No. 28066 (Amendment): R414-504. Nursing Facility Payments

DAR File No.: 28066
Filed: 07/01/2005, 04:21
Received by: NL

 

RULE ANALYSIS

Purpose of the rule or reason for the change:

This rulemaking is necessary to simplify and improve the accuracy of nursing facility rate calculations.

 

Summary of the rule or change:

This rulemaking amends the nursing facility payments rule by specifying the months of the year in which the nursing facility rates will be adjusted, and specifying the 3-month period of case mix data to be included in the calculation of the case mix component of the rate.

 

State statutory or constitutional authorization for this rule:

Sections 26-1-5 and 26-18-3

 

Anticipated cost or savings to:

the state budget:

There is no impact to the state budget because the clarifications in this rulemaking do not change the amount of state and federal funds that will be distributed to regulated health care facilities.

 

local governments:

There is no budget impact to local governments because the clarifications in this rulemaking do not change the amount of state and federal funds that will be distributed to regulated health care facilities.

 

other persons:

There is no budget impact to other persons because the clarifications in this rulemaking do not change the amount of state and federal funds that will be distributed to regulated health care facilities.

 

Compliance costs for affected persons:

There are no compliance costs because the clarifications in this rulemaking do not change the amount of state and federal funds that will be distributed to regulated health care facilities.

 

Comments by the department head on the fiscal impact the rule may have on businesses:

This rule clarification makes current policy of the Department on rate setting clearer and will not have a negative fiscal impact on this industry. David N. Sundwall, MD, Executive Director

 

The full text of this rule may be inspected, during regular business hours, at the Division of Administrative Rules, or at:

Health
Health Care Financing, Coverage and Reimbursement Policy
CANNON HEALTH BLDG
288 N 1460 W
SALT LAKE CITY UT 84116-3231

 

Direct questions regarding this rule to:

Craig Devashrayee at the above address, by phone at 801-538-6641, by FAX at 801-538-6099, or by Internet E-mail at [e-mail]

 

Interested persons may present their views on this rule by submitting written comments to the address above no later than 5:00 p.m. on:

08/15/2005

 

This rule may become effective on:

08/16/2005

 

Authorized by:

David N. Sundwall, Executive Director

 

 

RULE TEXT

R414. Health, Health Care Financing, Coverage and Reimbursement Policy.

R414-504. Nursing Facility Payments.

R414-504-3. Principles of Facility Case Mix Rates and Other Payments.

The following principles apply to the payment of freestanding and provider based nursing facilities for services rendered to nursing care level I, II, and III Medicaid patients, as defined in R414-502. This rule does not affect the system for reimbursement for intensive skilled Medicaid patients.

(1) Approximately 59% of total payments in aggregate to nursing facilities for nursing care level I, II and III Medicaid patients are based on a prospective facility case mix rate. In addition, these facilities shall be paid a flat basic operating expense payment equal to approximately 29% of the total payments. The balance of the total payments will be paid in aggregate to facilities as required by 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) Pending federal approval of the Medicaid rate adjustment, the request to allow the implementation of the Utah Nursing Care Facility Assessment Act, and consequent rules, the case mix rate in effect on July 2, 2004, as well as other components of the total rate will be the same as those in effect on June 30, 2004.

(3) Upon federal approval of the nursing care facility rate adjustment and the assessment pursuant to R414-504-3(2), rate components will be adjusted retroactively to July 2, 2004, to reflect the additional funding made available. The adjusted rate will be further adjusted retroactive to September 15, 2004 to include the application of a Fair Rental Value reimbursement system for property as addressed in R414-504-3(7).

(4) The Department calculates [each nursing facility's]a new case mix index for each nursing facility quarterly. The case mix index is based [up]on [the previous ]3[-]months [moving average case mix history]of MDS assessment data. The newly calculated case mix index is applied to [the case mix]a new rate [one month after]at the [end of the]beginning of a quarter according to the following schedule[.]:

(a) January, February and March MDS assessments are used for July 1 rates.

(b) April, May and June MDS assessments are used for October 1 rates.

(c) July, August and September MDS assessments are used for January 1 rates.

(d) October, November and December MDS assessments are used for April 1 rates.

(e) To ensure the inclusion of all MDS assessments, the initial MDS dataset used to calculate case mix under this section includes all months not previously used in a case mix calculation.

(5) A facility may apply for a special add-on rate for behaviorally complex residents by filing a written request with the Division of Health Care Financing. 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 RUGS 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 Resident Assessment Section will make the determination as to qualification for any additional payment. The Division of Health Care Financing shall determine the amount of any add-on.

(6) Property costs are paid separately from the RUGS rate.

 

. . . . . . .

 

KEY: Medicaid

2005

26-1-5

26-18-3

26-35a