Texas Administrative Code
Title 1 - ADMINISTRATION
Part 15 - TEXAS HEALTH AND HUMAN SERVICES COMMISSION
Chapter 353 - MEDICAID MANAGED CARE
Subchapter G - STAR+PLUS
Section 353.608 - Minimum Payment Amounts to Qualified Nursing Facilities
Universal Citation: 1 TX Admin Code ยง 353.608
Current through Reg. 49, No. 38; September 20, 2024
(a) Introduction. This section establishes minimum payment amounts for certain non-state government-owned nursing facility providers participating in the STAR+PLUS Program, or other Medicaid managed care programs offering nursing facility services, and the conditions for receipt of these amounts.
(b) Definitions.
(1) Calculation Period--A month
used to calculate the Minimum Payment Amount. There are six calculation periods
in Eligibility Period One, twelve calculation periods in Eligibility Period
Two, nine calculation periods in Eligibility Period Two-A, and five calculation
periods in Eligibility Period Three.
(2) CHOW Application--An application filed
with the Department of Aging and Disability Services for a nursing facility
change of ownership.
(3) Clean
Claim--A claim submitted by a provider for health care services rendered to an
enrollee with the data necessary for the managed care organization to
adjudicate and accurately report the claim. Claims for Nursing Facility Unit
Rate services that meet the Department of Aging and Disability Services'
criteria for clean claims submission are considered Clean Claims. Additional
information regarding Department of Aging and Disability Services' criteria for
clean claims submission is included in HHSC's Uniform Managed Care Manual,
which is available on HHSC's website.
(4) DADS--The Texas Department of Aging and
Disability Services, or its successor agency.
(5) Eligibility Period--A period of time for
which a Qualified Nursing Facility may receive the Minimum Payment Amounts
described in this section.
(6)
Eligibility Period One--The first period of time for which a Qualified Nursing
Facility may receive the Minimum Payment Amounts described in this section,
covering dates of service from the later of March 1, 2015, or the date on which
nursing facility services become managed care services, to August 31,
2015.
(7) Eligibility Period
Two--The second period of time for which a Qualified Nursing Facility may
receive the Minimum Payment Amounts described in this section, covering dates
of service from September 1, 2015, to August 31, 2016.
(8) Eligibility Period Two-A--The third
period of time for which a Qualified Nursing Facility may receive the Minimum
Payment Amounts described in this section, covering dates of service from
December 1, 2015, to August 31, 2016.
(9) Eligibility Period Three--The fourth
period of time for which a Qualified Nursing Facility may receive the Minimum
Payment Amounts described in this section, covering dates of service from April
1, 2017, to August 31, 2017. Centers for Medicare & Medicaid Services (CMS)
approval is required for any payments to be made under this section for
Eligibility Period Three.
(10)
First Payment--The payment made in the ordinary course of business by MCOs to
Qualified Nursing Facilities for the provision of covered services to Medicaid
recipients.
(11) HHSC--The Texas
Health and Human Services Commission or its designee.
(12) Intergovernmental transfer (IGT)--A
transfer of public funds from a non-state governmental entity to
HHSC.
(13) IGT Responsibility--The
IGT owed by a non-state governmental entity, as determined by HHSC, for funding
the non-federal share of the increase in the payments to the MCOs due to the
Minimum Payment Amount program.
(14) MCO--A Medicaid managed care
organization contracted with HHSC to provide nursing facility services to
Medicaid recipients.
(15) Minimum
Payment Amount--The minimum payment amount for a Qualified Nursing Facility, as
calculated under subsection (d) of this section.
(16) Network Nursing Facility--A nursing
facility that has a contract with an MCO for the delivery of Medicaid covered
benefits to the MCO's enrollees.
(17) Non-state Governmental Entity--A
hospital authority, hospital district, health district, city or
county.
(18) Non-state
Government-owned Nursing Facility--A network nursing facility where a non-state
governmental entity holds the license and is a party to the nursing facility's
Medicaid provider enrollment agreement with the state.
(19) Nursing Facility Add-on Services--The
types of services that are provided in the nursing facility setting by a
provider, but are not included in the Nursing Facility Unit Rate, including but
not limited to emergency dental services, physician-ordered rehabilitative
services, customized power wheel chairs, and augmentative communication
devices.
(20) Nursing Facility Unit
Rate--The types of services included in the DADS daily rate for nursing
facility providers, such as room and board, medical supplies and equipment,
personal needs items, social services, and over-the-counter drugs. The Nursing
Facility Unit Rate also includes applicable nursing facility rate enhancements
as described in §
RSA
355.308 of this title (relating to Direct
Care Staff Rate Component), and professional and general liability insurance.
Nursing Facility Unit Rates exclude Nursing Facility Add-on Services.
(21) Qualified Nursing Facility--A Non-state
Government-Owned Network Nursing Facility that meets the eligibility
requirements described in subsection (e) of this section.
(22) Public Funds--Funds derived from taxes,
assessments, levies, investments, and other public revenues within the sole and
unrestricted control of a non-state governmental entity that holds the license
and is party to the Medicaid provider enrollment agreement with the state.
Public funds do not include gifts, grants, trusts, or donations, the use of
which is conditioned on supplying a benefit solely to the donor or grantor of
the funds.
(23) Regional Healthcare
Partnership (RHP)--A collaboration of interested participants that work
collectively to develop and submit to the state a regional plan for health care
delivery system reform as defined and established under Chapter 354, Subchapter
D of this title (relating to Texas Healthcare Transformation and Quality
Improvement Program).
(24) RUG--For
the purpose of calculations described in subsection (d)(1) of this section, a
resource utilization group under Medicare Part A as established by the Centers
for Medicare & Medicaid Services (CMS). For the purpose of calculations
described in subsection (d)(2) of this section, a resource utilization group
under the RUG-III 34 group classification system, Version 5.20, index
maximizing, as established by the state and CMS.
(25) Second Payment--The amount a Qualified
Nursing Facility can receive that is equal to the Minimum Payment Amount less
adjustments to that amount, as described in subsection (d) of this
section.
(c) Payment of Minimum Payment Amount to Qualified Nursing Facilities.
(1) An MCO must pay a Qualified Nursing
Facility at or above the Minimum Payment Amount in two installment payments for
a Calculation Period, using the calculation methodology described in subsection
(d) of this section.
(A) The MCO must make
the First Payment no later than ten calendar days after a Qualified Nursing
Facility or its agent submits a Clean Claim for a Nursing Facility Unit Rate to
the HHSC-designated portal or the MCO's portal, whichever occurs first. The MCO
will make the First Payment for the Nursing Facility Unit Rate at or above the
prevailing rate established by HHSC for the date of service. HHSC's website
includes information concerning HHSC's prevailing rates. The MCO must make the
Second Payment no later than 10 calendar days after being notified of the
Second Payment amount by HHSC. The Second Payment will be the difference
between the Minimum Payment Amount and the adjustment to the Minimum Payment
Amount, as calculated by HHSC and described in subsection (d) of this
section.
(B) For purposes of
illustration only, if a Qualified Nursing Facility provider files a Clean Claim
for a Nursing Facility Unit Rate on March 6, 2015, the MCO must make the First
Payment no later than March 16, 2015, and the Second Payment no later than 10
calendar days after being notified of the Second Payment amount by
HHSC.
(2) HHSC will
provide each MCO with a list of its Qualified Nursing Facilities for each
Calculation Period as well as the Second Payment amount, as calculated by HHSC
and described in subsection (d) of this section, associated with the MCO's
members for each of its Qualified Nursing Facilities.
(d) Calculation of the Second Payment. HHSC will calculate the Second Payment for each Qualified Nursing Facility using the methodology detailed in this subsection. If a Qualified Nursing Facility is contracted with more than one MCO, HHSC will calculate a separate Second Payment for each MCO with which the Qualified Nursing Facility is contracted.
(1) Calculate the Minimum Payment Amount. The
Minimum Payment Amount is made up of multiple subsidiary amounts. There is a
subsidiary amount for each RUG.
(A) To
determine the subsidiary amount for a particular RUG, use the formula:
Subsidiary Amount = Days of Service x Medicare Rate, where:
(i) "Days of Service" is the total Medicaid
days of service for a particular RUG for clean claims for services that were
provided during the Calculation Period; and
(ii) "Medicare Rate" is the Medicare skilled
nursing facility payment rate for the RUG in effect on the date of
service.
(B) The Minimum
Payment Amount is equal to the sum of all subsidiary amounts calculated in
accordance with subparagraph (A) of this paragraph.
(2) Calculate the Adjustment to the Minimum
Payment Amount. The adjustment to the Minimum Payment Amount is equal to the
sum of all adjustments for each RUG. The adjustment to the Minimum Payment
Amount is determined as follows:
(A) First,
determine the amount of the First Payment to the nursing facility using the
formula: First Payment = Days of Service x MCO Rate, where:
(i) "Days of Service" is the total Medicaid
days of service for a particular RUG for clean claims for services that were
provided during the Calculation Period; and
(ii) "MCO Rate" is the rate paid by the MCO
for the particular RUG.
(B) Second, sum the result in subparagraph
(A) of this paragraph for each RUG.
(C) Third, add or subtract, as necessary, the
amount of payment adjustments to Nursing Facility Unit Rate claims for services
that were provided during the Calculation Period from the result in
subparagraph (B) of this paragraph.
(D) Fourth, determine the amount related to
the Nursing Facility Add-on Services using the formula: Nursing Facility Add-on
Amount = Days of Service x Per Diem, where:
(i) "Days of Service" equals the number used
in subparagraph (A)(i) of this paragraph; and
(ii) "Per Diem" is an estimate, as determined
by HHSC, of the weighted average per diem payment amount for Nursing Facility
Add-on Services provided to Medicaid recipients in Qualified Nursing
Facilities.
(I) For Eligibility Period One,
the per diem will equal $3.48.
(II)
For Eligibility Period Two, the per diem will equal $3.48 plus medical
inflation between the mid-point of Eligibility Period One and the mid-point of
Eligibility Period Two, as determined by HHSC.
(III) For Eligibility Period Two-A, the per
diem will equal $3.48 plus medical inflation between the mid-point of
Eligibility Period One and the mid-point of Eligibility Period Two-A, as
determined by HHSC.
(IV) For
Eligibility Period Three, the per diem will equal $3.48 plus medical inflation
between the mid-point of Eligibility Period One and the mid-point of
Eligibility Period Three, as determined by HHSC.
(E) Fifth, sum the result in
subparagraph (D) of this paragraph for each RUG.
(F) Sixth, determine the adjustment to the
Minimum Payment Amount by adding the result from subparagraph (E) of this
paragraph from the result from subparagraph (C) of this paragraph.
(3) Calculate the Second Payment.
To determine the Second Payment, subtract the adjustment to the Minimum Payment
Amount described in paragraph (2)(F) of this subsection from the Minimum
Payment Amount described in paragraph (1) of this subsection.
(e) Eligibility for Receipt of Minimum Payment Amounts.
(1) A nursing
facility is eligible to receive the Minimum Payment Amounts described in this
section if it complies with the requirements described in this subsection for
each Eligibility Period.
(2)
Eligibility Period One. A nursing facility is eligible to receive Minimum
Payment Amounts for Eligibility Period One if it meets the following
requirements:
(A) The nursing facility must
be a Non-state Government-owned Nursing Facility with a Medicaid contract
effective date of October 1, 2014, or earlier. HHSC will finalize its list of
eligible facilities on November 1, 2014. A facility may only be eligible if its
contract is assigned by DADS to a non-state government entity by October 31,
2014, with an effective date of October 1, 2014, or earlier.
(B) The Non-state Governmental Entity that
owns the nursing facility must have entered into an IGT Responsibility
agreement with HHSC by November 3, 2014. The IGT Responsibility agreement will
cover the estimated IGT Responsibility for the nursing facility for the
Eligibility Period.
(C) The
Non-state Governmental Entity that owns the nursing facility must certify the
following facts on a form prescribed by HHSC and the form must be received by
HHSC by November 3, 2014.
(i) That it is a
Non-state Government-owned Nursing Facility where a Non-state Governmental
Entity holds the license and is party to the facility's Medicaid
contract.
(ii) That all funds
transferred to HHSC via IGT for use as the state share of payments are Public
Funds.
(iii) That no part of any
payment made under the Minimum Payment Amount program under this section will
be used to pay a contingent fee, consulting fee, or legal fee associated with
the nursing facility's receipt of the Minimum Payment Amount funds.
(3) Eligibility Period
Two. A nursing facility is eligible to receive the Minimum Payment Amounts for
Eligibility Period Two if it has met the following requirements:
(A) The nursing facility must be a Non-state
Government-owned Nursing Facility with a Medicaid contract effective date of
March 1, 2015, or earlier. HHSC will finalize its list of eligible facilities
on March 1, 2015. A facility may only be eligible if its contract is assigned
by DADS to a non-state government entity by February 28, 2015, with an
effective date of March 1, 2015, or earlier.
(B) The Non-state Governmental Entity that
owns the nursing facility must have entered into an IGT Responsibility
agreement with HHSC by February 28, 2015. The IGT Responsibility agreement will
cover the estimated IGT Responsibility for the nursing facility for the
Eligibility Period.
(C) The
Non-state Governmental Entity that owns the nursing facility must certify the
following facts on a form prescribed by HHSC and the form must be received by
HHSC by February 28, 2014.
(i) That it is a
Non-state Government-owned Nursing Facility where a Non-state Governmental
Entity holds the license and is party to the facility's Medicaid
contract.
(ii) That all funds
transferred to HHSC via IGT for use as the state share of payments are Public
Funds.
(iii) That no part of any
payment made under the Minimum Payment Amount program under this section will
be used to pay a contingent fee, consulting fee, or legal fee associated with
the nursing facility's receipt of the Minimum Payment Amount funds.
(D) The Non-state Governmental
Entity that owns the nursing facility must submit to HHSC, upon demand, copies
of any contracts it has with third parties that reference the administration
of, or payments from, the Minimum Payment Amount program.
(4) Eligibility Period Two-A. A nursing
facility is eligible to receive the Minimum Payment Amounts for Eligibility
Period Two-A if it has met the following requirements:
(A) The nursing facility must not be eligible
to receive the Minimum Payment Amounts for Eligibility Period Two.
(B) The nursing facility must be a Non-state
Government-owned Nursing Facility with a Medicaid contract effective date of
June 1, 2015, or earlier. HHSC will finalize its list of eligible facilities on
June 1, 2015. A facility may only be eligible if its contract is assigned by
DADS to a non-state government entity by May 31, 2015, with an effective date
of June 1, 2015, or earlier.
(C)
The nursing facility must have given DADS written notice of the change of
ownership on or before February 1, 2015, but have not qualified for Eligibility
Period Two because its contract was not assigned by DADS to a non-state
government entity by February 28, 2015.
(D) DADS must have received all required
documents pertaining to the change of ownership (i.e., DADS must have a
complete application for a change of ownership license as described under 40
TAC §RSA 19.201(b) (relating to Criteria for Licensing)) by April 15,
2015.
(E) The Non-state
Governmental Entity that owns the nursing facility must have entered into an
IGT Responsibility agreement with HHSC by May 31, 2015. The IGT Responsibility
agreement must cover the estimated IGT Responsibility for the nursing facility
for the Eligibility Period.
(F) The
Non-state Governmental Entity that owns the nursing facility must certify the
following facts on a form prescribed by HHSC and the form must be received by
HHSC by May 31, 2015:
(i) that it is a
Non-state Government-owned Nursing Facility where a Non-state Governmental
Entity holds the license and is party to the facility's Medicaid
contract;
(ii) that all funds
transferred to HHSC via IGT for use as the state share of payments are Public
Funds; and
(iii) that no part of
any payment made under the Minimum Payment Amount program under this section
will be used to pay a contingent fee, consulting fee, or legal fee associated
with the nursing facility's receipt of the Minimum Payment Amount
funds.
(G) The Non-state
Governmental Entity that owns the nursing facility must submit to HHSC, upon
demand, copies of any contracts it has with third parties that reference the
administration of, or payments from, the Minimum Payment Amount
program.
(5) Eligibility
Period Three. A nursing facility is eligible to receive the Minimum Payment
Amounts for Eligibility Period Three if it has met the following requirements:
(A) The nursing facility was eligible to
receive the Minimum Payment Amounts for Eligibility Period Two or Eligibility
Period Two-A.
(B) The Non-state
Governmental Entity that owns the nursing facility must have submitted its
estimated IGT responsibility for the entire eligibility period no later than a
date determined by HHSC.
(C) The
Non-state Governmental Entity that owns the nursing facility must certify the
following facts on a form prescribed by HHSC and the form must be received by
HHSC by a date determined by HHSC:
(i) that
it is a Non-state Government-owned Nursing Facility where a Non-state
Governmental Entity holds the license and is party to the facility's Medicaid
contract;
(ii) that all funds
transferred to HHSC via IGT for use as the state share of payments are Public
Funds; and
(iii) that no part of
any payment made under the Minimum Payment Amount program under this section
will be used to pay a contingent fee, consulting fee, or legal fee associated
with the nursing facility's receipt of the Minimum Payment Amount
funds.
(D) The Non-state
Governmental Entity that owns the nursing facility must submit to HHSC, upon
demand, copies of any contracts it has with third parties that reference the
administration of, or payments from, the Minimum Payment Amount
program.
(6) Geographic
Proximity to Nursing Facility.
(A) For
eligibility period one, any nursing facility with a CHOW Application approved
by DADS with an effective date on or after October 1, 2014, must be located in
the same Regional Healthcare Partnership (RHP) as the Non-state Governmental
Entity taking ownership of the nursing facility.
(B) For eligibility periods two, two-A, and
three, any nursing facility with a CHOW Application approved by DADS with an
effective date on or after October 1, 2014, must be located in the same RHP as,
or within 150 miles of, the Non-state Governmental Entity taking ownership of
the nursing facility.
(f) Claims Filing Deadline. A Qualified Nursing Facility must file a Clean Claim for a Nursing Facility Unit Rate no later than 60 calendar days after the end of the Calculation Period within which the service is provided for the claim to qualify for the Minimum Payment Amount described in this section. The MCO must pay a Clean Claim that is filed after this deadline but within 365 calendar days of the date of service, at the standard rate established in the network provider agreement for Nursing Facility Unit Services; however, claims filed after the 60 deadline will not be incorporated in the calculation of the Minimum Payment Amount.
(g) IGT Responsibility.
(1) Timing. HHSC will determine IGT
responsibilities prior to finalizing the managed care capitation rates that
include the increase in payments to the MCOs due to the Minimum Payment Amounts
program for the Eligibility Period.
(2) Aggregate IGT Responsibility. The
aggregate IGT responsibility for all Qualified Nursing Facilities for an
Eligibility Period will be equal to the non-federal share of the increase in
the MCOs' capitation rates due to the Minimum Payment Amount program multiplied
by the estimated number of member months for which the MCOs will receive the
capitation rate during the eligibility period multiplied by 1.1.
(3) Allocation of Aggregate IGT
Responsibility to Individual Nursing Facilities. HHSC will allocate the
aggregate IGT responsibility to each qualified nursing facility based on the
percentage of the total increase in the MCOs' capitation rates due to the
Minimum Payment Amount program associated with the nursing facility in the base
period data used to develop the capitation rates.
(4) Reconciliation. HHSC will complete the
reconciliation in two parts.
(A) The first
reconciliation will occur no later than 120 days after the end of the
eligibility period.
(i) HHSC will compare the
amount transferred by the Non-state Governmental Entity to HHSC for the
eligibility period to the non-federal amount expended during the eligibility
period by HHSC for all Qualified Nursing Facilities owned by the Non-state
Governmental Entity.
(ii) The
calculation of the non-federal amount expended during the eligibility period by
HHSC for all Qualified Nursing Facilities owned by the Non-state Governmental
Entity will be the same as the calculation of allocated aggregate IGT
responsibility to all Qualified Nursing Facilities owned by the Non-state
Governmental Entity as described in paragraphs (2) and (3) of this subsection
with two exceptions:
(I) "Member months" will
be revised to reflect actual known member months for the eligibility period.
The revision will be conducted no sooner than the day after the last day of the
eligibility period and no later than 120 days after the end of the eligibility
period.
(II) The "Aggregate IGT
Responsibility" described in paragraph (2) of this subsection will be equal to
the non-federal share of the increase in the MCO's capitation rates due to the
Minimum Payment Amount program multiplied by the revised member months. The
calculation will not include the additional ten percent included in the
calculation of the original aggregate IGT responsibility.
(III) No other changes will be made to the
calculation of the allocated aggregate IGT responsibility and no other data
points included in the calculation will be updated for purposes of this
reconciliation.
(iii) If
the amount transferred by the Non-state Governmental Entity exceeds the
non-federal amount expended during the eligibility period by HHSC for all
Qualified Nursing Facilities owned by the Non-state Governmental Entity, HHSC
will refund the excess amount to the Non-state Governmental Entity, less two
percent of the amount expended during the eligibility period by HHSC for all
Qualified Nursing Facilities owned by the Non-state Governmental
Entity.
(iv) If the amount
transferred by the Non-state Governmental Entity is less than the non-federal
amount expended during the eligibility period by HHSC for all Qualified Nursing
Facilities owned by the Non-state Governmental Entity, HHSC will notify the
Non-state Governmental Entity of the amount of the shortfall and of a deadline
for the Non-state Governmental Entity to transfer the shortfall plus two
percent of the amount expended during the eligibility period by HHSC for all
Qualified Nursing Facilities owned by the Non-state Governmental
Entity.
(B) For
Eligibility Period Three only, HHSC may complete interim reconciliations
between August 31, 2017, and August 31, 2019, as updated enrollment data for
the Program Period, as reflected in adjusted member months, becomes available.
HHSC will follow the process described in subparagraph (A) of this paragraph
for such interim reconciliations.
(C) The second reconciliation will occur no
later than 25 months after the end of the eligibility period.
(i) HHSC will compare the amount transferred
by the Non-state Governmental Entity to HHSC for the eligibility period to the
non-federal amount expended during the eligibility period by HHSC for all
Qualified Nursing Facilities owned by the Non-state Governmental
Entity.
(ii) The calculation of the
non-federal amount expended during the eligibility period by HHSC for all
Qualified Nursing Facilities owned by the Non-state Governmental Entity will be
the same as the calculation of allocated aggregate IGT responsibility to all
Qualified Nursing Facilities owned by the Non-state Governmental Entity as
described in subparagraph (A) of this paragraph except that member months will
be revised to reflect updated actual known member months for the eligibility
period. The revision will be conducted sometime during the 25th month after the
end of the eligibility period.
(iii) If the amount transferred by the
Non-state Governmental Entity exceeds the non-federal amount expended during
the eligibility period by HHSC for all Qualified Nursing Facilities owned by
the Non-state Governmental Entity, HHSC will refund the excess amount to the
Non-state Governmental Entity.
(iv)
If the amount transferred by the Non-state Governmental Entity is less than the
non-federal amount expended during the eligibility period by HHSC for all
Qualified Nursing Facilities owned by the Non-state Governmental Entity, HHSC
will notify the Non-state Governmental Entity of the amount of the shortfall
and of a deadline for the Non-state Governmental Entity to transfer the
shortfall.
(D) If the
Non-state Governmental Entity does not timely complete the transfer described
in subparagraph (A), (B), or (C) of this paragraph, HHSC may:
(i) withhold any or all future Medicaid
payments from the Non-state Governmental Entity until HHSC has recovered an
amount equal to the shortfall; and
(ii) retain any funds that would normally be
returned to the Non-state Governmental Entity as part of the reconciliation
process.
(5)
All IGT calculations are solely at the discretion of HHSC and are not open to
desk review or appeal.
(h) Changes of Ownership. If a Qualified Nursing Facility changes ownership to another non-state government entity during either of the eligibility periods described in subsection (e) of this section, then the data used for the calculations described in subsection (d) of this section will include data from the facility for the entire Calculation Period, including data relating to payments for days of service provided under the prior owner.
(i) Recoupment.
(1) If payments under this section result in
an overpayment to a nursing facility, or in the event of a disallowance by CMS
of federal participation related to a nursing facility's receipt of or use of
payment amounts authorized under subsection (d) of this section, the MCO(s) may
recoup an amount equivalent to the amount of the second payment amount that was
overpaid or disallowed.
(2) Second
payment amount payments under this section may be subject to any adjustments
for payments made in error, including, without limitation, adjustments made
under the Texas Administrative Code, the Code of Federal Regulations and state
and federal statutes. The MCO(s) may recoup an amount equivalent to any such
adjustment from the nursing facility in question.
(3) If HHSC determines that part of any
payment made under the Minimum Payment Amount program was used to pay a
contingent fee, consulting fee, or legal fee associated with the nursing
facility's receipt of the Minimum Payment Amount funds, the MCO(s) may recoup
an amount equal to the second payment amount from the nursing facility in
question.
(4) If HHSC determines
that an ownership change to a Non-state Governmental Entity was based on
fraudulent or misleading statements on a nursing facility CHOW application or
during the CHOW process, the MCO(s) may recoup an amount equal to the second
payment amount from the nursing facility in question for any eligibility period
affected by the fraudulent or misleading statement.
(j) Dates the Minimum Payment Amount is available. The minimum payment requirements described in this section will only cover dates of service from the later of March 1, 2015, or the date on which nursing facility services become managed care services, to August 31, 2017.
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