Current through Register Vol. 51, No. 19, September 20, 2024
A. For dates of service from January 1, 2015
through December 31, 2016, a 2012 final per diem rate shall be determined based
on the following from each nursing facility's cost report ending in 2012 and
shall be adjusted by the nursing facility budget changes implemented from the
settled 2012 rate through and including December 31, 2016:
(1) The Administrative and Routine final per
diem rate identified under Regulation .08B of this chapter;
(2) The Other Patient Care final per diem
rate identified under Regulation .09B of this chapter;
(3) The kosher kitchen add-ons identified
under Regulations .08H and .09H of this chapter;
(4) The total amount of therapy payments
identified under Regulation .09-1 of this chapter divided by the total Medicaid
days excluding hospital bed hold days for the cost reporting period;
(5) The Capital component calculated as:
(a) Capital payments identified under
Regulation .10 of this chapter, less the Nursing Facility Quality Assessment
expense; and
(b) Divided by the
total Medicaid days excluding hospital bed hold days; and
(6) The Nursing payments identified under
Regulation .11C of this chapter divided by the total Medicaid days less
Hospital Bed Hold Days and Therapeutic Leave Days.
B. Per diem rates paid for services beginning
January 1, 2015, shall be calculated as follows:
(1) Rates paid for services January 1, 2015,
through December 31, 2015, shall be calculated as the sum of:
(a) 75 percent of the 2012 final per diem
rate in accordance with §A of this regulation;
(b) 25 percent of the prospective rate;
and
(c) The Nursing Facility
Quality Assessment add-on identified in Regulation .10-1E of this
chapter;
(2) Rates paid
for services January 1, 2016, through June 30, 2016, shall be calculated as the
sum of:
(a) 50 percent of the 2012 final per
diem rate in accordance with §A of this regulation;
(b) 50 percent of the prospective rate;
and
(c) The Nursing Facility
Quality Assessment add-on identified in Regulation .10-1E of this
chapter;
(3) Rates paid
for services July 1, 2016, through December 31, 2016, shall be calculated as
the sum of:
(a) 25 percent of the 2012 final
per diem rate in accordance with §A of this regulation;
(b) 75 percent of the prospective rate;
and
(c) The Nursing Facility
Quality Assessment add-on identified in Regulation .10-1E of this chapter;
and
(4) Rates paid for
services after December 31, 2016, shall be calculated as 100 percent of the
prospective rate plus the Nursing Facility Quality Assessment add-on identified
in Regulation .10-1E of this chapter.
C. Hold Harmless.
(1) For each provider, the Department shall
determine the difference between the rate calculated in §A of this
regulation excluding any budget changes implemented after June 30, 2014 and the
rate calculated under §B(1)(a) and (b) of this regulation.
(2) If a provider's rate determined under
§B(1)(a) and (b) of this regulation is less than the rate under §A of
this regulation excluding any budget changes implemented after June 30, 2014,
the provider shall be paid the rate determined under §B(1) of this
regulation plus 100 percent of the amount calculated in §C(1) of this
regulation.
(3) During
implementation of §B(2) of this regulation, providers identified in
§C(2) of this regulation shall be paid the rate determined under
§B(2) of this regulation plus 50 percent of the amount calculated in
§C(1) of this regulation.
D. Hold Harmless Offset.
(1) The Department shall determine the total
aggregate amount under §C(1) of this regulation for all facilities for
which the rate determined under §B(1)(a) and (b) of this regulation is
less than the rate under §A of this regulation excluding any budget
changes implemented after June 30, 2014.
(2) The Department shall determine the total
aggregate amount under §C(1) of this regulation for all facilities for
which the rate determined under §B(1)(a) and (b) of this regulation is
greater than the rate under §A of this regulation excluding any budget
changes implemented after June 30, 2014.
(3) The Department shall determine the
percentage of the amount in §D(2) of this regulation that is equal to the
amount calculated under §D(1) of this regulation.
(4) The Department shall identify all
facilities that have a rate determined under §B(1)(a) and (b) of this
regulation that is greater than the rate identified under §A of this
regulation excluding any budget changes implemented after June 30,
2014.
(5) For each facility
identified in §D(4) of this regulation, the Department shall multiply the
amount by which §B(1)(a) and (b) of this regulation is greater than the
rate identified under §A of this regulation, excluding any budget changes
implemented after June 30, 2014, by the percentage determined in §D(3) of
this regulation.
(6) During
implementation of §B(1) of this regulation, providers identified in
§D(4) of this regulation shall be paid the amount determined under
§B(1) of this regulation, minus 100 percent of the amount determined under
§D(5) of this regulation.
(7)
During implementation of §B(2) of this regulation, providers identified in
§D(4) of this regulation shall be paid the amount determined under
§B(2) of this regulation, minus 50 percent of the amount determined under
§D(5) of this regulation.
E. When necessary, each facility's per diem
rate paid for services January 1, 2015 and after shall be reduced by the same
percentage to maintain compliance with the Medicare upper payment limit
requirement.
F. Power wheelchairs
and bariatric beds are not included in either the 2012 final per diem rate or
the prospective rate, but may be preauthorized for payment in accordance with
COMAR 10.09.12.
G. Support
Surfaces.
(1) Support surfaces are not
included in either the 2012 final per diem rate or the prospective
rate.
(2) A provider shall be paid
a per diem rate for providing appropriate specialized support surfaces to
patients with pressure ulcers or in recovery from myocutaneous flap or graft
surgery for a pressure ulcer.
(3) A
Class A support surface is a mattress replacement which has been approved as a
Group 2 Pressure Reducing Support Surface by the Medical Policy of the Medicare
Durable Medical Equipment Regional Carrier. A Class A support surface shall be
reimbursed per day at the Medicare Durable Medical Equipment Regional Carrier
Maryland monthly fee cap, in effect at the beginning of the State fiscal year,
for HCPCS Code E0277 multiplied by 12 and then divided by the number of days in
the State fiscal year.
(4) A Class
B support surface is an air fluidized bed which has been approved as a Group 3
Pressure Reducing Support Surface by the Medical Policy of the Medicare Durable
Medical Equipment Regional Carrier. A Class B support surface shall be
reimbursed per day at the Medicare Durable Medical Equipment Regional Carrier
Maryland monthly fee cap, in effect at the beginning of the State fiscal year,
for HCPCS Code E0194 multiplied by 12 and then divided by the number of days in
the State fiscal year.
H. Negative pressure wound therapy is not
included in either the 2012 final per diem rate or the prospective rate, but is
reimbursed in accordance with rates established under COMAR 10.09.12.
Reimbursement shall include the cost of pumps, dressings, and containers
associated with this procedure.
I.
Nursing facilities that are owned and operated by the State are not paid in
accordance with the provisions of §§A-C of this regulation, but are
reimbursed reasonable costs based upon Medicare principles of reasonable costs
as described at 42 CFR Part 413 . Aggregate payments for these facilities may
not exceed Medicare upper payment limits as specified at
42 CFR § 447.272. If the Medicare upper payment limit
is above aggregate costs for this ownership class, the State may elect to make
supplemental payments to increase payments up to the Medicare upper payment
limit.
J. Final facility rates for
the period July 1, 2015 through December 31, 2015 shall be each nursing
facility's quarterly rate reduced by the budget adjustment factor of 1.96
percent plus the Nursing Facility Quality Assessment add-on identified in
Regulation .10-1E of this chapter.
K. Final facility rates for the period
January 1, 2016 through June 30, 2016 shall be each nursing facility's
quarterly rate reduced by the budget adjustment factor of 3.28 percent plus the
Nursing Facility Quality Assessment add-on identified in Regulation .10-1E of
this chapter.
L. Final facility
rates for the period July 1, 2016 through December 31, 2016 shall be each
nursing facility's quarterly rate, exclusive of the amount identified in
Regulation .11-8A (2) of this chapter, reduced by the budget adjustment factor
of 6.076 percent, plus the Nursing Facility Quality Assessment add-on
identified in Regulation .10-1E of this chapter and the ventilator care add-on
amount identified in Regulation .11-8A (2) of this chapter when
applicable.
M. Final facility rates
for the period January 1, 2017 through June 30, 2017 shall be each nursing
facility's quarterly rate, exclusive of the amount identified in Regulation
.11-8A (2) of this chapter, reduced by the budget adjustment factor of 8.212
percent, plus the Nursing Facility Quality Assessment add-on identified in
Regulation .10-1E of this chapter and the ventilator care add-on amount
identified in Regulation .11-8A (2) of this chapter when applicable.
N. Final facility rates for the period July
1, 2017, through June 30, 2018, shall be each nursing facility's quarterly
rate, exclusive of the amount identified in Regulation .11-8A (2) of this
chapter, reduced by the budget adjustment factor of 9.652 percent, plus the
Nursing Facility Quality Assessment add-on identified in Regulation JO-IE of
this chapter and the ventilator care add-on amount identified in Regulation
.11-8A (2) of this chapter when applicable.
