Utah Administrative Code
Topic - Health
Title R414 - Integrated Healthcare
Rule R414-504 - Nursing Facility Payments
Section R414-504-3 - Principles of Facility Case Mix Rates and Other Payments
Current through Bulletin 2024-06, March 15, 2024
The following principles apply to the payment of freestanding and provider-based nursing facilities for services provided to qualified Medicaid patients, as defined in Rule R414-502. This rule does not affect the system for reimbursement for intensive-skilled Medicaid patient add-on amounts.
(1) A portion of total payments to nursing facilities for qualified Medicaid patients is based on a prospective facility case mix rate. In addition, these facilities shall be paid a flat basic operating expense payment. The balance of the total payments will be paid in aggregate to facilities as required by Section R414-504-3 based on other authorized factors, including property and behaviorally complex residents, in the proportion that the facility qualifies for the factor.
(2) Each quarter, the Department shall calculate a new case mix index for each nursing facility. The case mix index is based on three months of MDS assessment data. The newly calculated case mix index is applied to a new rate at the beginning of a quarter according to the following schedule:
(3) MDS and optional state assessment (OSA) data is used in calculating each facility's case mix index and upper payment limit (UPL) gap. Beginning July 1, 2023, each facility must complete an OSA in conjunction with any Omnibus Budget Reconciliation Act or prospective payment system assessments. This information is required by the state to calculate the case mix index. The MDS and OSA data is submitted by each facility and each facility is responsible for the accuracy of its data. Each facility shall ensure needed sections of the MDS and OSA are completed so that a PDPM or resource utilization group score may be calculated. The Department may exclude inaccurate or incomplete MDS data from calculations.
(4)
(5) A facility may apply for a special add-on rate for behaviorally complex residents by filing a written request with the Division of Integrated Healthcare (DIH). The Department may approve an add-on rate if an assessment of the acuity and needs of the patient demonstrates that the facility is not adequately reimbursed by the case mix score for that patient. The rate is added on for the specific resident's payment and is not subsumed as part of the facility case mix rate. The Office of Long -Term Services and Supports determines qualification for any additional payment. DIH shall determine the amount of any add-on.
(6) The Department pays property costs separately from the case mix rate.
(7) Reimbursement for nursing home rates is in accordance with Attachment 4.19-D of the Medicaid State Plan, which is incorporated by reference in Section R414-1-5.
(8) A provider may challenge the rate set pursuant to this rule using the appeal in Rule R410-14. This applies to which rate methodology is used as well as to the specifics of implementation of the methodology. A provider must exhaust administrative remedies before challenging rates in any other forum.
(9) The Department reimburses swing beds, transitional care unit beds, and small health care facility beds that are used as nursing facility beds, using the prior calendar year statewide average of the daily nursing facility rate.
(10) Unless specified otherwise, the Department may withhold Title XIX payments from providers if:
(11) The Department shall provide written notice before withholding payments.
(12) When the Department rescinds withholding of payments to a provider, it will, without notice, resume payments according to the regular claims payment cycle.