PROPOSED RULEMAKING
[55 PA. CODE CH. 1187]
MA Day of Care Definition
[34 Pa.B. 4462] The Department of Public Welfare (Department), under the authority of 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), proposes to amend § 1187.2 (relating to definitions).
Purpose of the Proposed Rulemaking
The proposed rulemaking expands the definition of ''MA day of care'' under § 1187.2 to include additional categories of days of care provided to Medical Assistance (MA) nursing facility residents. In addition, the proposed rulemaking adds definitions for ''LTCCAP--Long Term Care Capitated Assistance Program'' and ''MA MCO--Medical Assistance Managed Care Organization,'' as these terms are included in the amended definition of ''MA day of care.''
Need for the Proposed Rulemaking
Currently, § 1187.2 defines an MA day of care as ''a day of care for which the Department pays 100% of the MA rate for an MA resident or a day of care for which the Department and the resident pay 100% of the MA rate for the MA resident's care.'' Under the case-mix payment system in Chapter 1187 (relating to nursing facility services), the Department uses the definition of ''MA day of care'' for two purposes. First, the Department uses the definition to determine which residents are included in the calculation of every nursing facility's quarterly MA Case-Mix Index (CMI) under § 1187.93 (relating to CMI calculations). Under § 1187.93(2), a nursing facility's MA CMI is ''the arithmetic mean of the individual CMIs for residents for whom the Department paid an MA day of care on the [quarterly] picture date.'' The Department uses the MA CMI to adjust a nursing facility's case-mix per diem rate every quarter during the rate year as specified in § 1187.95(b)(1) (relating to general principles for rate and price setting).
Second, the Department uses the definition of ''MA day of care'' to determine which nursing facilities are eligible to receive a disproportionate share incentive payment under § 1187.111 (relating to disproportionate share incentive payments). To qualify for a disproportionate share incentive payment, a nursing facility must maintain an annual overall occupancy rate of at least 90% along with an annual MA occupancy rate of at least 80%. A nursing facility's MA occupancy rate is determined by dividing the MA days of care paid by the Department by the total actual days of care provided by the nursing facility.
As it is presently written, the definition only recognizes as an ''MA day of care'' days for which payment is made under the Department's Fee-For-Service Program (Program). While most MA nursing facility residents receive nursing facility services through the Program, some MA recipients may receive nursing facility services through the HealthChoices Program, the Department's managed care program, and the Long Term Care Capitated Assistance Program (LTCCAP), the Department's community-based managed care program for the frail and elderly. When a HealthChoices managed care organization under contract with the Department (MA MCO) or an LTCCAP provider authorizes nursing facility services for an enrolled MA recipient, the MA MCO or LTCCAP provider, and not the Department, pays the nursing facility for the days of care which the nursing facility provides to the MA recipient. Since these days of care do not meet the current definition of ''MA day of care,'' they are not counted in calculating the nursing facility's MA CMI or in determining whether the nursing facility qualifies for a disproportionate share incentive payment.
During the past several years, the number of MA recipients receiving services under the HealthChoices Program and the LTCCAP has grown. As these managed care programs continue to expand, more MA recipients who are admitted to nursing facilities will likely be enrolled in either an MA MCO or the LTCCAP and more days of care provided in nursing facilities will be paid for by MA MCOs and LTCCAP providers. In anticipation of this change in circumstance, MA nursing facility providers have asked the Department to modify its policies to recognize these days as MA days of care. Upon consideration of this request, the Department agrees that expanding the current definition of ''MA day of care'' is appropriate and in the best interest of the MA Program.
Requirements
The Department is proposing to expand the definition of ''MA day of care'' to include days of care for which an MA MCO or an LTCCAP provider pays 100% of its negotiated rate or fee for the MA resident's care in a nursing facility and days of care for which the resident and an MA MCO or an LTCCAP provider pays 100% of their negotiated rate or fee for the MA resident's care in a nursing facility. The Department is also proposing to amend the definition to clarify that days of care provided to an MA resident receiving hospice services in a nursing facility which are paid for by the Department are also considered as MA days of care.
In addition, the definitions for ''LTCCAP'' and ''MA MCO'' are being added to clarify the terms included in the revised definition of ''MA day of care.'' LTCCAP is the Department's community-based managed care program for the frail elderly based on the Federal Program of All-Inclusive Care for the Elderly. MA MCO is an entity under contract with the Department that manages the purchase and provision of health services, including nursing facility services, for MA recipients who are enrolled as members in the entity's health service plan.
The intent of the proposed rulemaking is to define an MA day of care in a manner that fully recognizes the services that nursing facilities are providing to MA recipients. This proposed rulemaking is consistent with the Department's ongoing efforts to ensure that MA recipients continue to receive access to medically necessary nursing facility services.
Affected Organizations
The proposed rulemaking will affect nursing facilities enrolled in the MA Program.
Accomplishments and Benefits
Consistent with the recommendation of nursing facility providers, the proposed rulemaking will amend the current regulation to expand the definition of ''MA day of care.'' The proposed rulemaking may result in increased reimbursement and, therefore, benefit both nursing facility providers and residents who will be assured continued access to medically necessary nursing facility services.
Fiscal Impact
Public Sector
Commonwealth
By expanding the definition of ''MA day of care,'' more nursing facilities may qualify for disproportionate share incentive payments and nursing facilities that currently receive disproportionate share incentive payments may experience an increase in those payments. Nursing facilities may also experience an increase in their case-mix per diem rates as a result of an increase in the MA CMI used to establish the nursing facility's case-mix per diem rate.
Political Subdivisions
The amendment to the definition of ''MA day of care'' may result in increased disproportionate share incentive payments to county operated nursing facilities that provide nursing facility services to MA recipients. County operated nursing facilities may also experience an increase in their case-mix per diem rates as a result of an increase in the MA CMI used to establish the nursing facility's case-mix per diem rate.
Private Sector
The amendment to the definition of ''MA day of care'' may result in increased disproportionate share incentive payments to qualified privately owned and operated nursing facilities that provide nursing facility services to MA recipients. Privately owned and operated nursing facilities may also experience an increase in their case-mix per diem rates as a result of an increase in the MA CMI used to establish the nursing facility's case-mix per diem rate.
General Public
Although the proposed rulemaking amends policies that may result in increased disproportionate share incentive payments and case-mix per diem rates to MA nursing facilities, there will be no fiscal impact on the general public.
Paperwork Requirements
There are no new or additional paperwork requirements.
Effective Date
The Department proposes that the amendment to the definition of ''MA day of care'' should take effect January 1, 2004, and apply to disproportionate share incentive payments for fiscal periods ending on and after December 31, 2003, and to the MA CMI for picture dates beginning February 1, 2004.
Sunset Date
There is no sunset date. The Department will review the effectiveness of this regulation on an ongoing basis and evaluate the need for further amendments.
Public Comments
Interested persons are invited to submit written comments, suggestions or objections regarding the proposed rulemaking to the Department of Public Welfare, Division of Long Term Care Client Services, P. O. Box 2675, Harrisburg, PA 17105, Attn: Gail Weidman within 30 calendar days after the date of publication in the Pennsylvania Bulletin. Persons with a disability may use the AT&T Relay Service, (800) 654-5984 (TDD users) or (800) 654-5988 (voice users).
Regulatory Review
Under section 5(a) of the Regulatory Review Act (71 P. S. § 745.5(a)), on August 3, 2004, the Department submitted a copy of this proposed rulemaking and a copy of a Regulatory Analysis Form to the Independent Regulatory Review Commission (IRRC) and to the Chairpersons of the House Committee on Health and Human Services and the Senate Committee on Public Health and Welfare. A copy of this material is available to the public upon request.
Under section 5(g) of the Regulatory Review Act, IRRC may convey any comments, recommendations or objections to the proposed rulemaking within 30 days of the close of the public comment period. The comments, recommendations or objections shall specify the regulatory review criteria which have not been met. The Regulatory Review Act specifies detailed procedures for review, prior to final publication of the rulemaking, by the Depart-ment, the General Assembly and the Governor of comments, recommendations or objections raised.
ESTELLE B. RICHMAN,
SecretaryFiscal Note: 14-486. (1) General Fund; (2) Implementing Year 2003-04 is $106,000; (3) 1st Succeeding Year 2004-05 is $237,000; 2nd Succeeding Year 2005-06 is $245,000; 3rd Succeeding Year 2006-07 is $252,000; 4th Succeeding Year 2007-08 is $260,000; 5th Succeeding Year 2008-09 is $268,000; (4) 2002-03 Program--$777,084,000; 2001-02 Program--$761,877,000; 2000-01 Program--$722,565,000; (7) Medical Assistance--Long Term Care; (8) recommends adoption. Funding for this proposed rulemaking has been provided through the Department's Intergovernmental Transfer Agreement for fiscal years 2003-04 and 2004-05.
Annex A
TITLE 55. PUBLIC WELFARE
PART III. MEDICAL ASSISTANCE MANUAL
CHAPTER 1187. NURSING FACILITY SERVICES
Subchapter A. GENERAL PROVISIONS § 1187.2. Definitions.
The following words and terms, when used in this chapter, have the following meanings, unless the context clearly indicates otherwise:
* * * * * LTCCAP--Long Term Care Capitated Assistance Program--The Department's community-based managed care program for the frail elderly based on the Federal Program of All-inclusive Care for the Elderly (PACE) (see section 1894 of the Social Security Act (42 U.S.C.A. § 1395eee)).
* * * * * MA day of care--[A day of care for which the Department pays 100% of the MA rate for an MA resident or a day of care for which the Department and the resident pay 100% of the MA rate for the MA resident's care.] A day of care for which one of the following applies:
(i) The Department pays 100% of the MA rate for an MA resident.
(ii) The Department and the resident pay 100% of the MA rate for an MA resident.
(iii) An MA MCO or an LTCCAP provider that provides managed care to MA residents, pays 100% of the negotiated rate or fee for an MA resident's care.
(iv) The resident and either an MA MCO or LTCCAP provider that provides managed care to an MA resident, pays 100% of the negotiated rate or fee for an MA resident's care.
(v) The Department pays for care provided to an MA resident receiving hospice services in a nursing facility.
MA MCO--Medical Assistance Managed Care Organization--An entity under contract with the Department that manages the purchase and provision of health services, including nursing facility ser-vices, for MA recipients who are enrolled as members in the entity's health service plan.
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[Pa.B. Doc. No. 04-1491. Filed for public inspection August 13, 2004, 9:00 a.m.]
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