Pennsylvania Code
Title 55 - HUMAN SERVICES
Part III - MEDICAL ASSISTANCE MANUAL
Chapter 1187 - NURSING FACILITY SERVICES
Subchapter G - RATE SETTING
Section 1187.96 - Price- and rate-setting computations
Universal Citation: 55 PA Code ยง 1187.96
Current through Register Vol. 54, No. 44, November 2, 2024
(a) Using the NIS database in accordance with this subsection and § 1187.91 (relating to database), the Department will set prices for the resident care cost category.
(1) The Department will use each nursing
facility's cost reports in the NIS database to make the following computations:
(i) The total resident care cost for each
cost report will be divided by the total facility CMI from the available
February 1 picture date closest to the midpoint of the cost report period to
obtain case-mix neutral total resident care cost for the cost report
year.
(ii) The case-mix neutral
total resident care cost for each cost report will be divided by the total
actual resident days for the cost report year to obtain the case-mix neutral
resident care cost per diem for the cost report year.
(iii) The Department will calculate the
3-year arithmetic mean of the case-mix neutral resident care cost per diem for
each nursing facility to obtain the average case-mix neutral resident care cost
per diem of each nursing facility.
(2) The average case-mix neutral resident
care cost per diem for each nursing facility will be arrayed within the
respective peer groups, and a median determined for each peer group.
(3) For rate years 2006-2007, 2007-2008,
2009-2010, 2010-2011 and 2011-2012, the median used to set the resident care
price will be the phase-out median as determined in accordance with §
1187.98 (relating to phase-out
median determination).
(4) The
median of each peer group will be multiplied by 1.17, and the resultant peer
group price assigned to each nursing facility in the peer group.
(5) The price derived in paragraph (4) for
each nursing facility will be limited by §
1187.107 (relating to limitations
on resident care and other resident related cost centers) and the amount will
be multiplied each quarter by the respective nursing facility MA CMI to
determine the nursing facility resident care rate. The MA CMI picture date data
used in the rate determination are as follows: July 1 rate-February 1 picture
date; October 1 rate-May 1 picture date; January 1 rate-August 1 picture date;
and April 1 rate-November 1 picture date.
(6) For rate years 2010-2011, 2011-2012 and
2012-2013, unless the nursing facility is a new nursing facility, the resident
care rate used to establish the nursing facility's case-mix per diem rate will
be a blended resident care rate.
(i) The
nursing facility's blended resident care rate for the 2010-2011 rate year will
equal 75% of the nursing facility's 5.01 resident care rate calculated in
accordance with subparagraph (iv) plus 25% of the nursing facility's 5.12
resident care rate calculated in accordance with subparagraph (iv).
(ii) The nursing facility's blended resident
care rate for the 2011-2012 rate year will equal 50% of the nursing facility's
5.01 resident care rate calculated in accordance with subparagraph (v) and 50%
of the nursing facility's 5.12 resident care rate calculated in accordance with
subparagraph (v).
(iii) The nursing
facility's blended resident care rate for the 2012-2013 rate year will equal
25% of the nursing facility's 5.01 resident care rate calculated in accordance
with subparagraph (v) and 75% of the nursing facility's 5.12 resident care rate
calculated in accordance with subparagraph (v).
(iv) For the rate year 2010-2011, each
nursing facility's blended resident care rate will be determined based on the
following calculations:
(A) For the first
quarter of the rate year (July 1, 2010-September 30, 2010), the Department will
calculate each nursing facility's blended resident care rate as follows:
(I) The Department will calculate a 5.12
resident care rate for each nursing facility in accordance with paragraphs
(1)-(5). The CMI values the Department will use to determine each nursing
facility's total facility CMIs and facility MA CMI, computed in accordance with
§
1187.93 (relating to CMI
calculations), will be the RUG-III version 5.12 44 group values as set forth in
Appendix A. The resident assessment that will be used for each resident will be
the most recent classifiable resident assessment of any type.
(II) The Department will calculate a 5.01
resident care rate for each nursing facility in accordance with paragraphs
(1)-(5). The CMI values the Department will use to determine each nursing
facility's total facility CMIs and facility MA CMI, computed in accordance with
§
1187.93, will be the RUG-III
version 5.01 44-group values as set forth in Appendix A. The resident
assessment that will be used for each resident will be the most recent
comprehensive resident assessment.
(III) The nursing facility's blended resident
care rate for the quarter beginning July 1, 2010, and ending September 30,
2010, will be the sum of the nursing facility's 5.01 resident care rate
multiplied by 0.75 and the nursing facility's 5.12 resident care rate
multiplied by 0.25.
(B)
For the remaining 3 quarters of the 2010-2011 rate year (October 1 through
December 31; January 1 through March 31; April 1 through June 30), the
Department will calculate each nursing facility's blended resident care rate as
follows:
(I) The Department will calculate a
quarterly adjusted 5.12 resident care rate for each nursing facility in
accordance with paragraph (5). The CMI values used to determine each nursing
facility's MA CMI, computed in accordance with §
1187.93, will be the RUG-III
version 5.12 44 group values as set forth in Appendix A. The resident
assessment that will be used for each resident will be the most recent
classifiable resident assessment of any type.
(II) The Department will calculate a
quarterly adjusted 5.01 resident care rate for each nursing facility by
multiplying the nursing facility's prior quarter 5.01 resident care rate by the
percentage change between the nursing facility's current quarter 5.12 resident
care rate and the nursing facility's previous quarter 5.12 resident care rate.
The percentage change will be determined by dividing the nursing facility's
current quarter 5.12 resident care rate by the nursing facility's previous
quarter 5.12 resident care rate.
(III) The nursing facility's blended resident
care rate for the 3 remaining quarters of the rate year will be the sum of the
nursing facility's quarterly adjusted 5.01 resident care rate multiplied by
0.75 and the nursing facility's quarterly adjusted 5.12 resident care rate
multiplied by 0.25.
(v) For rate years 2011-2012 and 2012-2013,
each nursing facility's blended resident care rate will be determined based on
the following calculations:
(A) For the first
quarter of each rate year (July 1-September 30), the Department will calculate
each nursing facility's blended resident care rate as follows:
(I) The Department will calculate a 5.12
resident care rate for each nursing facility in accordance with paragraphs
(1)-(5). The CMI values used to determine each nursing facility's total
facility CMIs and facility MA CMI, computed in accordance with § 1187.93,
will be the RUG-III version 5.12 44 group values as set forth in Appendix A.
The resident assessment that will be used for each resident will be the most
recent classifiable resident assessment of any type.
(II) The Department will calculate a 5.01
resident care rate for each nursing facility by multiplying the nursing
facility's prior April 1st quarter 5.01 resident care rate by the percentage
change between the nursing facility's current 5.12 resident care rate and the
nursing facility's prior April 1st quarter 5.12 resident care rate. The
percentage change will be determined by dividing the nursing facility's current
5.12 resident care by the nursing facility's April 1st quarter 5.12 resident
care rate.
(III) The nursing
facility's blended resident care rate for the quarter beginning July 1, 2011,
and ending September 30, 2011, will be the sum of the nursing facility's 5.01
resident care rate multiplied by 0.50 and the nursing facility's 5.12 resident
care rate multiplied by 0.50.
(IV)
The nursing facility's blended resident care rate for the quarter beginning
July 1, 2012, and ending September 30, 2012, will be the sum of the nursing
facility's 5.01 resident care rate multiplied by 0.25 and the nursing
facility's 5.12 resident care rate multiplied by 0.75.
(B) For the remaining 3 quarters of each rate
year (October 1 through December 31; January 1 through March 31; April 1
through June 30), the Department will calculate each nursing facility's blended
resident care rate as follows:
(I) The
Department will calculate a quarterly adjusted 5.12 resident care rate for each
nursing facility in accordance with paragraph (5). The CMI values used to
determine each nursing facility's MA CMI, computed in accordance with §
1187.93, will be the RUG-III version 5.12 44 group values as set forth in
Appendix A. The resident assessment that will be used for each resident will be
the most recent classifiable resident assessment of any type.
(II) The Department will calculate a
quarterly adjusted 5.01 resident care rate for each nursing facility by
multiplying the nursing facility's prior quarter 5.01 resident care rate by the
percentage change between the nursing facility's current quarter 5.12 resident
care rate and the nursing facility's previous quarter 5.12 resident care rate.
The percentage change will be determined by dividing the nursing facility's
current quarter 5.12 resident care rate by the nursing facility's previous
quarter 5.12 resident care rate.
(III) For the remaining 3 quarters of rate
year 2011-2012 (October 1 through December 31; January 1 through March 31;
April 1 through June 30), each nursing facility's blended resident care rate
will be the sum of the nursing facility's quarterly adjusted 5.01 resident care
rate multiplied by 0.50 and the nursing facility's quarterly adjusted 5.12
resident care rate multiplied by 0.50.
(IV) For the remaining 3 quarters of rate
year 2012-2013 (October 1 through December 31; January 1 through March 31;
April 1 through June 30), each nursing facility's blended resident care rate
will be the sum of the nursing facility's quarterly adjusted 5.01 resident care
rate multiplied by 0.25 and the facility's quarterly adjusted 5.12 resident
care rate multiplied by 0.75.
(7) Beginning with rate year 2013-2014, and
thereafter, the Department will calculate each nursing facility's resident care
rate in accordance with paragraphs (1)-(5). The CMI values used to determine
each nursing facility's total facility CMIs and facility MA CMI, computed in
accordance with § 1187.93, will be the RUG-III version 5.12 44 group
values as set forth in Appendix A. The resident assessment that will be used
for each resident will be the most recent classifiable resident assessment of
any type.
(b) Using the NIS database in accordance with this subsection and § 1187.91, the Department will set prices for the other resident related cost category.
(1) The Department will use each nursing
facility's cost reports in the NIS database to make the following computations:
(i) The total other resident related cost for
each cost report will be divided by the total actual resident days for the cost
report year to obtain the other resident related cost per diem for the cost
report year.
(ii) The Department
will calculate the 3-year arithmetic mean of the other resident related cost
for each nursing facility to obtain the average other resident related cost per
diem of each nursing facility.
(2) The average other resident related cost
per diem for each nursing facility will be arrayed within the respective peer
groups and a median determined for each peer group.
(3) For rate years 2006-2007, 2007-2008,
2009-2010, 2010-2011 and 2011-2012, the median used to set the other resident
related price will be the phase-out median as determined in accordance with
§ 1187.98.
(4) The median of
each peer group will be multiplied by 1.12, and the resultant peer group price
assigned to each nursing facility in the peer group. This price for each
nursing facility will be limited by §
1187.107 to determine the nursing
facility other resident related rate.
(c) Using the NIS database in accordance with this subsection and § 1187.91, the Department will set prices for the administrative cost category.
(1) The Department will use each nursing
facility's cost reports in the NIS database to make the following computations:
(i) The total actual resident days for each
cost report will be adjusted to a minimum 90% occupancy, if applicable, in
accordance with §
1187.23 (relating to nursing
facility incentives and adjustments).
(ii) The total allowable administrative cost
for each cost report will be divided by the total actual resident days,
adjusted to 90% occupancy, if applicable, to obtain the administrative cost per
diem for the cost report year.
(iii) The Department will calculate the
3-year arithmetic mean of the administrative cost for each nursing facility to
obtain the average administrative cost per diem of each nursing
facility.
(2) The average
administrative cost per diem for each nursing facility will be arrayed within
the respective peer groups and a median determined for each peer
group.
(3) For rate years
2006-2007, 2007-2008, 2009-2010, 2010-2011 and 2011-2012, the median used to
set the administrative price will be the phase-out median as determined in
accordance with § 1187.98.
(4)
The median of each peer group will be multiplied by 1.04, and the resultant
peer group price will be assigned to each nursing facility in the peer group to
determine the nursing facility's administrative rate.
(d) Using the NIS database in accordance with this subsection and § 1187.91, the Department will set a rate for the capital cost category for each nursing facility by adding the nursing facility's fixed property component, movable property component and real estate tax component and dividing the sum of the three components by the nursing facility's total actual resident days, adjusted to 90% occupancy, if applicable.
(1) The Department will determine
the fixed property component of each nursing facility's capital rate as
follows:
(i) The Department will multiply the
total number of the nursing facility's allowable beds as of April 1,
immediately preceding the rate year, by $26,000 to determine the nursing
facility's allowable fixed property cost.
(ii) The Department will multiply the result
by the financial yield rate.
(2) The Department will determine the movable
property component of each nursing facility's capital rate based on the audited
actual costs of major movable property as set forth in the most recent audited
MA-11 cost report available in the NIS database in accordance with §
1187.91. This amount is referred to as the nursing facility's allowable movable
property cost.
(3) The Department
will determine the real estate tax cost component of each nursing facility's
capital rate based on the audited actual real estate tax cost as set forth in
the most recent audited MA-11 cost report available in the NIS
database.
(e) The following applies to the computation of nursing facilities' per diem rates:
(1) The nursing facility per diem rate will
be computed by adding the resident care rate, the other resident related rate,
the administrative rate and the capital rate for the nursing
facility.
(2) For each quarter of
the 2006-2007 and 2007-2008 rate-setting years, the nursing facility per diem
rate will be computed as follows:
(i)
Generally. If a nursing facility is not a new nursing facility
or a nursing facility experiencing a change of ownership during the rate year,
that nursing facility's resident care rate, other resident related rate,
administrative rate and capital rate will be computed in accordance with
subsections (a)-(d) and the nursing facility's per diem rate will be the sum of
those rates multiplied by a budget adjustment factor determined in accordance
with subparagraph (iv).
(ii)
New nursing facilities. If a nursing facility is a new nursing
facility for purposes of §
1187.97(1)
(relating to rates for new nursing facilities, nursing facilities with a change
of ownership, reorganized nursing facilities and former prospective payment
nursing facilities) that nursing facility's resident care rate, other resident
related rate, administrative rate and capital rate will be computed in
accordance with §
1187.97(1), and
the nursing facility's per diem rate will be the sum of those rates multiplied
by a budget adjustment factor determined in accordance with subparagraph
(iv).
(iii)
Nursing
facilities with a change of ownership and reorganized nursing
facilities. If a nursing facility undergoes a change of ownership
during the rate year, that nursing facility's resident care rate, other
resident related rate, administrative rate and capital rate will be computed in
accordance with §
1187.97(2), and
the nursing facility's per diem rate will be the sum of those rates multiplied
by a budget adjustment factor determined in accordance with subparagraph
(iv).
(iv)
Budget
adjustment factor. The budget adjustment factor for the rate year will
be determined in accordance with the formula set forth in the Commonwealth's
approved State Plan.
(3)
For rate years 2010-2011, 2011-2012 and 2012-2013, unless the nursing facility
is a new nursing facility, the nursing facility per diem rate will be computed
by adding the blended resident care rate, the other resident related rate, the
administrative rate and the capital rate for the nursing facility.
The provisions of this §1187.96 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 § 1187.80 (relating to failure to file an MA-11); 55 Pa. Code § 1187.93 (relating to CMI calculations); 55 Pa. Code § 1187.91 (relating to database); 55 Pa. Code § 1187.95 (relating to general principles for rate and price setting); 55 Pa. Code § 1187.97 (relating to rates for new nursing facilities, nursing facilities with a change of ownership, reorganized nursing facilities, and former prospective payment nursing facilities); 55 Pa. Code § 1187.98 (relating to phase-out median determination); 55 Pa. Code § 1187.104 (relating to limitations on payment for reserved beds); and 55 Pa. Code § 1187.141 (relating to nursing facility's right to appeal and to a hearing).
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