Pennsylvania Code
Title 55 - HUMAN SERVICES
Part III - MEDICAL ASSISTANCE MANUAL
Chapter 1187 - NURSING FACILITY SERVICES
Subchapter A - GENERAL PROVISIONS
Section 1187.2 - Definitions
Current through Register Vol. 53, No. 52, December 30, 2023
The following words and terms, when used in this chapter, have the following meanings, unless the context clearly indicates otherwise:
Accrual basis-An accounting method by which revenue is recorded in the period when it is earned, regardless of when it is collected, and expenses are recorded in the period when they are incurred, regardless of when they are paid.
Allowable bed-A nursing facility bed that is not subject to the limitation in § 1187.113 (relating to capital component payment limitation).
Allowable costs-Costs as identified in this chapter which are necessary and reasonable for an efficiently and economically operated nursing facility to provide services to MA residents.
Amortization-administrative costs-Costs not directly related to capital formation which are expended over a period greater than 1 year.
Amortization-capital costs-Preopening and ongoing costs directly related to capital formation and development which are expended over a period greater than 1 year. These costs include loan acquisition expenses as well as interest paid during the construction or preopening purchase period on a debt to acquire, build or carry real property.
Audited MA-11 cost reports-MA-11 cost reports that have been subjected to desk or field audit procedures by the Commonwealth and issued to providers.
Benefits, fringe-Nondiscriminatory employee benefits which are normally provided to nursing facility employees in conjunction with their employment status.
Benefits, nonstandard or nonuniform-Employe benefits provided to selected individuals, which are not provided to all nursing facility employes in conjunction with their employment status, or benefits which are not normally provided to employes.
CMI-Case-Mix Index-A number value score that describes the relative resource use for the average resident in each of the groups under the RUG-III classification system based on the assessed needs of the resident.
CMI Report-A report generated by the Department from submitted resident assessment records and tracking forms and verified by a nursing facility each calendar quarter that identifies the total facility and MA CMI average for the picture date, the residents of the nursing facility on the picture date and the following for each identified resident:
(i) The resident's payor status.
(ii) The resident's RUG category and CMI.
(iii) The resident assessment used to determine the resident's RUG category and CMI and the date and type of the assessment.
Classifiable data element-A data element on the Federally Approved Pennsylvania Specific Minimum Data Set (PA specific MDS) which is used for the classification of a resident into one of the RUG-III categories.
Cost centers-The four general categories of costs:
(i) Resident care costs.
(ii) Other resident related costs.
(iii) Administrative costs.
(iv) Capital costs.
County nursing facility-
(i) A long-term care nursing facility that is:
(ii) For the purposes of this definition, "controlled" in clause (C) means the power to direct or cause to direct the management and policies of the nursing facility, whether through equitable ownership of voting securities or otherwise.
(iii) The term does not include intermediate care facilities for persons with an intellectual disability controlled or totally funded by a county institution district or county government.
DME-Durable medical equipment-
(i) Movable property that:
(ii) Any item of DME is an item of movable property. There are two classes of DME:
Department-The Department of Public Welfare, which is the Commonwealth agency designated as the single State agency responsible for the administration of the Commonwealth's MA Program.
Department of Aging-The Commonwealth agency that, under a memorandum of understanding with the Department, conducts prescreening of target applicants applying for nursing facility services and the screening of MA nursing facility applicants to determine the need for services.
Department of Health-The Commonwealth agency that, under a memorandum of understanding with the Department, conducts certification surveys of nursing facilities in the MA Program.
Depreciated replacement cost-
(i) As used in conjunction with fixed property, depreciated replacement cost is the amount required to replace the fixed property with new and modern fixed property using the most current technology, code requirements/standards and construction materials that will duplicate the production capacity and utility of the existing fixed property at current market prices for labor and materials, less an allowance for accrued depreciation.
(ii) As used in conjunction with movable property, depreciated replacement cost is the amount required to replace the movable property with new and modern movable property, less an allowance for accrued depreciation.
Depreciation-A loss of utility and a reduction in value caused by obsolescence or physical deterioration such as wear and tear, decay, dry rot, cracks, encrustation or structural defects of property, plant and equipment.
Facility MA CMI-The arithmetic mean CMI for MA residents in the nursing facility for whom the Department paid an MA day of care on the picture date.
Federally Approved Pennsylvania (PA) Specific Minimum Data Set (MDS)- A minimum core of assessment items with definitions and coding categories needed to comprehensively assess a nursing facility resident.
Financial yield rate-The composite Aaa Corporate Bond Yield Average as reported in Moody's Bond Record for the 60-month period ending in March of each year.
Fixed property-Land, land improvements, buildings including detached buildings and their structural components, building improvements, and fixed equipment located at the site of the licensed nursing facility that is used by the nursing facility in the course of providing nursing facility services to residents. Included within this term are heating, ventilating, and air-conditioning systems and any equipment that is either affixed to a building or structural component or connected to a utility by direct hook-up.
Hospital-based nursing facility-A nursing facility that was receiving a hospital-based rate as of June 30, 1995, and is:
(i) Located physically within or on the immediate grounds of a hospital.
(ii) Operated or controlled by the hospital.
(iii) Licensed or approved by the Department of Health and meets the requirements of 28 Pa. Code § 101.31 (relating to hospital requirements) and shares support services and administrative costs of the hospital.
Independent assessor-An agent of the Department who performs comprehensive evaluations and makes recommendations to the Department regarding the need for nursing facility services or the need for specialized services, or both, for individuals seeking admission to or residing in nursing facilities.
Initial Federally-approved PA Specific MDS-The first assessment or tracking form completed for a resident upon admission.
Interest-
(i)Capital interest. The direct actual cost incurred for funds borrowed to obtain fixed property, major movable property or minor movable property.
(ii)Other interest. The direct actual cost incurred for funds borrowed on a short-term basis to finance the day-to-day operational activities of the nursing facility, including the acquisition of supplies.
Intergovernmental Transfer Agreement-The formal document that executes the transfer of funds or certification of funds to the Commonwealth by another unit of government within this Commonwealth in accordance with section 1903 of the Social Security Act (42 U.S.C.A. § 1396b(w)(6)(A).
Investment income-Actual or imputed income available to or accrued by a nursing facility from funds which are invested, loaned or which are held by others for the benefit of the nursing facility.
LTCCAP-Long-Term Care Capitated Assistance Program-The Department's community-based managed care program for the frail elderly based on the Federal Program of All-inclusive Care for the Elderly (PACE) (see section 1894 of the Social Security Act (42 U.S.C.A. § 1395eee)).
MA MCO-Medical Assistance Managed Care Organization-An entity under contract with the Department that manages the purchase and provision of health services, including nursing facility services, for MA recipients who are enrolled as members in the entity's health service plan.
MA conversion resident-A nursing facility resident who applies for and meets the eligibility requirements for MA payment for nursing facility services.
MA day of care-A day of care for which one of the following applies:
(i) The Department pays 100% of the MA rate for an MA resident.
(ii) The Department and the resident pay 100% of the MA rate for an MA resident.
(iii) An MA MCO or an LTCCAP provider that provides managed care to MA residents, pays 100% of the negotiated rate or fee for an MA resident's care.
(iv) The resident and either an MA MCO or LTCCAP provider that provides managed care to an MA resident, pays 100% of the negotiated rate or fee for an MA resident's care.
(v) The Department pays for care provided to an MA resident receiving hospice services in a nursing facility.
MA-11-Financial and Statistical Report Schedules (uniform nursing facility cost report)-A package of certifications, schedules and instructions which makes up the comprehensive cost report.
MSA group-Metropolitan Statistical Area-A statistical standard classification designated and defined by the Federal Office of Management and Budget following a set of official published standards.
Medicare Provider Reimbursement Manual (Centers for Medicare and Medicaid Services (CMS) Pub. 15-1)-Guidelines and procedures for Medicare reimbursement.
Movable property-A tangible item that is used in a nursing facility in the course of providing nursing facility services to residents and that is not fixed property or a supply. There are two classes of movable property:
(i)Major movable property. Any movable property that has an acquisition cost of $500 or more.
(ii)Minor movable property. Any movable property that has an acquisition cost of less than $500.
NIS-Nursing Information System-The comprehensive automated database of nursing facility, resident and fiscal information needed to operate the Pennsylvania Case-Mix Payment System.
Net operating costs-The following cost centers:
(i) Resident care costs.
(ii) Other resident related costs.
(iii) Administrative costs.
New nursing facility-A newly constructed, licensed and certified nursing facility; or an existing nursing facility that has never participated in the MA Program or an existing nursing facility that has not participated in the MA Program during the past 2 years.
Nursing facility-
(i) A long-term care nursing facility, that is:
(ii) The term does not include intermediate care facilities for persons with an intellectual disability, Federal or State-owned longterm care nursing facilities, Veteran's homes or county nursing facilities.
Peer groups-Groupings of nursing facilities for payment purposes under the case-mix system.
Pennsylvania Case-Mix Payment System-The nursing facility payment system which combines the concepts of resident assessments and prospective payment.
Per diem rate-A comprehensive rate of payment to a nursing facility for covered services for a resident day.
Picture date-The first calendar day of the second month of each calendar quarter.
Preadmission screening and resident review-The preadmission screening process that identifies target residents regardless of their payment source; and the resident review process that reviews target residents to determine the continued need for nursing facility services and the need for specialized services.
Price-A derivative of the allowable costs of the net operating cost centers which has been adjusted by 117% for resident care costs; 112% for other resident related costs; and 104% for administrative costs.
Private pay rate-The nursing facility's usual and customary charges made to the general public for a semiprivate room inclusive of ancillary charges.
Private pay resident-An individual for whom payment for services is made with the individual's resources, private insurance or funds from liable third parties other than the MA Program.
RNAC-Registered Nurse Assessment Coordinator-An individual licensed as a registered nurse by the State Board of Nursing and employed by a nursing facility, and who is responsible for coordinating and certifying completion of the resident assessment.
RUG-III-Resource Utilization Group, Version III-A category-based resident classification system used to classify nursing facility residents into groups based on their characteristics and clinical needs.
Real estate tax cost-The cost of real estate taxes assessed against a nursing facility for a 12-month period, except that, if the nursing facility is contractually or otherwise required to make a payment in lieu of real estate taxes, that nursing facility's "cost of real estate taxes" is deemed to be the amount it is required to pay for a 12-month period.
Rebasing-The process of updating cost data for subsequent rate years.
Related party-A person or entity that is associated or affiliated with or has control of or is controlled by the nursing facility or has an ownership or equity interest in the nursing facility. The term "control," as used in this definition, means the direct or indirect power to influence or direct the actions or policies of an organization, institution or person.
Related services and items-Services and items necessary for the effective use of exceptional DME. The term is limited to:
(i) Delivery, set up and pick up of the equipment.
(ii) Service, maintenance and repairs of the equipment to the extent covered by an agreement to rent the equipment.
(iii) Extended warranties.
(iv) Accessories and supplies necessary for the effective use of the equipment.
(v) Periodic assessments and evaluations of the resident.
(vi) Training of appropriate nursing facility staff and the resident in the use of the equipment.
Reorganized nursing facility-An MA participating nursing facility that changes ownership as a result of the reorganization of related parties or a transfer of ownership between related parties.
Resident assessment-A standardized evaluation of each resident's physical, mental, psychosocial and functional status.
Resident Data Reporting Manual-The Department's Manual of instructions for submission of resident assessment records and tracking forms and verification of the CMI report.
Resident day-The period of service for one resident for a continuous 24 hours of service. The day of the resident's admission is counted as a resident day. The day of discharge is not counted as a resident day.
Resident personal funds-Funds entrusted to a nursing facility by a resident which are in the possession and control of a nursing facility and are held, safeguarded, managed and accounted for by the facility in a fiduciary capacity for the resident.
Specially adapted DME-DME that is uniquely constructed or substantially adapted or modified in accordance with the written orders of a physician for the particular use of one resident, making its contemporaneous use by another resident unsuitable.
Special rehabilitation facility-A nursing facility with residents more than 70% of whom have a neurological/neuromuscular diagnosis and severe functional limitations.
Supply-
(i) A tangible item that is used in a nursing facility in the course of providing nursing facility services to residents and is normally consumed either in a single use or within a single 12-month period.
(ii) Examples of supplies include:
Target applicant or resident-An individual with a serious mental illness, intellectual disability or other related condition seeking admission to or residing in a nursing facility.
Total facility CMI-The arithmetic mean CMI of all residents regardless of the residents' sources of funding.
UMR-Utilization Management Review-An audit conducted by the Department's medical and other professional personnel to monitor the accuracy and appropriateness of payments to nursing facilities and to determine the necessity for continued stay of residents.
Year one of implementation-The period of January 1, 1996, through June 30, 1996.
Year two of implementation-The period of July 1, 1996, through June 30, 1997.
Year three of implementation and thereafter-The period of July 1, 1997, through June 30, 1998, and each subsequent Commonwealth fiscal year.
The provisions of this § 1187.2 amended February 9, 2002, effective retroactively to November 1, 1999, for the definitions of "DME-durable medical equipment," "related services and items" "specially adapted DME." The remainder of amendment takes effect July 1, 2002, 32 Pa.B. 734; corrected April 19, 2002, effective 2/9/2002, 32 Pa.B. 1962; amended the definition of "MA day of care" effective 1/1/2004, and applies to DSH payments for fiscal periods ending on and after December 31, 2003, and to the MA CMI for picture dates beginning February 1, 2004, 35 Pa.B. 5120; amended June 23, 2006, effective 7/1/2006, 36 Pa.B. 3207; amended November 26, 2010, effective 11/27/2010, 40 Pa.B. 6782; amended August 26, 2011, effective retroactive to July 1, 2010, 41 Pa.B. 4630; amended July 18, 2014, effective 7/19/2014, 44 Pa.B. 4498.
The provisions of this § 1187.2 amended under sections 201(2), 206(2), 403(b), 443.1(5) and 454 of the Public Welfare Code (62 P. S. §§ 201(2), 206(2), 403(b), 443.1(5) and 454).
This section cited in 55 Pa. Code § 41.92 (relating to expedited disposition for certain appeals); 55 Pa. Code § 1187.2a (relating to clarification of the term "written"-statement of policy); 55 Pa. Code § 1187.91 (relating to database); 55 Pa. Code § 1187.152 (relating to additional reimbursement of nursing facility services related to exceptional DME); 55 Pa. Code § 1187.155 (relating to exceptional DME grants-payment conditions and limitations); 55 Pa. Code § 1187.158 (relating to appeals); and 55 Pa. Code § 1189.2 (relating to definitions).
