Current through September 17, 2024
The Department determines rates for facilities under the
following cost-based prospective methodology.
007.01
RATE PERIODS.
The Rate Periods are defined as July 1 through December 31, and January 1
through June 30. Rates paid during the rate periods are determined from base
year cost reports. For purposes of this section, base year cost reports means
full and part-year cost reports filed with a base year report period ending
date of June 30.
007.02
REPORT PERIOD. Each facility must file a cost report
each year for the reporting period of July 1 through June 30 or part-year cost
reports, when applicable.
007.03
CARE CLASSIFICATIONS. A portion of each individual
facility's rate may be based on the urban or rural location of the
facility.
007.04
PROSPECTIVE RATES. Subject to the allowable,
unallowable, and limitation provisions of this chapter, the Department
determines facility-specific prospective per diem rates, one rate corresponding
to each level of care, based on the facility's allowable costs incurred and
documented during the base year report period. The rates are based on
financial, acuity, and statistical data submitted by facilities, and are
subject to the component maximums and minimums. Component maximums and minimums
are computed using audited data following the initial desk audits and are not
revised based on subsequent changes to the data. Only cost reports with a full
year's data are used in the computations. Cost reports from providers entering
or leaving Medicaid during the immediately preceding report period are not used
in the computations. Each facility's prospective rates are the sum of the
following components; the direct nursing component adjusted by the inflation
factor and weighted for level of care; the support services component adjusted
by the inflation factor; the fixed cost component; the nursing facility quality
assessment component; and the quality measures component. The direct nursing
component and the support services component are subject to maximum and minimum
per diem payments based on Median or Maximum computations. For each care
classification, the median for the direct nursing component is computed using
nursing facilities within that care classification with an average occupancy of
40 or more residents, excluding waivered, or facilities with partial or initial
or final full year cost reports. For each care classification, the median for
the support services component is computed using nursing facilities within that
care classification with an average occupancy of 40 or more residents,
excluding hospital based, waivered, or facilities with partial or initial or
final full year cost reports. The Department will reduce the direct nursing
component median by 2% for facilities that are waivered from the 24-hour
nursing requirement to take into account those facilities' lowered nursing care
costs. The maximum per diem is computed as 105% of the median direct nursing
component, and 100% of the median support services component. The Department
will reduce the direct nursing component maximum by 2% for facilities that are
waivered from the 24-hour nursing requirement to take into account those
facilities' lowered nursing care costs. The minimum per diem is computed as 77%
of the median direct nursing component, and 72% of the median support services
component. The fixed cost component is subject to a maximum Per Diem of $27.00,
excluding personal property and real estate taxes.
007.04(A)
DIRECT NURSING
COMPONENT. This component of the prospective rate is computed by
dividing the base year allowable direct nursing costs, lines 94 through 103 of
Form FA-66, Long Term Care Cost Report, by the base year weighted resident days
for each facility. The resulting quotient is the facility's computed base year
per diem. The computed base year per diem is subject to the component maximum
per diem and minimum per diem for rate determination purposes.
007.04(B)
SUPPORT SERVICES
COMPONENT. This component of the prospective rate is computed by
dividing the base year allowable costs for support services, lines 34, 63, 78,
93, 104 through 127, 163, 184, and 185 from the FA-66; Resident Transportation
-Medical from the Ancillary Cost Center, line 219 from the FA-66; and
respiratory therapy from the Ancillary Cost Center, line 210 from the FA-66, by
the total base year inpatient days for each facility. The computed base year
per diem is subject to the component maximum per diem and minimum per diem for
rate determination purposes.
007.04(C)
FIXED COST
COMPONENT. This component of the prospective rate is computed by
dividing the facility's base year allowable interest, depreciation,
amortization, long-term rent or lease payments, personal property tax, real
estate tax, and other fixed costs by the facility's total base year inpatient
days. Rate determination for the Fixed Cost Component for an individual
facility is computed using the lower of its own per diem as computed above,
plus any prior approved increase under 471 NAC 45-007.05, or a maximum per diem
of $27.00 excluding personal property and real estate taxes.
007.04(D)
NURSING FACILITY
QUALITY ASSESSMENT COMPONENT. The Nursing Facility Quality
Assessment component shall not be subject to any cost limitation or revenue
offset. For purposes of this section, facilities exempt from the quality
assurance assessment are state-operated veterans' homes; nursing facilities and
skilled nursing facilities with twenty-six or fewer licensed beds; and
continuing care retirement communities. the quality assessment component rate
will be determined by calculating the anticipated tax payment' during the rate
year and then dividing the total anticipated tax payments by total anticipated
nursing facility or skilled nursing facility patient days, including bed hold
days and Medicare patient days. for each rate year, July 1 through the
following June 30, total facility patient days, including bed hold days, less
Medicare days, for the four most recent calendar quarters available at the time
rates are determined will be used to calculate the anticipated tax payments.
Total facility patient days, including bed hold days and Medicare days, for the
same four calendar quarters will be used to calculate the anticipated nursing
facility or skilled nursing facility patient days. For new providers entering
the Medicaid program to operate a nursing facility not previously enrolled in
Medicaid, for the rate period beginning on the Medicaid certification date
through the following June 30, the quality assessment rate component is
computed as the quality assurance assessment amount due from the provider's
first quality assurance assessment form covering a full calendar quarter,
divided by total resident days in licensed beds from the same quality assurance
assessment form. for existing providers changing from exempt to non-exempt
status, for the rate period beginning on the first day of the first full month
the provider is subject to the quality assurance assessment through the
following June 30, the quality assessment rate component is computed as the
quality assurance assessment amount due from the provider's first quality
assurance assessment form covering a full calendar quarter, divided by total
resident days in licensed beds from the same quality assurance assessment form.
For existing providers changing from non-exempt to exempt status, for rate
periods beginning with the first day of the first full month the provider is
exempt from the quality assurance assessment, the quality assessment rate
component will be $0.00 (zero dollars).
007.04(E)
BASE YEAR REPORT PERIOD
AND INFLATION FACTOR. For the Rate Periods July 1 through December
31 and January 1 through June 30, the base year is updated no less frequently
than every 5 years. The inflation factor is updated annually.
007.04(F)
QUALITY MEASURES
COMPONENT. This component of the prospective rate is based on the
quality measures component of the Centers for Medicare & Medicaid nursing
facility star rating system. The published rating as of May 1 is used to
determine the rate component for the following July 1 through December 31 rate
period. The published rating as of November 1 is used to determine the rate
component for the following January 1 through June 30 rate period. Per Diem
amounts corresponding to the quality measures rating are: 5 star rating =
$10.00 a day; 4 star rating = $6.75 a day; 3 star rating = $3.50 a day; 1 star,
2 star, or NR (no rating) = $0.00 (zero dollars). This component applies to all
nursing facility care levels (101-180).
007.05
EXCEPTION
PROCESS. An individual facility may request, on an exception
basis, the Medicaid Director or designee, to consider specific facility
circumstance or circumstances, which warrant an exception to the facility's
rate computed for its fixed cost component. For existing facilities, an
exception may only be requested if the facility's total annualized fixed costs,
total costs, not per diem rate, as compared to the annualized base year costs,
have increased by twenty percent or more. Facilities without a base year cost
report, and with 1,000 or more annualized Medicaid days, may only request an
exception if the facility's fixed costs per day, computed using an 85% minimum
occupancy, exceeds the care classification average fixed cost component by 20%
or more. In addition, the facility's request must include: Specific
identification of the increased cost or costs that have caused the facility's
total fixed costs to increase by 20% or more, with justification for the
reasonableness and necessity of the increase; Whether the cost increase or
increases are an ongoing or a one-time occurrence in the cost of operating the
facility; and If applicable, preventive management action that was implemented
to control past and future cause or causes of identified cost increase or
increases. Approved increases from July 1 through December 31, will be
effective the following January 1. Approved increases from January 1 through
June 30, will be effective the following July 1.
007.06
RATE PAYMENT FOR ASSISTED
LIVING LEVELS OF CARE. The payment rate for Levels of Care 201 and
202 is the applicable rate in effect for assisted living services under the
Home and Community-Based Waiver Services for Aged Persons or Adults or Children
with Disabilities adjusted to include the nursing facility quality assessment
component and quality measures component.
007.07
OUT-OF-STATE
FACILITIES. The Department pays out-of-state facilities
participating in Medicaid at the rates established by that state's Medicaid
program for nursing facility days, bed hold days and therapeutic leave days at
the time of establishment of the Medicaid provider agreement. The rates are
periodically updated to align with the current and applicable rates assigned by
the out-of-state facility's State Medicaid program..
007.08
RATES FOR PROVIDERS
WITHOUT A BASE YEAR COST REPORT. A provider without a base year
cost report is an individual or entity which obtains their initial,
facility-specific provider agreement to operate an existing nursing facility,
meaning the business operation, not the physical property, due to a change in
ownership, or to operate a nursing facility not previously enrolled in
Medicaid, after the base year cost report end date; or a provider with 1,000 or
fewer Medicaid inpatient days in the base year. Prospective Medicaid rates for
providers without a base year cost report are the sum of the following
components:
(A) The applicable urban or rural
average direct nursing base rate component of all other providers in the same
care classification, adjusted by the inflation factor; and weighted for level
of care;
(B) The applicable urban
or rural average support services base rate component of all other providers in
the same care classification, adjusted by the inflation factor;
(C) The applicable urban or rural average
fixed cost base rate component of all other providers in the same care
classification;
(D) The Nursing
Facility Quality Assessment component; and
(E) The quality measures component.
007.09
PROVIDERS
LEAVING THE MEDICAID. Providers leaving Medicaid as a result of
change of ownership or exit from the program shall comply with provisions of
this chapter.
007.10
SPECIAL FUNDING PROVISIONS FOR GOVERNMENTAL
FACILITIES. City and county-owned and operated nursing facilities
are eligible to receive the federal financial participation share of allowable
costs exceeding the rates paid for the direct nursing, support services, and
fixed cost Components for all Medicaid residents. The reimbursement is subject
to the payment limits of 42
CFR 447.272.
007.10(A)
CITY OR COUNTY OWNED
FACILITIES. City or county-owned facilities with a 40% or more
Medicaid mix of inpatient days are eligible to receive the federal financial
participation share of allowable costs exceeding the applicable maximums for
the direct nursing, support services, and fixed cost components. This amount is
computed after desk audit and determination of final rates for a report period
by multiplying the current Medicaid federal financial participation percentage
by the facility's allowable costs above the respective maximum for the direct
nursing, support services, and fixed cost components. Verification of the
eligibility of the expenditures for federal financial participation is
accomplished during the audit process.
007.11
SPECIAL FUNDING PROVISIONS
FOR INDIAN HEALTH SERVICES NURSING FACILITY PROVIDERS. Indian
Health Services nursing facility providers are eligible to receive the federal
financial participation share of allowable costs exceeding the rates paid for
the direct nursing, support services, and fixed cost components for all
Medicaid residents.
007.11(A)
INDIAN HEALTH SERVICES. Indian Health Services
providers may receive quarterly, interim Special Funding payments by filing
quarterly cost reports, FA-66, for periods ending September 30, December 31, or
March 31. Quarterly, interim special funding payments are retroactively
adjusted and settled based on the provider's corresponding annual cost report
for the period ending June 30. Quarterly, interim payments and the retroactive
settlement amount are calculated in accordance with section (ii) below. If the
average daily census from a quarterly cost report meets or exceeds 85% of
licensed beds, this shall be the final quarterly cost report filed by the
provider. Subsequent quarterly, interim special funding payments shall be based
on the final quarterly cost report. Quarterly, interim Special Funding payments
may also be revised based on data from the annual cost reports.
(i) Quarterly, interim special funding
payments shall be made within 30 days of receipt of the quarterly cost report
or requested supporting documentation. Quarterly, interim special funding
payments subsequent to the payment for the final quarterly cost report shall be
made on or about 90-day intervals following the previous payment.
(ii) The special funding amount is computed
after desk audit and determination of allowable costs for the report period.
The amount is calculated by adding the following two figures:
(1) The allowable federal medical assistance
percentage for Indian Health Services-eligible Medicaid residents multiplied by
the difference between the allowable costs for all Indian Health
Services-eligible Medicaid residents and the total amount paid for all Indian
Health Services-eligible Medicaid residents, if greater than zero;
and
(2) The allowable federal
medical assistance percentage for non-Indian Health Services-eligible Medicaid
residents multiplied by the difference between the allowable costs for all
non-Indian Health Services-eligible Medicaid residents and the total amount
paid for all non-Indian Health Services-eligible Medicaid residents, if greater
than zero.
