New York Codes, Rules and Regulations
Title 10 - DEPARTMENT OF HEALTH
Chapter II - Administrative Rules and Regulations
Subchapter L - Hospitals and Related Facilities
Part 86 - Reporting and Rate Certifications for Facilities
Subpart 86-2 - Residential Health Care Facilities
Section 86-2.31 - Recalibration
Universal Citation: 10 NY Comp Codes Rules and Regs § 86-2.31
Current through Register Vol. 47, No. 12, March 26, 2025
(a) For rate years 1989, 1990 and 1991, notwithstanding any other provision of this Subpart and subject to the provisions of paragraph (1) of this subdivision, payment rates shall be adjusted in accordance with this subdivision to reflect a percentage recalibration adjustment based on the change in each facility's case mix which has been determined by the department to be due to factors other than changes in patient population or condition. Such payment rate adjustments shall be implemented utilizing the direct component of facility rates for such rate years determined in accordance with sections 86-2.10 and 86-2.11 of this Subpart.
(1) The percentage recalibration adjustment
provided for in this subdivision shall neither exceed 3.035 percent nor be less
than 0 percent.
(2) The percentage
recalibration adjustment shall be calculated as follows for each facility.
(i) A statewide distribution of patients in
each patient classification group shall be determined by utilizing the patient
data for the assessment of all patients obtained in the patient assessment
period March 1, 1985 through September 30, 1985 (the 1985 period) conducted
pursuant to section
86-2.30 of this Subpart.
(ii) The statewide distribution of patients
in each patient classification group shall be further segregated by the
following length of stay (LOS) groups.
(a)
less than or equal to 90 days;
(b)
greater than 90 days but less than or equal to one year;
(c) greater than 1 year but less than or
equal to two years;
(d) greater
than two years but less than or equal to three years;
(e) greater than three years but less than or
equal to four years;
(f) greater
than four years but less than or equal to five years; or
(g) greater than five years.
(iii) A statewide average initial
case mix index for each LOS group for the 1985 period shall be calculated by
multiplying the initial distribution of patients in each patient classification
group within each LOS group times the case mix index for each patient
classification group as contained in Appendix 13-A herein and dividing the sum
of the results by the total number of patients in all patient classification
groups within each LOS group.
(iv)
For each facility, a 1985 distribution of patients in each patient
classification group and a 1985 distribution of patients by the LOS groups
specified in subparagraph (ii) of this paragraph shall be determined by
utilizing the patient data for the assessment of all patients obtained in the
1985 period, conducted pursuant to section
86-2.30 of this Subpart. In the
event a facility commenced operations after the patient assessment period,
March 1, 1985 through September 30, 1985 (the 1985 period) but prior to January
1, 1988, or if the facility has the lesser of ten cases or twenty percent of
its patients in the distributions as determined in this subparagraph for the
1985 period, or if the facility had undergone the appointment of a receiver or
the establishment of a new operator subsequent to the 1985 period but prior to
January 1, 1988 and had filed a new cost report in accordance with the
provisions of section
86-2.10(k) of
this Subpart which was used in the calculation of the payment rate, the
distribution of patients to be used for the purposes of this subparagraph shall
be that distribution pertaining to the earliest full patient assessment period
conducted pursuant to section
86-2.30 of this Subpart subsequent
to the 1985 period or subsequent to the effective date of the appointment of a
receiver or the change in operator (the "substituted 1985 period"), and such
distribution shall be deemed the facility's "substituted 1985 distribution" of
patients for the calculations in subparagraphs (vi) and (vii) of this
paragraph. For purposes of this subparagraph, the only patients to be included
in the distributions shall be patients that have been identified by the
department as also having been included in the patient assessment period July
1, 1988 through December 31, 1988.
(v) For each facility, a 1988 distribution of
patients in each patient classification group and a 1988 distribution of
patients by the LOS groups specified in subparagraph (ii) of this paragraph
shall be determined by utilizing the patient data obtained in the patient
assessment period July 1, 1988 through December 31, 1988. For purposes of this
subparagraph, the only patients to be included in the distributions shall be
patients that were admitted to the facility in which they are presently
residing before October 1, 1985 and have been identified by the department as
also having been included in the patient assessments during the 1985 period. In
the event a facility commenced operations after the patient assessment period,
March 1, 1985 through September 30, 1985 (the 1985 period) but prior to January
1, 1988, or if the facility had the lesser of ten cases or twenty percent of
its patients in the distributions for the 1985 period as determined pursuant to
subparagraph (iv) of this paragraph, or if the facility had undergone the
appointment of a receiver or the establishment of a new operator subsequent to
the 1985 period but prior to January 1, 1988 and had filed a new cost report in
accordance with the provisions of section
86-2.10(k) of
this Subpart which was used in the calculation of the payment rate, the
facility's substituted 1985 period, as defined in subparagraph (iv) of this
paragraph, shall be used in lieu of the 1985 period for the purposes of this
subparagraph, and the only patients to be included shall be patients that were
admitted to the facility in which they are presently residing before the end
date of the facility's substituted 1985 period and have been identified by the
department as also having been included in the patient assessments during the
substituted 1985 period.
(vi) A
percentage increase in case mix attributable to LOS shall, for each facility,
be determined as follows:
(a) A 1985
aggregate case mix index shall be determined by multiplying the facility's 1985
distribution of patients, or a substituted 1985 distribution of patients where
applicable, within each LOS group, determined pursuant to subparagraph (iv) of
this paragraph by the statewide average initial case mix index for each LOS
group for the 1985 period, as determined pursuant to subparagraph (iii) of this
paragraph, and dividing the sum of the results by the facility's total number
of patients in all LOS groups, as determined pursuant to subparagraph (iv) of
this paragraph.
(b) A 1988 LOS
adjusted case mix index shall be determined by multiplying the facility's 1988
distribution of patients within each LOS group determined pursuant to
subparagraph (v) of this paragraph by the statewide average initial case mix
index for each LOS group for the 1985 period, as determined pursuant to
subparagraph (iii) of this paragraph, and dividing the sum of the results by
the facility's total number of patients in all LOS groups, as determined
pursuant to subparagraph (v) of this paragraph.
(c) The 1985 aggregate case mix index shall
be subtracted from the 1988 LOS adjusted case mix index and the result divided
by the 1985 aggregate case mix index to arrive at the percentage increase in
case mix attributable to LOS.
(vii) An actual percentage increase in case
mix shall, for each facility, be determined as follows:
(a) A 1985 actual case mix index shall be
determined by multiplying the facility's 1985 distribution of patients, or a
substituted 1985 distribution of patients where applicable, in each patient
classification group, as determined pursuant to subparagraph (iv) of this
paragraph, by the case mix index for each patient classification group as
contained in Appendix 13-A herein and dividing the sum of the results by the
facility's total number of patients in all patient classification groups, as
determined pursuant to subparagraph (iv) of this paragraph.
(b) A 1988 actual case mix index shall be
determined by multiplying the facility's 1988 distribution of patients in each
patient classification group, as determined pursuant to subparagraph (v) of
this paragraph, by the case mix index for each patient classification group as
contained in Appendix 13-A herein and dividing the sum of the results by the
facility's total number of patients in all patient classification groups, as
determined pursuant to subparagraph (v) of this paragraph.
(c) The 1985 actual case mix index shall be
subtracted from the 1988 actual case mix index and the result divided by the
1985 actual case mix index to arrive at an actual percentage increase in case
mix.
(viii) Except as
provided in subparagraph (ix) of this paragraph, a percentage recalibration
adjustment shall be determined by annualizing the result obtained by
subtracting the percentage increase in case mix attributable to LOS determined
pursuant to subparagraph (vi) of this paragraph from the actual percentage
increase in case mix determined pursuant to subparagraph (vii) of this
paragraph.
(ix) If a facility had
undergone the appointment of a receiver or the establishment of a new operator
on or after January 1, 1988 but prior to January 1, 1992, and filed a new cost
report in accordance with the provisions of section
86-2.10(k) of
this Subpart which was used in the calculation of a revised payment rate, or
for new facilities who received an initial operating certificate on or after
January 1, 1988 but prior to January 1, 1992, the percentage recalibration
adjustment provided for in this subdivision shall be 0 percent for such revised
rate or such new facilities.
(3) The operating portion of each residential
health care facility's rate of payment, as defined pursuant to section
86-2.10(a)(7) of
this Subpart, shall be reduced by a per diem recalibration adjustment which
shall be determined as follows:
(i) The
percentage recalibration adjustment identified in subparagraph (2)(viii) of
this subdivision shall be applied to the direct component of the rate
determined in accordance with sections 86-2.10 and
86-2.11 of this Subpart, to arrive
at each facility's per diem recalibration adjustment in 1983 base year
dollars.
(ii) Each facility's per
diem recalibration adjustment in 1983 base year dollars shall then be trended
to the rate year by the applicable roll factor as defined in section
86-2.10(a)(8) of
this Subpart.
(b) For rate years 1992 and thereafter, notwithstanding any other provision of this Subpart and subject to the provisions of paragraph (1) of this subdivision and subdivision (c) of this section, payment rates shall be adjusted in accordance with this subdivision to reflect a percentage recalibration adjustment based on the change in each facility's case mix which has been determined by the department to be due to factors other than changes in patient population or condition. Such payment rate adjustments shall be implemented utilizing the direct component of facility rates for such rate years determined in accordance with sections 86-2.10 and 86-2.11 of this Subpart.
(1) The percentage recalibration adjustment
provided for in this subdivision shall not be less than 0 percent nor greater
than 150 percent of the statewide weighted average percentage recalibration
adjustment obtained by utilizing the facility-specific percentage recalibration
adjustments as determined pursuant to this subdivision.
(2) The percentage recalibration adjustment
shall be calculated as follows for each facility:
(i) A statewide distribution of patients in
each patient classification group shall be determined by utilizing the patient
data for the assessment of all patients obtained in the patient assessment
period March 1, 1985 through September 30, 1985 (the 1985 period) conducted
pursuant to section
86-2.30 of this Subpart.
(ii) The statewide distribution of patients
in each patient classification group shall be further segregated by the
following length of stay (LOS) groups:
(a)
less than or equal to 90 days;
(b)
greater than 90 days but less than or equal to one year;
(c) greater than one year but less than or
equal to two years;
(d) greater
than two years but less than or equal to three years;
(e) greater than three years but less than or
equal to four years;
(f) greater
than four years but less than or equal to five years; or
(g) greater than five years;
(iii) A statewide average initial
case mix index for each LOS group for the 1985 period shall be calculated by
multiplying the initial distribution of patients in each patient classification
group within each LOS group times the case mix index for each patient
classification group as contained in Appendix 13-A herein and dividing the sum
of the results by the total number of patients in all patient classification
groups within each LOS group.
(iv)
For each facility, a 1985 distribution of patients in each patient
classification group and a 1985 distribution of patients by the LOS groups
specified in subparagraph (ii) of this paragraph shall be determined by
utilizing the patient data for the assessment of all patients obtained in the
1985 period, conducted pursuant to section
86-2.30 of this Subpart. In the
event a facility commenced operations after the patient assessment period,
March 1, 1985 through September 30, 1985 (the 1985 period) but prior to January
1, 1988, or if the facility has the lesser of ten cases or twenty percent of
its patients in the distributions as determined in this subparagraph for the
1985 period, or if the facility had undergone the appointment of a receiver or
the establishment of a new operator subsequent to the 1985 period but prior to
January 1, 1988 and had filed a new cost report in accordance with the
provisions of section
86-2.10(k) of
this Subpart which was used in the calculation of the payment rate, the
distribution of patients to be used for the purposes of this subparagraph shall
be that distribution pertaining to the earliest full patient assessment period
conducted pursuant to section
86-2.30 of this Subpart subsequent
to the 1985 period or subsequent to the effective date of the appointment of a
receiver or the change in operator (the "substituted 1985 period"), and such
distribution shall be deemed the facility's "substituted 1985 distribution" of
patients for the calculations in subparagraphs (vi) and (vii) of this
paragraph. For purposes of this subparagraph, the only patients to be included
in the distributions shall be patients that have been identified by the
department as also having been included in the patient assessment period July
1, 1988 through December 31, 1988.
(v) For each facility, a 1988 distribution of
patients in each patient classification group and a 1988 distribution of
patients by the LOS groups specified in subparagraph (ii) of this paragraph
shall be determined by utilizing the patient data obtained in the patient
assessment period July 1, 1988 through December 31, 1988. For purposes of this
subparagraph, the only patients to be included in the distributions shall be
patients that were admitted to the facility in which they are presently
residing before October 1, 1985 and have been identified by the department as
also having been included in the patient assessments during the 1985 period. In
the event a facility commenced operations after the patient assessment period,
March 1, 1985 through September 30, 1985 (the 1985 period) but prior to January
1, 1988, or if the facility had the lesser of ten cases or twenty percent of
its patients in the distributions for the 1985 period as determined pursuant to
subparagraph (iv) of this paragraph, or if the facility had undergone the
appointment of a receiver or the establishment of a new operator subsequent to
the 1985 period but prior to January 1, 1988 and had filed a new cost report in
accordance with the provisions of section
86-2.10(k) of
this Subpart which was used in the calculation of the payment rate, the
facility's substituted 1985 period, as defined in subparagraph (iv) of this
paragraph, shall be used in lieu of the 1985 period for the purposes of this
subparagraph, and the only patients to be included shall be patients that were
admitted to the facility in which they are presently residing before the end
date of the facility's substituted 1985 period and have been identified by the
department as also having been included in the patient assessments during the
substituted 1985 period.
(vi) A
percentage increase in case mix attributable to LOS shall, for each facility,
be determined as follows:
(a) A 1985
aggregate case mix index shall be determined by multiplying the facility's 1985
distribution of patients, or a substituted 1985 distribution of patients where
applicable, within each LOS group, determined pursuant to subparagraph (iv) of
this paragraph by the statewide average initial case mix index for each LOS
group for the 1985 period, as determined pursuant to subparagraph (iii) of this
paragraph, and dividing the sum of the results by the facility's total number
of patients in all LOS groups, as determined pursuant to subparagraph (iv) of
this paragraph.
(b) A 1988 LOS
adjusted case mix index shall be determined by multiplying the facility's 1988
distribution of patient within each LOS group determined pursuant to
subparagraph (v) of this paragraph by the statewide average initial case mix
index for each LOS group for the 1985 period, as determined pursuant to
subparagraph (iii) of this paragraph, and dividing the sum of the results by
the facility's total number of patients in all LOS groups, as determined
pursuant to subparagraph (v) of this paragraph.
(c) The 1985 aggregate case mix index shall
be subtracted from the 1988 LOS adjusted case mix index and the result divided
by the 1985 aggregate case mix index to arrive at the percentage increase in
case mix attributable to LOS.
(vii) An actual percentage increase in case
mix shall, for each facility, be determined as follows:
(a) A 1985 actual case mix index shall be
determined by multiplying the facility's 1985 distribution of patients, or a
substituted 1985 distribution of patients where applicable, in each patient
classification group as determined pursuant to subparagraph (iv) of this
paragraph, by the case mix index for each patient classification group as
contained in Appendix 13-A herein and dividing the sum of the results by the
facility's total number of patients in all patient classification groups, as
determined pursuant to subparagraph (iv) of this paragraph.
(b) A 1988 actual case mix index shall be
determined by multiplying the facility's 1988 distribution of patients in each
patient classification group, as determined pursuant to subparagraph (v) of
this paragraph, by the case mix index for each patient classification group as
contained in Appendix 13-A herein and dividing the sum of the results by the
facility's total number of patients in all patient classification groups, as
determined pursuant to subparagraph (v) of this paragraph.
(c) The 1985 actual case mix index shall be
subtracted from the 1988 actual case mix index and the result divided by the
1985 actual case mix index to arrive at an actual percentage increase in case
mix.
(viii) Except as
provided in subparagraph (ix) of this paragraph, a percentage recalibration
adjustment shall be determined by annualizing the result obtained by
subtracting the percentage increase in case mix attributable to LOS determined
pursuant to subparagraph (vi) of this paragraph from the actual percentage
increase in case mix determined pursuant to subparagraph (vii) of this
paragraph.
(ix) If a facility
undergoes the appointment of a receiver or the establishment of a new operator
on or after January 1, 1992 and files a new cost report in accordance with the
provisions of section
86-2.10(k) of
this Subpart which is used in the calculation of a revised payment rate, or for
new facilities who receive an initial operating certificate on or after January
1, 1992, the percentage recalibration adjustment provided for in this
subdivision shall be 0 percent for such revised payment rate or for such new
facilities.
(3) The
operating portion of each residential health care facility's rate of payment,
as defined pursuant to section
86-2.10(a)(7) of
this Subpart, shall be reduced by a per diem recalibration adjustment which
shall be determined as follows:
(i) The
percentage recalibration adjustment identified in subparagraph (2)(viii) of
this subdivision shall be applied to the direct component of the rate
determined in accordance with sections 86-2.10 and
86-2.11 of this Subpart, to arrive
at each facility's per diem recalibration adjustment in 1983 base year
dollars.
(ii) Each facility's per
diem recalibration adjustment in 1983 base year dollars shall then be trended
to the rate year by the applicable roll factor as defined in section
86-2.10(a)(8) of
this Subpart.
(c) For a residential health care facility receiving a percentage recalibration adjustment greater than 0 percent, as determined in subdivision (b) of this section, the percentage recalibration adjustment may be modified as provided in this subdivision.
(1) In order to be eligible for a
modification, a facility shall meet all of the following conditions.
(i) A modification request shall be submitted
by a facility as an appeal application and shall be submitted within the time
limit set forth in section
86-2.13(a) of
this Subpart.
(ii) A facility shall
document that the percentage change in the facility's reported case mix index
(CMI) from the annual rate period 1985 through 1988, such percentage reduced by
the percentage recalibration adjustment as determined by subdivision (b) of
this section, is at least 10 percent. The percentage change in the facility's
reported CMI, for purposes of this subparagraph, shall utilize the CMI
calculated from the facility's patient data obtained during the patient
assessment period, March 1, 1985 through September 30, 1985, to the patient
assessment period July 1, 1988 through December 31, 1988, conducted pursuant to
section 86-2.30 of this Subpart, and shall
be calculated by subtracting from the reported 1988 CMI, the reported 1985 CMI
and the result divided by the reported 1985 CMI.
(iii)
(iii)
(a) Except as provided in clause (b) of this
subparagraph, a facility shall document that the percentage change in direct
care cost over trend from the annual rate period 1985 through 1988, as defined
by those cost centers listed in section
86-2.10(c) of
this Subpart, is at least 10 percent. The percentage change in direct care cost
over trend for purposes of this subparagraph shall be calculated by subtracting
from the 1988 annual reported direct care cost, the 1985 annual reported direct
care cost trended to 1988 by the applicable trend factors promulgated by the
department for 1986, 1987 and 1988, and the result divided by the trended 1985
direct care cost. The annual reported direct care costs for 1985 and 1988, for
purposes of this subparagraph, shall be those which the facility has submitted
using the result of the single step-down method of cost allocation as defined
in section
451.29 of this Title.
(b) In the event a facility's
facility-specific cost based direct price per day exceeds the facility-specific
ceiling direct price per day, as determined pursuant to section
86-2.10(c)(4) of
this Subpart, for the annual rate period 1988, such excess percentage shall be
used to determine a credit to be added to the facility's percentage change in
direct care cost over trend as determined in clause (a) of this subparagraph
for the purposes of meeting the required percentage change in direct care cost
over trend identified in clause (a) of this subparagraph. The amount of the
credit shall be equal to such excess percentage if the facility documents that
its percentage change in indirect care cost over trend from the annual rate
period 1985 through 1988, as defined by those cost centers listed in section
86-2.10(d) of
this Subpart, does not exceed its percentage change in direct care cost over
trend for this period, as determined in clause (a) of this subparagraph, and if
the facility cannot so document, the credit identified in this clause shall be
reduced (but not be less than 0 percent) by the extent to which the percentage
change in indirect care cost over trend exceeds the percentage change in direct
care cost over trend. The percentage change in indirect care cost over trend
for purposes of this subparagraph shall be calculated by subtracting from the
1988 annual reported indirect care cost, the 1985 annual reported indirect care
cost trended to 1988 by the applicable trend factors promulgated by the
department for 1986, 1987 and 1988, and the result divided by the trended 1985
indirect care cost. The annual reported indirect care costs for 1985 and 1988,
for purposes of this subparagraph, shall be those which the facility has
submitted using the result of the single stepdown method of cost allocation as
defined in section
451.29 of this Title.
(iv) Documentation shall be
included in an appeal filed by the facility to the department that supports the
reasons for the direct care cost increase which shall be based on increases in
staffing levels and/or range and/or types of patient services. Increased direct
care cost resulting solely from an increase in the bed complement of a facility
shall not constitute sufficient justification for granting a modification
pursuant to this subdivision.
(2) For a facility meeting all conditions
specified in paragraph (1) of this subdivision, the modified percentage
recalibration adjustment shall be determined as follows.
(i) The modification to the percentage
recalibration adjustment shall be determined by annualizing the result obtained
by subtracting the percentage change in the facility's reported CMI reduced by
the percentage recalibration adjustment, as determined in subparagraph (1)(ii)
of this subdivision, from the percentage change in direct care cost over trend,
as determined in subparagraph (1)(ii) of this subdivision.
(ii) The modified percentage recalibration
adjustment shall be equal to the result obtained by subtracting the
modification to the percentage recalibration adjustment, as determined in
subparagraph (1) of this paragraph, from the percentage recalibration
adjustment identified in subparagraph (b)(2)(viii) of this section.
(iii) The modified percentage recalibration
adjustment, as determined in subparagraph (ii) of this paragraph, shall not be
less than 0 percent.
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