Current through Register 1531, September 27, 2024
(1)
Certification of Public
Expenditures of a Nursing Facility Owned and Operated by a
Municipality.
(a) Within 60 days
after the filing of its Medicare CMS-2540 cost report, a nursing facility,
which is owned and operated by a municipality, may submit a request for
Certified Public Expenditures (CPE) to EOHHS. This CPE will account for its
public expenditures of providing Medicaid services to eligible Medicaid
recipients. The submission will be based on the inpatient routine service cost
reported on the CMS-2540 Medicare cost report.
(b) Following review of the nursing
facility's submission, EOHHS will, within 60 days of the submission, approve,
deny, or revise the amount of the CPE request based upon its evaluation of the
reported costs and payments. The final approved amount will be equal to the
difference between the Medicaid interim payments and the total allowable
Medicaid costs as determined by EOHHS. This final determined amount will be
certified by the municipality as eligible for federal match.
(c) Interim payments are based on the
standard payment methodology pursuant to
101 CMR
206.00.
(d) EOHHS will determine total allowable
Medicaid costs based on the Medicare CMS-2540 Cost Report and will determine a
per diem rate calculated as follows.
1.
Medicaid Allowable Skilled
Nursing Facility Costs. Total allowable costs (Worksheet B, Part
I, Line 30, Col 18), divided by total days (Worksheet S-3, Line 1, Col 7),
times Medicaid days (worksheet S-3, Line 1, Col 5).
2.
Medicaid Allowable Nursing
Facility Costs. Total allowable costs (Worksheet B, Part I, Line
31, Col 18), divided by total days (Worksheet S-3, Line 3, Col 7), times
Medicaid days (Worksheet S-3, Line 3, Col 5).
3.
Total Allowable Medicaid
Costs. The sum of the amount determined in
101
CMR 206.06(1)(d)1. and
2.
(e) EOHHS will
calculate an interim reconciliation based on the difference between the interim
payments and total allowable Medicaid costs from the as-filed CMS-2540 Cost
Report. The nursing facility must notify EOHHS immediately if the CMS-2540 is
reopened or an audit is completed. Within 60 days after receiving notification
of the final Medicare settlement EOHHS will retroactively adjust the final
settlement amount.
(2)
Quality Adjustments. Effective October 1, 2023, a
nursing facility may be eligible for a quality adjustment in the form of an
increase or decrease applied to the facility's nursing standard rate and
operating standard rate at each PDPM nursing case mix category. The quality
adjustment will be equal to the sum of the percent increase or decrease
assessed for performance on each of the following four quality measures:
Quality Achievement Based on CMS Score, Quality Improvement Based on CMS Score,
Quality Achievement Based on DPH Score, and Quality Improvement based on DPH
Score.
(a)
Quality Achievement
Based on CMS Score. The quality adjustment a nursing facility will
incur under the measure "Quality Achievement Based on CMS Score" will be based
on the facility's overall rating on the Centers for Medicare and Medicaid
Services Nursing Home Compare 5-Star Quality Rating Tool as of June 2023, as
described in the table below. Facilities that CMS has designated as not rated
due to a history of serious quality issues (
i.e., Special
Focus Facilities) will be considered to have a score of 1 for the purposes of
this quality adjustment.
|
CMS Overall Score as of June
2023 |
Adjustment
Percentage |
|
1 |
-1.00% |
|
2 |
-0.75% |
|
3 |
0.00% |
|
4 |
0.75% |
|
5 |
1.00% |
(b)
Quality Improvement Based on CMS Score. The quality
adjustment a nursing facility will incur under the measure "Quality Improvement
Based on CMS Score" will be based on the facility's overall rating on the
Centers for Medicare and Medicaid Services Nursing Home Compare 5-Star Quality
Rating Tool, as follows. If a facility has a score of 5 Stars as of June 2023,
its adjustment for this measure will be 2.0%, regardless of whether it meets
any other criteria in the following table. If a facility meets the criteria for
"CMS Chronic Low Quality," its adjustment for this measure will be -3.0%,
regardless of whether it meets any other criteria in the following table.
Facilities that CMS has designated as not rated due to a history of serious
quality issues (
i.e., Special Focus Facilities) will be
considered to meet the criteria for "CMS Chronic Low Quality" for the purposes
of this quality adjustment.
|
Criteria Based on CMS
Rating |
Adjustment
Percentage |
|
Facility has a score of five Stars as of June
2023 |
2% |
|
Facility experienced an increase of two or more Stars
from June 2022, to June 2023 |
1.5% |
|
Facility experienced an increase of one Star from
June 2022, to June 2023 |
1% |
|
Facility experienced no change to its Star rating
from June 2022, to June 2023 |
0% |
|
Facility experienced a decrease of one Star from June
2022, to June 2023, and had a score of five Stars as of June
2022 |
0% |
|
Facility experienced a decrease of one Star from June
2022, to June 2023, and did not have a score of five Stars as of June
2022 |
-2% |
|
Facility experienced a decrease of two or more Stars
from June 2022, to June 2023 |
-2.5% |
|
CMS Chronic Low Quality: The average of a facility's
scores as of June 2020, June 2021, June 2022, and June 2023 is less than or
equal to 1.5 Stars |
-3% |
(c)
Quality Achievement Based on DPH Score. The quality
adjustment a nursing facility will incur under the measure "Quality Achievement
Based on DPH Score" will be based on the facility's performance on the
Department of Public Health's Nursing Facility Survey Performance Tool (DPH
NFSPT) as of July 1, 2023, as follows:
|
DPH NFSPT Score as of July 1,
2023 |
Adjustment
Percentage |
|
110 or less |
-1.00% |
|
111 - 115 |
-0.75% |
|
116 - 119 |
0.00% |
|
120 - 123 |
0.75% |
|
124+ |
1.00% |
(d)
Quality Improvement Based on DPH Score. The quality
adjustment a nursing facility will incur under the measure "Quality Improvement
Based on DPH Score" will be based on the facility's performance on the DPH
NFSPT, as follows. If a facility has a DPH NFSPT score of 124 or higher as of
July 1, 2023, its adjustment for this measure will be 2.0%, regardless of
whether it meets any other criteria in the following table. If a facility meets
the criteria for "DPH Chronic Low Quality," its adjustment for this measure
will be -3.0%, regardless of whether it meets any other criteria in the
following table.
|
Criteria based on DPH FSPT
Score |
Adjustment
Percentage |
|
Facility has a score of 124 or higher as of July 1,
2023 |
2.0% |
|
Facility experienced an increase of four or more
points from July 1, 2022, to July 1, 2023 |
1.5% |
|
Facility experienced an increase of one, two, or
three points from July 1, 2022, to July 1, 2023 |
1.0% |
|
Facility experienced no change to its score from July
1, 2022, to July 1, 2023 |
0.0% |
|
Facility experienced a decrease of one, two, or three
points from July 1, 2022, to July 1, 2023, and had a score of 124 or higher as
of July 1, 2022 |
0.0% |
|
Facility experienced a decrease of one, two, or three
points from July 1, 2022, to July 1, 2023, and did not have a score of 124 or
higher as of July 1, 2022 |
-2.0% |
|
Facility experienced a decrease of four or more
points from July 1, 2022, to July 1, 2023 |
-2.5% |
|
DPH Chronic Low Quality: Facility had a score of less
than 100 as of each of the following dates: July 1, 2021; July 1, 2022; and
July 1, 2023 |
-3% |
(3)
Kosher Food
Services. Nursing facilities with kosher kitchen and food service
operations may receive an add-on of up to $5 per day to reflect the additional
costs of these operations.
(a)
Eligibility. To be eligible for this add-on, the
nursing facility must
1. maintain a fully
kosher kitchen and food service operation that is, at least annually,
rabbinically approved or certified; and in accordance with all applicable
requirements of law related to kosher food and food products including, but not
limited to, M.G.L. c. 94, § 156;
2. provide to the Center a written
certification from a certifying authority, including the complete name,
address, and phone number of the certifying authority, that the applicant's
nursing facility maintains a fully kosher kitchen and food service operation in
accordance with Jewish religious standards. For purpose of
101
CMR 206.06(3)(a)2., the
phrase "certifying authority" will mean a recognized kosher certifying
organization or rabbi who has received Orthodox rabbinical ordination and is
educated in matters of Orthodox Jewish law;
3. provide a written certification from the
administrator of the nursing facility that the percentage of the nursing
facility's residents requesting kosher foods or products prepared in accordance
with Jewish religious dietary requirements is at least 50%; and
4. upon request, provide the Center with
documentation of expenses related to the provision of kosher food services,
including but not limited to, invoices and payroll records.
(b)
Payment Amounts.
1. To determine the add-on amount, EOHHS will
determine the statewide median dietary expense per day for all facilities. The
add-on equals the difference between the eligible nursing facility's dietary
expense per day and the statewide median dietary expense per day, not to exceed
$5 per day. In calculating the per day amount, EOHHS will include allowable
expenses for dietary and dietician salaries, payroll taxes and related
benefits, food, dietary purchased service expense, dietician purchased service
expense, and dietary supplies and expenses. The days used in the denominator of
the calculation will be the higher of the nursing facility's actual days or 96%
of available bed days.
2. EOHHS
will compare the sum of the add-on amounts multiplied by each nursing
facility's projected annual rate period Medicaid days to the state
appropriation. In the event that the sum exceeds the state appropriation, each
nursing facility's add-on will be proportionally adjusted.
(5)
Leaves of
Absence. If a purchasing agency pays for leaves of absence, the
payment rate for a leave of absence day is $80.10 per day, unless otherwise
determined by the purchasing agency.
(6)
Nursing Cost.
Eligible facilities will receive an $91.79 per diem add-on to
reflect the difference between the standard payment amounts and actual base
year nursing spending. To be eligible for such payment, the Department of
Public Health must certify to EOHHS that over 75% of the nursing facility's
residents have a primary diagnosis of multiple sclerosis.
(7)
Pediatric Nursing
Facilities.
(a) Effective October
1, 2023, EOHHS will determine payments to facilities licensed to provide
pediatric nursing facility services using allowable reported operating costs,
excluding administrative and general costs, from the nursing facility's 2019
Cost Report. EOHHS will include an administrative and general payment capped at
the 85th percentile of the 2019 statewide
administrative and general costs. EOHHS will apply an appropriate cost
adjustment factor to operating, and administrative and general costs.
(b) The operating component of the rate is
increased by a cost adjustment factor of 21.94%.
(c) Facilities licensed to provide pediatric
nursing facility services will receive the operating rate which is the greater
of
1. the rates calculated as described in
101
CMR 206.06(7)(a) and
101
CMR 206.06(7)(b);
or
2. the Operating Cost Standard
rate as listed in
101
CMR
206.04(2).
(9)
Receiverships.
EOHHS may adjust a nursing facility's standard rates if a receiver has been
appointed under M.G.L. c. 111, § 72N solely to reflect the reasonable
costs, as determined by EOHHS and the MassHealth agency, associated with the
court-approved closure or sale of the nursing facility or other appropriate
situation.
(10)
Residential Care Beds. Effective October 1, 2023, the
total payment for nursing and other operating costs for residential care beds
in a dually licensed nursing facility is $140.41.
(11)
State-operated Nursing
Facilities. A nursing facility operated by the Commonwealth will
be paid at the nursing facility's reasonable cost of providing covered Medicaid
services to eligible Medicaid recipients.
(a)
EOHHS will establish an interim per diem rate using a base
year CMS-2540 cost report inflated to the rate year using the cost adjustment
factor calculated pursuant to
101
CMR 206.06(11)(b) and a
final rate using the final rate year CMS-2540 cost report.
(b) EOHHS will determine a cost adjustment
factor using a composite index using price level data from the CMS Nursing Home
without capital forecast, and regional health care consumer price indices, and
the Massachusetts-specific consumer price index (CPI), optimistic forecast.
EOHHS will use the Massachusetts CPI as proxy for wages and salaries.
(c) EOHHS may retroactively adjust
the final settled amount when the Medicare CMS-2540 cost report is reopened or
for audit adjustments.
(12)
Low Occupancy
Adjustment. Effective October 1, 2022, a nursing facility may be
subject to a Low Occupancy Adjustment to its payment rate, according to the
following methodology:
(a) Each facility's
occupancy is calculated as follows:
1.
Determine the facility's total resident days as reported on quarterly User Fee
Assessment Forms covering the period of July 1, 2021, through June 30,
2022;
2. Determine the facility's
total number of licensed beds as of June 30, 2022, minus licensed Level IV
beds. Multiply the result by the number of days in the year.
3. Calculate the facility's occupancy by
dividing the result of
101
CMR 206.06(12)(a)1. by the
result of
101
CMR 206.06(12)(a)2. and
rounding the result to the nearest hundredth of a percent.
(b) Based on the occupancy calculated in
101
CMR 206.06(12)(a), a
facility may face a reduction to its nursing standard rate and operating rate,
applied at each management minute category as follows:
1. Except as described in
101
CMR 206.06(12)(b)2., the
reduction is applied in accordance with the following chart:
|
Occupancy
Rate |
Low Occupancy
Penalty |
|
Occupancy below 80.00% |
-3.0% |
|
Occupancy of at least 80.00%, but below
84.00% |
-2.0% |
|
Occupancy of at least 84.00%, but below
88.00% |
-1.0% |
|
Occupancy of at least 88.00% |
0.0% |
2. For
the rate year running from October 1, 2022, through September 30, 2023, the
downward adjustment for nursing facilities with occupancy rates at 80.00% or
higher shall be waived and the downward adjustment for nursing facilities with
occupancy rates below 80.00% shall be -2%.
(c) A nursing facility will be eligible for a
one-time reconsideration of its Low Occupancy Adjustment as determined in
101
CMR 206.06(12)(b) to be
applied beginning February 1, 2023, if the nursing facility
1. reduces by any amount its number of
licensed beds from the number of licensed beds in the facility as of June 30,
2022, by January 1, 2023; and
2.
submits a completed Low Occupancy Adjustment Request form, along with
supporting documentation indicated on the form to EOHHS by January 1,
2023.
(d) Upon receiving
a completed Low Occupancy Adjustment Request form and supporting documentation
from a nursing facility as described in 206.06(12)(c)2, EOHHS will recalculate
the facility's occupancy, as follows:
1.
determine the facility's total resident days as reported on quarterly User Fee
Assessment Forms covering the period July 1, 2021, through June 30,
2022;
2. determine the facility's
total number of licensed beds as of January 1, 2023, minus licensed Level IV
beds. Multiply the result by the number of days in the year; and
3. calculate the facility's occupancy rate by
dividing the result of
101
CMR 206.06(12)(d)1. by the
result of
101
CMR 206.06(12)(d)2. and
rounding the result to the nearest hundredth of a percent.
(e) The facility's new occupancy rate, as
calculated in 206.06(12)(d)3., will be used to redetermine the amount or
applicability of the Low Occupancy Adjustment, as described 206.06(12)(b). Any
changes to a facility's Low Occupancy Adjustment as a result of a new occupancy
rate will apply solely prospectively, beginning February 1, 2023.
(f) EOHHS will not adjust any Low Occupancy
Adjustment solely because a facility under-reported total resident days on its
quarterly User Fee Assessment Form.
(13)
Direct Care
Add-on.
(a)
General. Effective October 1, 2023, a nursing facility
will be eligible for an upward adjustment of 3.252% applied to its nursing
standard rate and operating standard rate at each PDPM nursing case mix
category. Facilities must use the funds from this Direct Care Add-on solely for
direct care staff wages, benefits, incentive payments, or other direct care
compensation.
(b)
Reporting.
1. Each
facility will be required to report to EOHHS on the ways in which it uses its
received direct care add-on funds. The required reporting will be incorporated
in the interim or final DCC-Q reports that facilities are required to submit by
March 1, 2024, and July 30, 2024, respectively, in accordance with
101
CMR 206.12(3). Failure to
complete the required supplemental payment reporting on the interim or final
DCC-Q reports, as specified and required by MassHealth through administrative
bulletin or other written issuance, failure to timely submit the interim or
final DCC-Q reports, or failure to use direct care add-on funds on anything
other than direct care staff wages, benefits, incentive payments, or other
direct care compensation may result in partial or full recoupment of direct
care add-on funds as an overpayment under
130
CMR 450.237: Overpayments:
Determination.
2. All
information included in the reports regarding the direct care add-on funds is
subject to verification and audit by MassHealth. Failure to submit the required
reporting or comply with audits or document requests with respect to the
requirements herein may result in partial or full recoupment of the direct care
add-on funds as overpayments under
130
CMR 450.237: Overpayments:
Determination, or sanctions under
130
CMR 450.238: Sanctions:
General.
(14)
High Medicaid
Adjustment. Effective October 1, 2023, a nursing facility may be
eligible for a High Medicaid Adjustment to its payment rate, based on the
proportion of the facility's total resident days which are Massachusetts
Medicaid days, as reported on the facility's quarterly User Fee Assessment
Forms covering the period July 1, 2022, through June 30, 2023. For the purpose
of determining eligibility for the High Medicaid Adjustment, the proportion of
the facility's total resident days which are Massachusetts Medicaid days will
be rounded to the nearest hundredth of a percent.
(a) A facility for which its Massachusetts
Medicaid days are at least 75.00% and less than 90.00% of its total resident
days will receive a 7% upward adjustment applied to its nursing standard rate
and operating standard rate at each PDPM nursing case mix category.
(b) A facility for which Massachusetts
Medicaid days are at least 90.00% of its total resident days will receive a 9%
upward adjustment applied to its nursing standard rate and operating standard
rate at each PDPM nursing case mix category.
(c) EOHHS will not adjust any High Medicaid
Adjustment solely because a facility under-reported Massachusetts Medicaid days
in its quarterly User Fee Assessment Form.
(15)
Maximum Change
Adjustment. Effective October 1, 2023, a nursing facility will be
subject to an adjustment to its total standard nursing facility per
diem rate at each PDPM nursing case mix category established through
101
CMR 206.04,
101
CMR 206.05,
101
CMR 206.06(2) through (14),
and 101 CMR
206.12(4), if a facility's
proposed total average per diem rate, effective October 1,
2023, calculated using the facility's PDPM nursing case mix index in calendar
year 2022, is greater than 115% of the facility's total average per
diem standard nursing facility rate that was in effect on September
30, 2023, calculated using the facility's MMQ case mix in rate year 2022. The
adjustment will be calculated as follows:
(a)
determine the facility's proposed total average per diem rate,
calculated using PDPM nursing case mix in calendar year 2022, pursuant to
101
CMR 206.04,
101
CMR 206.05,
101
CMR 206.06(2) through (14),
and 101 CMR
206.12(4);
(b) determine 115% of the facility's average
per diem rate that was in effect on September 30, 2023,
calculated using the facility's MMQ case mix in rate year 2022;
(c) subtract the amount calculated in
101
CMR 206.06(15)(a) from the
amount calculated in
101
CMR 206.06(15)(b);
(d) divide the amount calculated in
101
CMR 206.06(15)(c) by the
amount calculated in
101
CMR 206.06(15)(a);
(e) the percentage calculated in
101
CMR 206.06(15)(d) will be
applied as a downward adjustment to the total proposed standard nursing
facility per diem rate, as established through
101
CMR 206.04,
101
CMR 206.05,
101
CMR 206.06(2) through (14),
and 101 CMR
206.12(4), at each PDPM
nursing case mix category.
