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 10.09.10.11-7 - Rate Calculation - Nursing Service Costs for Rates Effective January 1, 2015
Universal Citation: MD Code Reg 10.09.10.11-7
Current through Register Vol. 51, No. 19, September 20, 2024
A. The Nursing Service cost center includes all nursing expenses related to the direct provision of patient care.
B. The Department shall initially establish Nursing Service prices for the rate period January 1, 2015, through June 30, 2015, and thereafter rebase the Nursing Service prices between every 2 and 4 rate years. Prices may be rebased more frequently if the Department determines that there is an error in the data or in the calculation that results in a substantial difference in payment, or if a significant change in provider behavior or costs has resulted in payment that is inequitable across providers. The Department shall rebase based on the following steps:
(1) The indexed costs shall
be calculated as set forth in Regulation .08-1B(1)-(3) of this
chapter;
(2) Each cost report's
indexed Nursing Service costs shall be divided by the actual days of nursing
care to arrive at the indexed Nursing Service cost per diem;
(3) The indexed Nursing Service cost per diem
shall be normalized to the Statewide average case mix index by multiplying the
indexed Nursing Service cost per diem by the facility's normalization ratio
calculated as the Statewide average case mix index divided by the cost report
period case mix index rounded to four decimals which creates the Normalized
Nursing Cost per diem;
(4) For each
reimbursement class, each cost report's Medicaid resident days shall be used in
the array of cost per diems identified in §B(3) of this regulation to
calculate the Medicaid day weighted median using the method established in
Regulation .08-1B(5) of this chapter;
(5) The final price for Nursing Service costs
for each reimbursement class is calculated as the geographic regional Medicaid
day weighted median Nursing Service cost multiplied by 1.0825; and
(6) For years between periods when the prices
are rebased, the final price for Nursing Service costs shall be adjusted as set
forth in Regulation .08-1D of this chapter.
C. The final Nursing Service rate for each nursing facility for each quarter is calculated as follows:
(1) Determine the Nursing Service price for
the facility's geographic region;
(2) Calculate an initial nursing facility
rate by multiplying the price by the facility average Medicaid case mix index
divided by the Statewide average case mix index;
(3) Calculate a Medicaid adjusted Nursing
Service cost per diem by multiplying the per diem identified under §B(2)
or §C(5) of this regulation by the Medicaid case mix adjustment ratio
calculated as the facility average Medicaid case mix index divided by the cost
report period case mix index rounded to four decimals;
(4) Calculate the final Nursing Service rate
as the initial nursing facility rate reduced by any positive difference between
95 percent of the initial nursing facility rate and the Medicaid adjusted
Nursing Service cost per diem; and
(5) For years between periods when the prices
are rebased, the indexed Nursing Service cost per diem identified under
§B(2) of this regulation shall be adjusted as set forth in Regulation
.08-1D of this chapter.
D. The reimbursement classes for the Nursing Service cost center are specified under Regulation .24C of this chapter.
E. Resident Rosters.
(1) A nursing facility shall electronically
transmit MDS assessment information in a complete, accurate, and timely
manner.
(2) The Department shall
provide a preliminary resident roster to a nursing facility based on the
facility's transmitted MDS assessment information for a calendar quarter on the
fifth day of the second month following the end of the calendar quarter,
provided that the nursing facility has transmitted the MDS assessment
information by the 15th day following the end of the calendar
quarter.
(3) The distribution of
the preliminary resident roster shall serve as notice of the MDS assessments
transmitted and provide an opportunity for the nursing facility to correct and
transmit any missing MDS record.
(4) The Department shall provide a final
resident roster to a nursing facility based on the facility's transmitted MDS
assessment information for a calendar quarter, provided that the nursing
facility has transmitted the MDS assessment information by the 25th day of the
second calendar month following the end of the calendar quarter.
(5) The Department may not consider MDS
assessment information for the purpose of reimbursement rate calculations for a
calendar quarter that is not submitted by the 25th day of the second calendar
month following the end of the calendar quarter, except as provided in
§E(6) of this regulation.
(6)
The Department may only grant an exception to compliance with the electronic
MDS assessment transmission due dates if the delay has been caused by fire,
flood, act of God, or other good cause.
(7) The Department or its designated
contractor shall distribute preliminary and final resident rosters according to
the following schedule:
|
Resident Roster Quarter |
Preliminary Resident Roster Distributed |
Facility's Revised Resident Roster Transmission Due |
Final Resident Roster Distributed |
|
January 1 through March 31 |
May 5 |
May 25 |
June 15 |
|
April 1 through June 30 |
August 5 |
August 25 |
September 15 |
|
July 1 through September 30 |
November 5 |
November 25 |
December 15 |
|
October 1 through December 31 |
February 5 |
February 25 |
March 15 |
F. Case Mix Index Calculation.
(1) The Department shall use the resource
utilization group to adjust Nursing Service costs and to determine each nursing
facility's Nursing Service rate component
(2) The Department shall adjust a nursing
facility's case mix reimbursement rates quarterly based on the change in case
mix of each facility according to the following schedule:
(a) The facility average Medicaid case mix
index obtained from January 1 through March 31 shall be used to adjust rates
effective July 1 through September 30 of the same calendar year;
(b) The facility average Medicaid case mix
index obtained from April 1 through June 30 shall be used to adjust rates
effective October 1 through December 31 of the same calendar year;
(c) The facility average Medicaid case mix
index obtained from July 1 through September 30 shall be used to adjust rates
effective January 1 through March 31 of the following calendar year;
and
(d) The facility average
Medicaid case mix index obtained from October 1 through December 31 shall be
used to adjust rates effective April 1 through June 30 of the following
calendar year
(3) If the
Department or its contractor determines that a nursing facility has delinquent
MDS resident assessments, for purposes of determining both facility CMI
averages, the assessments shall be assigned the case mix index associated with
the RUG group "BC1" or its successor
(4) A delinquent MDS shall be assigned a CMI
value equal to the lowest CMI in the RUG classification system, or its
successor
(5) For each resident
roster quarter, the Department shall calculate a Statewide average case mix
index and a Statewide average Medicaid case mix index from all final resident
rosters.
(6) A Medicaid case mix
index equalizer shall be used to prevent any aggregate increase or decrease in
expected State fiscal year Medicaid program expenditures for the rate quarters
beginning every October, January and April as follows:
(a) The Statewide average Medicaid case mix
index for the July rate quarter shall be divided by the Statewide average
Medicaid case mix index for the rate quarter identified in §F(2) of this
regulation to determine the Medicaid case mix index equalizer for the
quarter;
(b) Each facility average
Medicaid case mix index for use in the rate quarter for each nursing facility
shall be multiplied by the Medicaid case mix index equalizer to result in a
facility Medicaid equalized case mix index; and
(c) The facility Medicaid equalized case mix
index shall be used in place of the facility Medicaid case mix index in the
calculation of the initial and final Nursing Service rate in §C of this
regulation for every October, January, and April rate quarter
(7) To determine cost report
period case mix index for cost reporting periods starting before the midpoint
of a calendar quarter, the associated quarterly resident roster period CMIs are
used If a cost report end date is before the midpoint of a calendar quarter,
the associated quarterly resident roster period CMIs are not used
G. Assignment of Different Geographic Region.
(1) The Department may
approve a provider's request to be included in a different Nursing Service cost
center geographic region of this chapter upon review of sufficient
documentation. Documentation shall show that the assigned geographic region is
not appropriate for the provider and that economic conditions have placed the
provider directly in competition with facilities in a geographic region other
than the one to which the provider has been assigned by the Department Payment
of higher wages, or higher total expenditures, is not in itself sufficient to
demonstrate that the provider is subject to economic conditions different from
other providers in its reimbursement class.
(2) All approved waivers for geographic
regions shall be effective for the following State fiscal year for the purpose
of establishing the final Nursing Service rate in §C of this
regulation,
(3) Nursing Service
prices established in §B of this regulation shall be based on all
facilities in a geographic region that do not have an approved waiver to be
included in a different geographic region plus facilities with an approved
waiver to receive prices in that geographic region.
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