center" means one of the groups into which similar categories of costs are
assigned for reimbursement rate determination: Administrative and Routine,
Other Patient Care, Nursing Service, and Capital.
(10) "Cost report period case mix index"
means the simple average of the day weighted facility case mix indices for
residents of all payer sources from the final quarterly resident rosters for a
nursing facility, carried to four decimal places, for the quarterly resident
roster periods that most closely match a cost reporting period
(11) "Credit balance" means:
(a) A third party payment, which is in
addition to the Medicaid payment;
(b) The Medicaid payment in excess of the
amount due the provider; or
(c) A
duplicate payment.
(12)
"Department" means the State Department of Health and Mental Hygiene, which is
the single State agency designated to administer the Maryland Medical
Assistance Program pursuant to Title XIX of the Social Security Act,
42 U.S.C. § 1396 et seq.
(13) "Facility" means a facility licensed
under COMAR 10.07.02 and certified as meeting the requirements of Title XIX of
the Social Security Act, 42
U.S.C. § 1396 et seq., for participation
as a nursing facility.
(14)
"Facility average Medicaid case mix index" means the day-weighted average case
mix index for all identified Medicaid days from each nursing facility's final
resident roster for each resident roster quarter calculated as the sum of the
number of days each assessment associated with a Medicaid payer source is
active times the assessment CMI divided by the sum of all Medicaid payer source
days.
(15) "Final report" means the
third party liability audit report issued to a provider stating the total
amount due to the Department as a result of the completed audit.
(16) "Fiscal year" means a 12-month reporting
period covering the same period as the facility's tax return, unless waived by
the Department according to standards found in Medicare Provider Reimbursement
Manual, HCFA Publication 15-1.
(17)
"Indemnity bond" means a bond posted by the provider to ensure that the
provider is able to fulfill any financial obligations to the Department upon
sale of the facility.
(18) "Interim
Working Capital Fund" means funding made available to providers on a temporary
basis that shall be repaid to the Department.
(19) "Market basket index" means inflation
indices from the latest Skilled Nursing Home without Capital Market Basket
Index, published 2 months before the period in which rates are being calculated
and which is available from CMS at www.cms.gov, or a comparable index available
from, and used by, CMS, if this index ceases to be published by Global Insight,
Inc. or its successor
(20)
"Maryland Health Care Commission" means the agency established by
Health-General Article, Title 19, Subtitle 1, Annotated Code of
Maryland.
(21) "Medicaid" means
Medical Assistance provided under the State Plan approved under Title XIX of
the Social Security Act.
(22)
"Medical Assistance Program" means a program of comprehensive medical and other
health-related care for indigent and medically indigent persons.
(23) "Medicare upper payment limit" means
that aggregate payments to nursing facilities may not exceed the limits
established for such payment in
42 CFR § 447.272.
(24) "Minimum Data Set (MDS) " means the MDS
required by 42 CFR § 483.20 and set forth in the Resident
Assessment Instrument published by CMS, and available at
www.cms.gov, incorporated herein by
reference, as amended and supplemented, a core set of screening, clinical, and
functional status elements, including common definitions and coding categories
that forms the foundation of the assessment required for all residents in
Medicare-certified or Medicaid-certified nursing facilities.
(25) "New facility" means:
(a) A facility that has not been a provider
during the previous 12-month period or, for rates effective January 1, 2015 and
after, does not have a cost report in the price database as set forth in
Regulation .09B(1) of this chapter; and
(b)A facility not defined as a replacement
facility.
(26)
"Noncompliant" means:
(a) A provider fails to
submit to the Department the required quarterly report of credit
balances;
(b) A provider fails to
submit a quarterly report which provides sufficient data relating to the credit
balances it maintained during that quarter; or
(c) A random audit by the Department reveals
errors or omissions in a provider's credit balance report.
(27) Nursing Facility (NF).
(a) "Nursing facility" means an institution
which is primarily engaged in providing to residents:
(i) Skilled nursing care and related services
for residents who require medical or nursing care;
(ii) Rehabilitation services for the
rehabilitation of injured, disabled, or sick persons; or
(iii) On a regular basis, health-related care
and services to individuals who, because of their mental or physical condition,
require care and services (above the level of room and board) which can be made
available to them only through institutional facilities.
(b) "Nursing facility" means an institution
which is licensed by the Department under COMAR 10.07.02.
(c) "Nursing facility" does not include an
institution which is primarily for the care and treatment of mental diseases,
an intellectually disability or a developmental disability.
(28) "Nursing facility services"
means services provided to individuals who do not require hospital care, but
who, because of their mental or physical condition, require skilled nursing
care and related services, rehabilitation services, or, on a regular basis,
health-related care and services (above the level of room and board) which can
be made available to them only through institutional facilities.
(29) "Owner" means a party or entity having
any ownership interest in the facility.
(30) "Patient day" means care of one patient
for 1 day of service. The day of admission is counted as 1 day of care, but the
day of discharge is not counted. If a patient is discharged on his day of
admission, 1 patient day will be counted.
(31) "Payroll-Based Journal" means a system
for facilities to submit staffing information to meet the requirements of
§ 6106 of the Affordable Care Act (ACA) that requires facilities to
electronically submit direct care staffing information (including agency and
contract staff) based on payroll and other auditable data.
(32) "Predischarge plan" means:
(a) A written document describing who has
operational responsibility for discharge planning;
(b) The manner in and methods by which that
person will function;
(c) The time
period in which each recipient's need for discharge planning will be
determined;
(d) The maximum time
period after which a reevaluation of each recipient's discharge plan will be
made;
(e) The local resources
available to the provider, the individual, and the attending physician to
assist in developing and implementing individual discharge plans; and
(f) Provisions for periodic review and
reevaluation of the provider's discharge planning program.
(33) "Program" means the Medical Assistance
Program.
(34) "Prospective rate"
means a facility-specific quarterly per diem rate based on the RUG
classification system, and calculated as the sum of:
(a) Administrative and Routine rate as
calculated in accordance with Regulation .09 of this chapter;
(b) Other Patient Care Rate as calculated in
accordance with Regulation .10 of this chapter;
(c) Capital Rate as calculated in accordance
with Regulation .11 of this chapter; and
(d) Nursing Rate as calculated in accordance
with Regulation .12 of this chapter.
(35) "Provider" means a facility which has in
effect a provider agreement with the Department.
(36) "Provider agreement" means the contract
between the Department and the provider covering the obligations of the parties
under the Medical Assistance Program.
(37) "Purchaser" means an entity that
participates in a change of ownership with a provider by:
(a) Having a provider merge into the
entity;
(b) Accepting the
assignment, transfer, disposition, or sale of all or substantially all of a
provider's assets; or
(c) Being a
new entity that results from the consolidation of the provider with a third
party.
(38) "Quality
measure" means a specific performance criterion, as described in Regulation .15
of this chapter, used to assess a facility's performance level.
(39) "Random sample" means the selection for
audit by the Department of representative share of the providers complying with
the requirement of submitting a quarterly report of credit balances to the
Department.
(40) "Recipient" means
a person who is certified as eligible for, and is receiving, Medical Assistance
benefits.
(41) "Recreational
services" means those organized activities provided for the enjoyment of the
patients that are designed to promote their physical, social, and mental
well-being.
(42) "Reimbursement
class" means the group of providers for which a separate per diem rate will be
prepared in the Administrative and Routine, Other Patient Care, and Nursing
Service cost centers based on geographic region as set forth in Regulation .30
of this chapter.
(43) "Relative of
the owner" means the owner's husband, wife, natural parent, natural child,
sibling, adopted child, adoptive parent, stepparent, stepchild, stepbrother,
stepsister, father-in-law, mother-in-law, son-in-law, daughter-in-law,
brother-in-law, sister-in-law, grandparent, or grandchild.
(44) "Replacement facility" means:
(a) A newly constructed nursing facility that
replaces an existing licensed and certified facility; or
(b)A facility that was closed for significant
renovation that reopens and is approved by the Department as a replacement
facility.
(45) "Resident
roster" means a list of all residents in a nursing facility for a calendar
quarter based on MDS assessments and tracking forms, accurately and
successfully transmitted by the nursing facility into the CMS-approved
submission system, used for the calculated day-weighted case mix indices for
Medicaid, Medicare, and other payment sources.
(46) "Resource" means that portion of a
recipient's income available toward the cost of medical and remedial care as
determined by the Department or its designee.
(47) "Resource Utilization Group (RUG) "
means the version IV (RUG-IV), 48-Group classification system, that has been
developed by CMS and set forth at
https://www.cms.gov/Medicare/Quality-Initiatives-Patient-
[File Link Not
Available]Assessment-Instruments/NursingHomeQualityInits/NHQIMDS30TechnicalInform
ation.html for grouping nursing facility residents according to the
residents' functional status and anticipated uses of services and resources as
identified from data supplied by the MDS.
(48) "Secretary" means the Secretary of
Health and Mental Hygiene.
(49)
"Special focus facility" means a facility identified by the Centers for
Medicare and Medicaid Services as having:
(a)
More problems than other nursing homes;
(b) More serious problems than other nursing
homes; and
(c) A pattern of serious
problems that has persisted over a long period of time.
(50) "Specialized rehabilitative therapy
services" means those services furnished by a provider as an integral part of a
patient's care plan ordered by a physician and provided in conjunction with
continuous nursing care for the purpose of the restoration of normal form and
function after injury or illness. The services shall be performed by a licensed
physical therapist, licensed physical therapy assistant, or registered
occupational therapist.
(51)
"Standby letter of credit" means a written instrument prepared by a provider's
bank authorizing the Department to draw on the bank, upon sale of the
facility.
(52) "Statewide average
case mix index" means the simple average of all of the cost report period case
mix indices for the rate year
(53)
"Statewide average Medicaid case mix index" means the Medicaid day weighted
average of all nursing facilities' case mix indices for the Medicaid days
identified on the final resident rosters for each resident roster
quarter
(54) "Substandard quality
of care" means that one or more requirements under 42 CFR § 483.13,
42 CFR § 483.15, or
42 CFR
483.25 were not met, to a degree constituting
immediate jeopardy to resident health or safety, and a pattern of actual harm,
widespread actual harm, or a widespread potential for more than minimal
harm.
(55) "Substandard quality of
care" means a finding of substandard care in accordance with
42 CFR § 488.301.
(56) "Third party liability audit" means a
financial review of Medical Assistance payments to a provider to ascertain the
legal liability of third parties to pay for care and services available under
the Medical Assistance Program.
(57) "Third party liability review" means a
financial review of the credit balances of a nursing facility to ascertain the
legal liability of third parties to pay for care and services available under
the Medical Assistance Program.
(58) "Uniform cost report" means the cost
report format which each facility is required to use in the submission of its
fiscal year cost and utilization data, including supplemental schedules and
other balance sheet and administrative data.
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