Pennsylvania Code
Title 55 - HUMAN SERVICES
Part III - MEDICAL ASSISTANCE MANUAL
Chapter 1189 - COUNTY NURSING FACILITY SERVICES
Subchapter E - PAYMENT CONDITIONS, LIMITATIONS AND ADJUSTMENTS
Section 1189.105 - Incentive payments
Universal Citation: 55 PA Code ยง 1189.105
Current through Register Vol. 54, No. 12, March 23, 2024
(a) Disproportionate share incentive payment.
(1) A disproportionate share incentive
payment will be made based on MA paid days of care times the per diem incentive
to facilities meeting the following criteria for a 12-month facility cost
reporting period:
(i) The county nursing
facility shall have an annual overall occupancy rate of at least 90% of the
total available bed days.
(ii) The
county nursing facility shall have an MA occupancy rate of at least 80%. The MA
occupancy rate is calculated by dividing the MA days of care paid by the
Department by the total actual days of care.
(2) The disproportionate share incentive
payments will be based on the following:
| Overall Occupancy | MA Occupancy (y) | Per Diem Incentive | |
| Group A | 90% | [GREATER THAN EQUAL TO] 90% y | $3.32 |
| Group B | 90% | 88% [LESS THAN EQUAL TO] y [LESS THAN] 90% | $2.25 |
| Group C | 90% | 86% [LESS THAN EQUAL TO] y [LESS THAN] 88% | $1.34 |
| Group D | 90% | 84% [LESS THAN EQUAL TO] y [LESS THAN] 86% | $0.81 |
| Group E | 90% | 82% [LESS THAN EQUAL TO] y [LESS THAN] 84% | $0.41 |
| Group F | 90% | 80% [LESS THAN EQUAL TO] y [LESS THAN] 82% | $0.29 |
(3)
The disproportionate share incentive payments as described in paragraph (2)
will be inflated forward using the first quarter issue CMS Nursing Home Without
Capital Market Basket Index to the end point of the rate setting year for which
the payments are made.
(4) These
payments will be made annually within 120 days after the submission of an
acceptable cost report provided that payment will not be made before 210 days
of the close of the county nursing facility fiscal year.
(5) For the period July 1, 2005, to June 30,
2009, the disproportionate share incentive payment to qualified county nursing
facilities shall be increased to equal two times the disproportionate share per
diem incentive calculated in accordance with paragraph (3).
(i) For the period commencing July 1, 2005,
through June 30, 2006, the increased incentive applies to cost reports filed
for the fiscal period ending December 31, 2005.
(ii) For the period commencing July 1, 2006,
through June 30, 2007, the increased incentive applies to cost reports filed
for the fiscal period ending December 31, 2006.
(iii) For the period commencing July 1, 2007,
through June 30, 2008, the increased incentive applies to cost reports filed
for the fiscal period ending December 31, 2007.
(iv) For the period commencing July 1, 2008,
through June 30, 2009, the increased incentive applies to cost reports filed
for the fiscal period ending December 31, 2008.
(b) Pay for performance incentive payment. The Department will establish pay for performance measures that will qualify a county nursing facility for additional incentive payments in accordance with the formula and qualifying criteria in the Commonwealth's approved State Plan. For pay for performance payment periods beginning on or after July 1, 2010, in determining whether a county nursing facility qualifies for a quarterly pay for performance incentive, the facility's MA CMI for a picture date will equal the arithmetic mean of the individual CMIs for MA residents identified in the facility's CMI report for the picture date. An MA resident's CMI will be calculated using the RUG-III version 5.12 44 group values in Chapter 1187, Appendix A (relating to resource utilization group index scores for case-mix adjustment in the nursing facility reimbursement system) and the most recent classifiable assessment of any type for the resident.
(c) Supplemental ventilator care and tracheostomy care payments.
(1)
Supplemental ventilator care
payments.
(i) A supplemental
ventilator care payment will be made each calendar quarter, effective July 1,
2012, through June 30, 2014, to county nursing facilities subject to the
following:
(A) To qualify for the supplemental
ventilator care payment, the county nursing facility shall satisfy both of the
following threshold criteria on the applicable picture date:
(I) The county nursing facility shall have a
minimum of ten MA-recipient residents who receive medically necessary
ventilator care.
(II) The county
nursing facility shall have a minimum of 10% of its MA-recipient resident
population receiving medically necessary ventilator care.
(B) For purposes of subparagraph (i), the
percentage of the county nursing facility's MA-recipient residents who require
medically necessary ventilator care will be calculated by dividing the total
number of MA-recipient residents who receive medically necessary ventilator
care by the total number of MA-recipient residents as described in subparagraph
(ii)(A). The result of this calculation will be rounded to two percentage
decimal points. (For example, 0.0945 will be rounded to 0.09 (or 9%); 0.1262
will be rounded to 0.13 (or 13%).)
(C) To qualify as an MA-recipient resident
who receives medically necessary ventilator care, the resident shall be listed
as an MA resident and have a positive response for the MDS item for ventilator
use on the Federally-approved PA-specific MDS assessment listed on the county
nursing facility's CMI report for the applicable picture date.
(D) The number of total MA-recipient
residents is the number of MA-recipient residents listed on the county nursing
facility's CMI report for the applicable picture date. MA-pending individuals
or those individuals found to be MA eligible after the county nursing facility
submits a valid CMI report for the picture date as provided under §
1187.33(a)(5)
(relating to resident data and picture date reporting requirements) may not be
included in the count and may not result in an adjustment of the percent of
ventilator dependent MA residents.
(E) The applicable picture dates and the
authorization of a quarterly supplemental ventilator care payment are as
follows:
| Picture Dates | Authorization Schedule |
| February 1 | September |
| May 1 | December |
| August 1 | March |
| November 1 | June |
(F)
If a county nursing facility fails to submit a valid CMI report for the picture
date as provided under §
1187.33(a)(5),
the facility cannot qualify for a supplemental ventilator care
payment.
(ii) A county
nursing facility's supplemental ventilator care payment is calculated as
follows:
(A) The supplemental ventilator care
per diem is ((number of MA-recipient residents who receive medically necessary
ventilator care/total MA-recipient residents) x $69) x (the number of
MA-recipient residents who receive medically necessary ventilator care/total
MA-recipient residents).
(B) The
amount of the total supplemental ventilator care payment is the supplemental
ventilator care per diem multiplied by the number of paid MA facility and
therapeutic leave days.
(2)
Supplemental ventilator care and
tracheostomy care payment.
(i) A
supplemental ventilator care and tracheostomy care payment will be made each
calendar quarter, effective July 1, 2014, to county nursing facilities subject
to the following:
(A) To qualify for the
supplemental ventilator care and tracheostomy care payment, the county nursing
facility shall satisfy both of the following threshold criteria on the
applicable picture date:
(I) The county
nursing facility shall have a minimum of ten MA-recipient residents who receive
medically necessary ventilator care or tracheostomy care.
(II) The county nursing facility shall have a
minimum of 10% of its MA-recipient resident population receiving medically
necessary ventilator care or tracheostomy care.
(B) For purposes of subparagraph (i), the
percentage of the county nursing facility's MA-recipient residents who require
medically necessary ventilator care or tracheostomy care will be calculated by
dividing the total number of MA-recipient residents who receive medically
necessary ventilator care or tracheostomy care by the total number of
MA-recipient residents as described in subparagraph (ii)(A). The result of this
calculation will be rounded to two percentage decimal points. (For example,
0.0945 will be rounded to 0.09 (or 9%); 0.1262 will be rounded to 0.13 (or
13%).)
(C) To qualify as an
MA-recipient resident who receives medically necessary ventilator care or
tracheostomy care, the resident shall be listed as an MA resident and have a
positive response for the MDS item for ventilator use or tracheostomy care on
the Federally-approved PA-specific MDS assessment listed on the county nursing
facility's CMI report for the applicable picture date.
(D) The number of total MA-recipient
residents is the number of MA-recipient residents listed on the county nursing
facility's CMI report for the applicable picture date. MA-pending individuals
or those individuals found to be MA eligible after the county nursing facility
submits a valid CMI report for the picture date as provided under §
1187.33(a)(5) may
not be included in the count and may not result in an adjustment of the percent
of ventilator dependent or tracheostomy care MA residents.
(E) The applicable picture dates and the
authorization of a quarterly supplemental ventilator care and tracheostomy care
payment are as follows:
| Picture Dates | Authorization Schedule |
| February 1 | September |
| May 1 | December |
| August 1 | March |
| November 1 | June |
(F)
If a county nursing facility fails to submit a valid CMI report for the picture
date as provided under §
1187.33(a)(5),
the facility cannot qualify for a supplemental ventilator care and tracheostomy
care payment.
(ii) A
county nursing facility's supplemental ventilator care and tracheostomy care
payment is calculated as follows:
(A) The
supplemental ventilator care and tracheostomy care per diem is ((number of
MA-recipient residents who receive medically necessary ventilator care or
tracheostomy care/total MA-recipient residents) x $69) x (the number of
MA-recipient residents who receive medically necessary ventilator care or
tracheostomy care/total MA-recipient residents).
(B) The amount of the total supplemental
ventilator care and tracheostomy care payment is the supplemental ventilator
care and tracheostomy care per diem multiplied by the number of paid MA
facility and therapeutic leave days.
(3)
Waiver to 180-day billing
requirement. If the Department grants a county nursing facility a
waiver to the 180-day billing requirement, the MA-paid days that may be billed
under the waiver and after the authorization date of the waiver will not be
included in the calculation of the supplemental ventilator care payment under
paragraph (1)(ii) or the supplemental ventilator care and tracheostomy care
payment under paragraph (2)(ii). The Department will not retroactively revise
the supplemental payment amount under paragraphs (1) and (2).
(4)
Calculation of quarterly
payments. The paid MA facility and therapeutic leave days used to
calculate a qualifying facility's supplemental ventilator care or supplemental
ventilator care and tracheostomy care payments under paragraphs (1)(ii) and
(2)(ii) will be obtained from the calendar quarter that contains the picture
date used in the qualifying criteria as described in paragraphs (1) and
(2).
(5)
Quarterly
payments. The supplemental ventilator care or supplemental ventilator
care and tracheostomy care payments will be made quarterly in each month listed
in paragraphs (1) and (2).
The provisions of this § 1189.105 amended under sections 201(2), 206(2), 403(b) and 443.1 of the Public Welfare Code (62 P. S. §§ 201(2), 206(2), 403(b) and 443.1).
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