NOTICES
Payment for Nursing Facility Services Provided by Special Rehabilitation Nursing Facilities; Change in Methods and Standards of Setting Payment Rates
[40 Pa.B. 7441]
[Saturday, December 25, 2010]This announcement provides notice that the Department of Public Welfare (Department) is considering amending its regulations and the Commonwealth's Title XIX State Plan to change its methods and standards for payment of Medical Assistance (MA) nursing facility services provided by Special Rehabilitation Nursing Facilities (SRF) beginning January 1, 2011.
Background
Currently, the MA Program pays for nursing facility services provided to MA eligible recipients in SRFs at per diem rates that are computed using the case-mix payment system set forth in the Department's regulations at 55 Pa. Code Chapter 1187, Subchapter G (relating to rate setting). The case-mix rates for SRFs are calculated using the same methodology as all other nonpublic nursing facilities except that, for the purposes of establishing peer group medians and prices, SRFs are classified in a Statewide peer group without regard to their size or geographic location.1 For a nursing facility to be classified in the SRF peer group, more than 70% of the nursing facility's residents must have a neurological/neuromus- cular diagnosis and severe functional limitations.2
When the case-mix system was implemented on January 1, 1996, three nursing facilities were approved as SRFs. The residents of these SRFs were, and continue to be, fairly homogeneous in their diagnosis and care needs—they are individuals with severe chronic impairments, often present since birth, who require ongoing rehabilitation to live as independently as possible.
Over the years, five additional SRFs were approved by the Department. The majority of these additional SRFs tend to specialize in the care of ventilator dependent residents. Given the differences in the types of services that may be provided in the SRFs, the Department is considering replacing the existing SRF definition and peer group with a new definition of ''Exceptional Nursing Facility (ENF)'' and different categories of ENFs to recognize the unique specialty areas of care provided by these nursing facilities. In addition, the Department is considering adopting a payment methodology to provide different ENF prices for each of the ENF categories.
Proposed Changes
1. Definitions of ''ENF'' and ''Exceptional Residents''
The Department is considering defining an ''ENF'' as a nursing facility that: (1) serves a disproportionate number of residents who are not commonly congregated in any one general nursing facility and who require specialized staffing and extraordinary staffing levels or staff training to attain and maintain their highest functional level; (2) requests recognition from the Department for and is approved by the Department as meeting ENF status; and (3) qualifies under one of the ENF payment categories designated by the Department as of March 31 of each rate year.
The Department is considering defining an ''exceptional resident'' as an MA resident of an ENF who has one or more qualifying service needs or diagnoses of an ENF Category designated by the Department. Beginning January 1, 2011, exceptional residents will be those residents of ENFs that have one or more qualifying service needs or diagnoses as identified in ENF Categories A and B as follows.
2. ENF Categories
Beginning January 1, 2011, the Department is proposing two categories of ENFs:
ENF Category A—Nursing facilities having 70% or more of their total resident population meeting one or more of the following qualifiers based on the February 1 Picture Date Minimum Data Set (MDS) records or the latest comprehensive MDS record when the qualifier is not available on the latest MDS record.
• Comatose.
• Paraplegia.
• Quadriplegia.
• Traumatic Brain Injury.
• Ventilator/Respirator.
• Tracheotomy care with suctioning.
AND a score of 3 (Extensive Assistance) or more in any two of the following activities of daily living or continence items:
• Bed Mobility Self-Performance.
• Transfer Self-Performance.
• Eating Self-Performance.
• Toilet Use Self-Performance.
• Bowel Continence (at least frequently incontinent).
• Bladder Continence (at least frequently incontinent).
ENF Category B—Nursing facilities having 70% or more of their total resident population meeting one or more of the following qualifiers, based on the February 1 Picture Date MDS records or the latest comprehensive MDS record when the qualifier is not available on the latest MDS record.
• Comatose.
• Cerebral palsy.
• Multiple sclerosis.
• Paraplegia.
• Quadriplegia.
• Traumatic Brain Injury.
• ICD-9 Diseases and Codes:3
• Batten's Disease 330.1
• Cerebral Degeneration 331.7
• Huntington's Chorea 333.4
• Genetic torsion dystonia 333.6
• Friedreich's Ataxia 334.0
• Cerebellar Ataxia 334.3
• Amyotrophic Sclerosis 335.2
• Primary Lateral Sclerosis 335.24
• Anoxic Brain Damage 348.1
• Encephalopathy NOS 348.30
• Metabolic Encephalopathy 348.31
• Toxic Encephalopathy 349.82
• Charcot Marie-Tooth Disease 356.1
• Congenital Hereditary Muscular Dystrophy 359.0
• Hereditary Progressive Muscular Dystrophy 359.1
• Late Effect Cerebral Aneurysm 438.20
• Myositis Ossificans Progressive 728.11
• Curvature of spine associated with other conditions 737.43 Scoliosis
• Spina Bifida with Hydrocephalus—Unspecified Region or Cervical Region or Dorsal Region or Lumbar Region Spina Bifida without Hydrocephalus—Unspecified Region or Cervical Region or Dorsal Region or Lumbar Region 741.00, 741.01,741.02, 741.03, 741.90, 741.91, 741.92, 741.93
• Spina Bifida Occulta 756.17
• Spinal Cord Injury at Birth 767.4
• Spinal Cord Injury NOS 952.9
AND a score of 3 (Extensive Assistance) or more in any two of the following activities of daily living or incontence items:
• Bed Mobility Self-Performance.
• Transfer Self-Performance.
• Eating Self-Performance.
• Toilet Use Self-Performance.
• Bowel Continence (at least frequently incontinent).
• Bladder Continence (at least frequently incontinent).
For rate years after Fiscal Year (FY) 2011-2012, the Department is proposing to annually designate the ENF categories, qualifying resident criteria and ENF qualification percentage threshold by notice in the Pennsylvania Bulletin. This annual notification will enable the Department to expand or modify the resident qualifiers for existing ENF categories and to add new categories of ENFs if the Department identifies a need for additional categories to help assure access and promote specialization.
3. Annual evaluation and redetermination of ENF status
The Department is considering requiring nursing facilities, not previously approved by the Department for recognition as an ENF, to apply each year by March 31 to be designated an ENF for the following July through June rate year. The Department will evaluate each nursing facility's ENF request to determine whether it qualifies as an ENF in one of the ENF categories designated for the rate year. The Department will use MDS records submitted by the facility for the February 1 Picture Date to make this evaluation. If upon review of the February 1 Picture Date data, the Department determines that a facility meets the ENF qualifications, the Department will approve the facility's request for ENF designation for the following July through June rate year.
For rate quarters January 1, 2011, through June 30, 2011, the Department does not intend to require existing SRFs to request ENF status, but will require existing SRFs to meet the ENF qualifying criteria for payment.
4. Payment rates for ENF facilities
The Department is considering establishing a blended net operating payment rate for all categories of ENFs, with the ENF price varying between categories.
The first portion of the blended rate will be the case-mix net operating (CMNO) rate. The CMNO rate will be calculated by placing the ENF in Peer Group 1 through 12 as set forth in 55 Pa. Code § 1187.94 based on the ENF's geographical location and bed size4 and calculating the Facility MA CMI5 using MDS data only for the ENF's nonexceptional MA residents. The CMNO rate will be adjusted quarterly based on the Facility MA CMI of the nonexceptional MA residents for the picture date. The results of this net operating calculation will be multiplied by the percentage of nonexceptional MA residents to total MA residents for the picture date (Nonexceptional MA%).
The second portion of the blended rate will be the predetermined ENF Price for the ENF Category. For the period January 1, 2011, through June 30, 2011, the ENF Price for Category A will be $540.81 and the ENF Price for Category B will be $430.17. The ENF Price will be multiplied by the percentage of ENF MA residents to the facility's total MA residents.
The ENF's quarterly rate will be the total of both portions of the blended net operating rate plus the facility's capital rate calculated in accordance with § 1187.96 (relating to price- and rate-setting computations). Each facility's blended net operating rate plus the capital rate will be multiplied by the Budget Adjustment Factor (BAF) for each year that the BAF is applied under 55 Pa. Code § 1187.96 or to any statutory requirements.
5. Phase In 3-year, Stop-Gain Provision
As with any major change in rate setting methodology, large variances in reimbursement rates may occur upon initial full implementation. To mitigate these circumstances, the Department is proposing a 3-year Stop-Gain provision to the ENF blended rate beginning January 1, 2011, and ending June 30, 2013. The stop-gain provision will be applicable only for those facilities that meet the ENF qualifications on January 1, 2011. For the initial phase in period of January 1, 2011, through June 30, 2011, for Category A facilities, the ENFs quarterly rate can be no more than the nursing facility's comparison rate (July 1, 2009, 5.016 rate with the BAF calculated as if all nonpublic nursing facilities had 5.01 rates) plus $14.50 (Stop-Gain amount). For Category B facilities, the ENFs quarterly rate can be no more than the nursing facility's comparison rate (July 1, 2009, 5.127 rate with the BAF calculated as if all nonpublic nursing facilities had 5.12 rates) plus $14.50 (Stop-Gain amount).
6. Annual updates to rate components and phase in components
For the second and third year of implementation, the facility-specific comparison rate will be inflated by the Centers for Medicare and Medicaid Services (CMS) Nursing Home without Capital Market Basket Index from the end point of the prior rate year to the midpoint of the rate year.
During the second and third years of phase in, the Stop-Gain amount will be inflated by the CMS Nursing Home without Capital Market Basket Index from the end point of the prior rate year to the mid point of the current rate year.
Starting the second rate year after implementation, and each year thereafter, the ENF price will be inflated by the CMS Nursing Home without Capital Market Basket Index from the end point of the prior rate year to the mid-point of the current rate year.
Fiscal Impact
There is no fiscal impact for FY 2010-2011. The fiscal impact will remain budget neutral as long as the BAF is reauthorized. The fiscal impact after 2010-2011 makes the assumption that the BAF is not reauthorized beyond June 30, 2011. The estimated fiscal impact for FY 2011-2012 is $0.637 million.
Public Comment
Interested persons are invited to submit written comments regarding these proposed changes to the Department of Public Welfare, Office of Long-Term Living, Attention: Yvette Sanchez-Roberts, Department of Public Welfare/Department of Aging, Office of Long-Term Living, Policy and Strategic Planning, 555 Walnut Street, Forum Place, 5th Floor, Harrisburg, PA 17101-1919. Comments received within 30 days will be reviewed and considered for any subsequent revision of the notice.
Persons with a disability who require an auxiliary aid or service may submit comments using the Pennsylvania AT&T Relay Service at (800) 654-5984 (TDD users) or (800) 654-5988 (voice users).
MICHAEL P. NARDONE,
Acting SecretaryFiscal Note: 14-NOT-676. (1) General Fund; (2) Implementing Year 2010-11 is $0; (3) 1st Succeeding Year 2011-12 is $637,000; 2nd Succeeding Year 2012-13 is $624,000; 3rd Succeeding Year 2013-14 is $4,655,000; 4th Succeeding Year 2014-15 is $4,709,000; 5th Succeeding Year 2015-16 is $4,768,000; The fiscal impact for 2011-12 and beyond assumes that the budget adjustment factor provided for in section 443.1 of the Public Welfare Code, which expires June 30, 2011, is not reauthorized beyond that date; (4) 2009-10 Program—$540,266,000; 2008-09 Program—$672,597,000; 2007-08 Program—$692,585,000; (7) MA—Long-Term Care; (8) recommends adoption. The 2010-11 enacted budget assumes no fiscal impact as a result of this notice.
[Pa.B. Doc. No. 10-2471. Filed for public inspection December 23, 2010, 9:00 a.m.] _______
1 Hospital-based nursing facilities are also classified in a state-wide peer group. See 55 Pa. Code § 1187.94 (relating to peer grouping for price setting).
2 See 55 Pa. Code § 1187.2 (relating to definitions).
3 The International Classification of Diseases, Ninth Revision (ICD-9), published by the World Health Organization, provides codes to classify diseases. Under this system, every health condition can be assigned to a unique category and given a code, up to six characters long. These codes are in the public domain.
4 Although ENFs will be classified into Peer Groups 1 through 12 for purposes of determining their CMNO rates, their audited allowable costs will not be used to determine the medians or prices for these Peer Groups.
5 For each Picture Date, only the Case Mix Indices (CMIs) associated with those MA residents that do not qualify as an exceptional resident will be used in the determination of the Facility MA CMI as set forth in 55 Pa. Code § 1187.33 (relating to resident data and picture date reporting requirements).
6 MDS RUG-III v. 5.01 referenced in the proposed regulations published at 40 Pa.B. 6525 (November 13, 2010).
7 MDS RUG-III v. 5.12 referenced in the proposed regulations published at 40 Pa.B. 6525.
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