Current through Register Vol. 46, No. 39, September 25, 2024
(a) Rates of
payment for a residential treatment facility with inadequate cost experience
shall be determined on the basis of satisfactory cost projections contained in
budgets and other information submitted to the commissioner by the residential
treatment facility. Budgets shall be submitted to the commissioner no later
than 120 days prior to the date on which the rates of payment will be
effective. The form and content of any such budgets may vary as prescribed by
the commissioner. A residential treatment facility shall submit to the
commissioner, within 15 days of a written request therefor, any additional
information the commissioner determines is necessary to compute or revise rates
of payment in accordance with this section.
(b) The rate of payment for a newly certified
residential treatment facility shall be computed from a budget report. The
budget report period shall cover the facility's first 12 months of operation.
The commissioner may require that the budget be divided into several interim
periods during the first 12 months and be extended to include subsequent
periods, not to exceed an additional 12 months. The commissioner may further
require specialized reports regarding staffing, utilization, capital costs, and
cash flow.
(1) For a newly certified
residential treatment facility which expects to achieve a minimum average
utilization of 90 percent during the first year of operation, the rate of
payment shall be developed from the first 12-month budget report.
(i) The budgeted operating and capital costs
shall be reviewed to determine the allowed costs in accordance with the
reimbursement principles contained in section
578.14
of this Part.
(ii) The operating
portion of the allowed cost shall then be adjusted from the budget period to
the period upon which the cost category standards were calculated using the
applicable trend factors as specified in section
578.8
of this Part, or as determined by the commissioner if trend factors are not
specified for a particular period.
(iii) The adjusted operating cost shall then
be limited to the maximum amounts contained in the cost category standards from
section
578.8(a)(2)-(4)
of this Part, and then trended to the appropriate rate period.
(iv) The operating per diem rate of payment
shall be calculated based upon the total possible patient days of the
residential treatment facility at 90 percent utilization.
(v) Capital costs shall be calculated on a
per diem basis using the total possible patient days of the residential
treatment facility at 90 percent utilization.
(2) For a newly certified residential
treatment facility which expects an average utilization of less than 90 percent
during the first year of operation, the rate of payment shall be developed from
the budget report(s), and a utilization and staffing plan approved by the
commissioner. The plan shall estimate the month-by-month utilization and
staffing of the residential treatment facility for the first 12 months of
operation, and for the second 12 months as applicable. In no instance shall the
phased utilization plan exceed one year.
(i)
The budgeted operating and capital costs shall be reviewed to determine the
allowed costs in accordance with the reimbursement principles contained in
section
578.14
of this Part.
(ii) The allowed
operating cost shall then be adjusted from the budget period to the period upon
which the cost category standards were calculated using the applicable trend
factors as specified in section
578.8
of this Part, or as determined by the commissioner if trend factors are not
specified for a particular period.
(iii) The adjusted allowed cost shall then be
limited to the maximum amounts as contained in the cost category standards from
section
578.8(a)(2)-(4)
of this Part. The maximum amount for administration, maintenance and support
costs shall be the cost category per diem multiplied by the total possible
patient days of the residential treatment facility at 90 percent utilization.
Reimbursement is calculated by determining the lower of the adjusted allowed
budgeted cost or the maximum amount, and trending the result to the budget
report period.
(iv) The per diem
rate of payment for operating and capital costs shall be calculated based upon
patient days contained in the approved utilization plan.
(v) More than one rate of payment may be
calculated to coincide with the residential treatment facility's planned
utilization, and budgeted costs; which shall be determined at the
commissioner's discretion.
(vi) The
residential treatment facility shall submit monthly reports of actual
utilization during the first year of operation.
(vii) If the residential treatment facility's
actual monthly utilization significantly exceeds the residential treatment
facility's planned monthly utilization, the rates of payment shall be
recalculated using reimbursable operating and capital costs as determined in
subparagraphs (i)-(iii) of this paragraph, trended to the appropriate period,
and divided by actual patient days. The commissioner may adjust retroactively
or prospectively the residential treatment facility's rates of
payment.
(c)
For a currently certified residential treatment facility increasing certified
bed capacity by 20 percent or more, the rate of payment shall be determined in
accordance with paragraph (b)(1) of this section. However, the commissioner
shall take into consideration the actual cost and patient day experience of the
existing residential treatment facility when reviewing budget(s), and shall
expect the reconfigured residential treatment facility to demonstrate economies
of scale.
(d) For a currently
certified residential treatment facility decreasing certified bed capacity by
20 percent or more, the rate of payment may be computed using the facility's
existing reimbursement adjusted by the budgeted variable costs associated with
the decrease in certified capacity. Rate(s) of payment may be calculated to
reflect a phase down period, and a budget based period thereafter. Each period
may not exceed 12 months.
(1) Rates of payment
calculated for the phase down period shall be developed from the residential
treatment facility's existing reimbursement, adjusted by any variable cost
decreases or extraordinary cost increases, and adjusted by the phase down
utilization. More than one rate of payment may be calculated to coincide with
the facility's phase down period, which shall be determined at the
commissioner's discretion.
(i) The existing
rate of payment is multiplied by the patient days used in the calculation of
that rate of payment, resulting in a dollar amount of reimbursement.
(ii) The amount of reimbursement is adjusted
by the applicable amount of variable cost decrease and the amount of any
extraordinary cost associated with the phase down.
(iii) The total reimbursement is then divided
by the product of the targeted certified capacity for the applicable period of
the phase down, multiplied by the number of days in the period and by a minimum
utilization of 96 percent.
(2) The rate of payment for the subsequent
budget based period shall be developed from the residential treatment
facility's existing reimbursement, adjusted by any variable cost decreases or
extraordinary cost increases, adjusted for inflation as appropriate, and
adjusted to the staffing standards for medical/clinical and nursing categories,
as approved by the commissioner.
(i) The
existing rate of payment is multiplied by the patient days used in the
calculation of that rate of payment, resulting in a dollar amount of
reimbursement. The reimbursement is then increased by an appropriate inflation
factor, as determined by the commissioner.
(ii) The amount of reimbursement is adjusted
by the applicable amount of variable cost decrease and the amount of any
extraordinary cost associated with the phase down.
(iii) Costs for the medical/clinical and
nursing categories are deleted, and are substituted as follows.
Medical/clinical and nursing costs are computed using the full time equivalent
staffing standards, as approved by the commissioner, multiplied by the
facility's salary and fringe benefit cost experience. The resulting combined
amount is subject to the average salary and fringe benefit screens, as
specified in section
578.8(a)(2)(ii) and
(iii) of this Part, multiplied by the
approved staffing standards. The cost data is made comparable by applying the
appropriate trend factors as determined by the commissioner.
(iv) Capital costs shall be updated in
accordance with the approved costs as specified in section
578.8(a)(5)
of this Part.
(v) The total
reimbursement (the sum of immediately preceding subparagraphs [i] through [iv]
of this paragraph) is then divided by the product of the certified capacity for
the phased down budget based period, multiplied by the number of days in the
period and by a minimum utilization of 96 percent.
(e) Financial reports pursuant to
section
578.5 of this
Part shall be submitted within 120 days as follows in accordance with whichever
is earlier, either:
(1) the first six-month
period during which the residential treatment facility has operated at an
average six-month utilization of at least 90 percent; or
(2) one year after the first resident was
admitted to the residential treatment facility. If the facility has not
attained an average of 90 percent utilization in the first year of operation,
the commissioner may adjust the report period to reflect a period where
utilization has averaged 90 percent.
(f) Upon submission of the financial reports
pursuant to subdivision (e) of this section, the commissioner may, at his
discretion, adjust retroactively the residential treatment facility's
budget-based rate(s) of payment to more accurately reflect the costs of
operating the facility. The facility shall receive the lower of its actual cost
or its budget based rate of payment.
