RULES AND REGULATIONS
Title 55—PUBLIC WELFARE
DEPARTMENT OF PUBLIC WELFARE
[ 55 PA. CODE CHS. 1187 AND 1189 ]
Transition to RUG-III Version 5.12 and Latest Assessment
[41 Pa.B. 4630]
[Saturday, August 27, 2011]The Department of Public Welfare (Department) amends Chapters 1187 and 1189 (relating to nursing facility services; and county nursing facility services) under the authority of sections 201(2), 206(2), 403(b) and 443.1 of the Public Welfare Code (code) (62 P. S. §§ 201(2), 206(2), 403(b) and 443.1). The proposed rulemaking was published at 40 Pa.B. 6525 (November 13, 2010).
Purpose of Final-Form Rulemaking
The purpose of this final-form rulemaking is to amend the payment methodology for Medical Assistance (MA) nursing facility services to phase-in the use of the Resource Utilization Group III (RUG-III) classification system, version (v.) 5.12 44 Grouper and the most recent classifiable resident assessments in determining the case-mix indices that are used in setting case-mix per diem rates for nonpublic nursing facilities and in making certain incentive payments to county nursing facilities.
This final-form rulemaking is needed to modify the version of the RUG-III classification system used by the Department in the case-mix payment system and in making county nursing facility pay for performance (P4P) payments as a result of the implementation of Minimum Data Set (MDS) 3.0 by the Centers for Medicare and Medicaid Services (CMS), effective October 1, 2010. In addition, the final-form rulemaking will permit the Department to use a more timely measurement of a nursing facility resident's care needs by permitting the use of the most recent classifiable resident assessment of any type when classifying residents into groups and assigning a Case-Mix Index (CMI) score. The proposed rulemaking stated the Department would use the most recent resident assessment of any type. However, the Department has found that not all resident assessments are classifiable under MDS 3.0 as they were under MDS 2.0; therefore, the Department will use the most recent classifiable resident assessment of any type.
The following is a summary of the major provisions in the final-form rulemaking.
§§ 1187.2 and 1187.33 (relating to definitions; and resident data and picture date reporting requirements)—Resident assessment
The Department amended the definition of ''resident assessment'' in § 1187.2 by deleting ''comprehensive'' from the definition. Section 1187.33(a)(6) is amended by removing the language regarding Medicare assessments.
Nursing facilities are required to conduct and electronically submit assessments other than ''comprehensive assessments'' for their residents. These assessments contain all MDS data elements needed to calculate each resident's RUG category and CMI score. When these assessments are completed after the latest comprehensive assessment, they provide more current information on a resident's condition and care needs than the resident's ''comprehensive assessment.''
The Department determines the RUG category and CMI score for each nursing facility resident using the assessment data from the resident's most recent comprehensive MDS assessment as submitted by the nursing facility. Using the CMI scores calculated for each resident, the Department calculates a total facility CMI score and a facility MA CMI score for each nursing facility and a Statewide average MA CMI score.
Rather than continuing to use older assessment data to determine a resident's RUG category and CMI score, the Department is amending its regulations to require use of the most recent classifiable assessment of any type for each resident, whether the assessment is comprehensive, effective July 1, 2010. This change will enable the Department to make acuity adjustments and P4P payments using the most up-to-date resident data available without additional administrative burdens or costs to either nursing facilities or the Department.
The CMI scores will be used to calculate the total facility CMIs and the MA CMIs for setting nonpublic nursing facility rates effective on and after July 1, 2010. In addition, the CMI scores will be used in determining which county nursing facilities are eligible to receive P4P payments beginning with the July 1—September 30, 2010, P4P payment period.
§ 1187.93 (relating to CMI calculations) and Chapter 1187, Appendix A (relating to resource utilization group index scores for case-mix adjustment in the nursing facility reimbursement system)—Case-mix classification tool
CMS developed a new version of the MDS resident assessment, MDS 3.0, which nursing facilities participating in the Medicare or MA Program, or both, were required to use effective October 1, 2010. The new version of the MDS has been designed to improve the reliability, accuracy and usefulness of the assessment tool, to include the resident in the assessment process and to incorporate the use of standard protocols used in other health care settings. According to CMS, the enhanced accuracy of the MDS 3.0 will improve clinical assessments and bolster programs that rely on the MDS for assessing the needs of consumers.
The MDS 3.0 assessment does not contain all the elements necessary for resident classification with the RUG-III v. 5.01 44 Grouper, which has been used to set nonpublic nursing facility rates since January 1, 1996. CMS no longer supports this Grouper with implementation of MDS 3.0. The Department changed the Grouper used in determining nursing facility residents' CMI scores effective for rate setting periods on and after July 1, 2010, to the RUG-III v. 5.12 44 Grouper. This RUG-III version, which is compatible with the MDS 3.0, is based on updated time studies conducted in 1995 and 1997 and reflects changes in nursing facility resident conditions and care since the original studies conducted in 1990. The combination of the use of the latest classifiable assessment to more accurately measure current resident acuity and a classification system based on more recent time studies will result in better distribution of scarce MA resources.
The Department amended § 1187.93 and Chapter 1187, Appendix A to reflect both the associated Nursing Only CMI scores established by CMS for the RUG-III v. 5.12 44 Grouper classification system and the CMI scores normalized for nursing facilities in this Commonwealth. Normalization of CMI scores is a common process used by states when implementing a RUG-III based case-mix payment system or when changing to a new RUG version. Scores are normalized so that the average Statewide CMI score equals 1.00. The normalized CMI scores the Department will use range from 0.48 to 1.75.
The Department will use the RUG-III v. 5.12 44 Grouper classification system in determining the CMIs of residents of both nonpublic and county nursing facilities. The CMI scores will be used to calculate the total facility CMIs and the MA CMIs used in setting nonpublic nursing facility rates effective on and after July 1, 2010. In addition, the CMI scores are used in determining which county nursing facilities are eligible to receive P4P payments beginning with the July 1—September 30, 2010, P4P payment period. The CMIs include the February 1, 2010, picture date total facility CMI and MA CMI; the total facility CMI for the February 1 picture dates from all of the cost report periods of the MA cost reports used in the July 1, 2010, rate setting database; the MA CMIs from the May 1, 2010, picture date, the August 1, 2010, picture date, the November 1, 2010, picture date; and the total facility CMIs and MA CMIs for all subsequent picture dates.
§ 1187.96 (relating to price- and rate-setting computations)—Phase-In—RUG-III v. 5.12 44 Grouper and the most recent resident assessment
The Department recognizes that the change in RUG-III Grouper and use of the most recent classifiable resident assessment of any type may cause a reduction in per diem rates for some nonpublic nursing facilities. Because there may be an adverse impact on nonpublic nursing facilities, the Department is applying a 3-year phase-in for the transition to the RUG-III v. 5.12 44 Grouper and the use of the most recent classifiable resident assessment for rate setting periods beginning July 1, 2010, and ending June 30, 2013. Phasing in the amendments provides nursing facilities the opportunity to gain competency using MDS 3.0 and become familiar with the new RUG-III Grouper and resident assessment selection process. The Department amended § 1187.96 to specify that for July 1, 2010, through June 30, 2013, unless the nursing facility is a new facility, the resident care rate that the Department will use to establish a nursing facility's case-mix per diem rate will be a blended resident care rate that will consist of a portion of a 5.01 resident care rate and a portion of a 5.12 resident care rate.
A phase-in provision, however, will not be applied to new nonpublic nursing facilities since the phase-in period is for a transition from one system to another. Therefore, the Department amended § 1187.97 (relating to rates for new nursing facilities, nursing facilities with a change of ownership, reorganized nursing facilities and former prospective payment nursing facilities) to specify that new facilities will be assigned a Statewide average MA CMI calculated using the RUG-III v. 5.12 44 group values in Chapter 1187, Appendix A and the most recent classifiable assessments. When a new nursing facility's assessment data is used in a rate determination the CMI values used to determine the new nursing facility's total facility CMIs and MA CMIs will be the RUG-III v. 5.12 44 group values in Chapter 1187, Appendix A and the most recent classifiable assessment.
§ 1189.105 (relating to incentive payments)—County nursing facilities—P4P payments
The Department calculates MA CMI scores for county nursing facilities and uses the scores in determining which county nursing facilities are eligible to receive quarterly P4P payments. To be eligible for a P4P payment, a county nursing facility must meet the definition of a ''county nursing facility'' at the time the quarterly P4P payment is being made. In addition, the county nursing facility's MA CMI for a picture date must be higher than the facility's MA CMI for the previous picture date. Since county nursing facility MA CMIs are used only for this limited purpose, the Department will not provide for a phase-in of the changes. The Department amended § 1189.105 to specify that, in determining whether a county nursing facility qualifies for a quarterly P4P incentive for P4P periods beginning on and after July 1, 2010, the facility's MA CMI for a picture date equals the arithmetic mean of the individual CMIs for MA residents identified in the facility's CMI report for the picture date and an MA resident's CMI is calculated using the RUG-III v. 5.12 44 group values in Chapter 1187, Appendix A and the most recent classifiable assessment of any type for the resident.
Affected Individuals and Organizations
This final-form rulemaking affects nonpublic nursing facilities enrolled in the MA Program and county nursing facilities that seek to qualify for P4P payments under § 1189.105(b).
Accomplishments and Benefits
This final-form rulemaking benefits MA nursing facility residents in this Commonwealth by assuring they will continue to have access to medically necessary nursing facility services while providing for reasonable and adequate payments to MA nursing facility providers consistent with the fiscal resources of this Commonwealth.
Fiscal Impact
There is no fiscal impact for Fiscal Year 2010-2011. The fiscal impact will remain budget neutral as long as the budget adjustment factor (BAF) is reauthorized. The fiscal impact after 2010-2011 makes the assumption that the BAF is not reauthorized beyond June 30, 2011. The implication of the change of the 5.12 is that nursing facilities' rates would be reduced by approximately $166.912 million ($74.994 million in State funds) on an annual basis.
Paperwork Requirements
There are no new or additional paperwork requirements.
Public Comment
The Department received one public comment letter from PANPHA, an association of Pennsylvania nonprofit aging services providers. The Independent Regulatory Review Commission (IRRC) also commented on the proposed rulemaking.
Discussion of Comments and Major Changes
Following is a summary of the comments received during the public comment period following publication of the proposed rulemaking and the Department's responses to those comments. A summary of major changes from proposed rulemaking is also included.
General—Use of RUG-III v. 5.12 44 Grouper and Most Recent Assessment
PANPHA is generally supportive of using the RUG-III v. 5.12 44 Grouper and the most recent assessment for rate-setting to better align resources with the most recently available data. PANPHA commented that while this change may have a negative short-term effect on some nursing facilities, residents should ultimately benefit by more accurately measuring resident acuity and, therefore, better reflect the needs and necessary resources than the current regulations.
Response
The Department recognizes that with almost 600 nonpublic nursing facilities enrolled in the MA Program, these changes may have a negative short-term effect on some nursing facilities. However, the 3-year phase-in, suggested by the industry, for the transition to the RUG-III v. 5.12 44 Grouper and the use of the most recent classifiable resident assessment should mitigate any adverse effect and provide nursing facilities the opportunity to gain competency using MDS 3.0 and become familiar with the new RUG-III Grouper and resident assessment selection process. Moreover, the combination of the use of the latest assessment to more accurately measure current resident acuity and a classification system based on more recent time studies will ultimately result in better distribution of the scarce MA resources.
General—Phasing-in Reimbursement Changes
PANPHA also supports the concept of phasing-in the reimbursement changes. However, PANPHA asked that the Department and stakeholders continue to monitor and address the effects of the new system and the phase-in to determine if any of these components cause a degree of variability that is too unpredictable for effective operation of facilities or that cause other unanticipated adverse effects.
Response
The Department will review the regulations on an ongoing basis to ensure compliance with Federal and State law and to assess the appropriateness and effectiveness of the regulations. In addition, if specific regulatory issues are raised by the Medical Assistance Advisory Committee (MAAC) and the Long-Term Care Delivery System Subcommittee of the MAAC, those issues will be researched and addressed as needed. The Department will also monitor the impact of the regulations through regular audits and utilization management reviews to determine the effectiveness of the regulations with respect to consumers of long-term care services and the industry.
§§ 1187.93, 1187.96 and 1187.97, Chapter 1187, Appendix A and § 1189.105—Implementation procedures
IRRC asked that the Department clarify how the new rates will occur retroactive to July 1, 2010.
Response
Currently, nonpublic nursing facilities enrolled in the MA program are being paid at their respective April 1, 2010, rates. The Department submitted a State Plan Amendment (SPA) to CMS to phase-in the use of the most recent classifiable resident assessments and the RUG-III classification system v. 5.12 44 Grouper in determining nursing facility residents' CMIs used in setting case-mix per diem rates for nonpublic nursing facilities and in making P4P incentive payments to county nursing facilities. The SPA was approved by CMS on October 27, 2010. Once this final-form rulemaking is promulgated, the Department will prepare rate adjustments retroactive to July 1, 2010, under §§ 1187.96 and 1187.97. A rate adjustment schedule will be sent by e-mail to the nursing facility providers and nursing facility associations and will be posted to the Department's web site. In addition, files will be created for the time periods (quarters) to be adjusted and will be loaded into PROMISe (claims processing system). Based on these files, a remittance advice will be generated for each nursing facility provider and the Treasury Department will generate the appropriate payment to the nursing facility providers.
Retroactive payments will not be made to county nursing facilities as a result of this final-form rulemaking. Under existing § 1189.105(b), incentive payments are made in accordance with the formula and qualifying criteria in the Commonwealth's State Plan. The Department submitted a SPA containing the formula as provided in amended § 1189.105(b). This SPA was approved by CMS on October 27, 2010. Therefore, payments were made in accordance with the approved State Plan and retroactive payments are not necessary.
Additional Changes
As previously stated, the Department has found that not all resident assessments are classifiable under MDS 3.0 as they were under MDS 2.0. Therefore, the Department changed the language to ''the most recent classifiable resident assessment of any type.'' In addition, the Department made a correction to § 1187.97(1)(i)(A). This section incorrectly cited § 1187.96(s)(5) instead of § 1187.96(a)(5). The Department also eliminated the numbering of the paragraphs in § 1189.105(b) to clarify that the items are not mutually exclusive and the P4P incentive payment is dependent upon an approved state plan.
Regulatory Review Act
Under section 5(a) of the Regulatory Review Act (71 P. S. § 745.5(a)), on June 16, 2011, the Department submitted a copy of the final-form rulemaking to IRRC and the Chairpersons of the House Committee on Human Services and the Senate Committee on Public Health and Welfare for review and comment.
Under section 5(c) of the Regulatory Review Act, IRRC and the House and Senate Committees were provided with copies of the comments received during the public comment period, as well as other documents when requested. In preparing the final-form rulemaking, the Department has considered all comments from IRRC, the House and Senate Committees and the public.
Under section 5.1(j.2) of the Regulatory Review Act (71 P. S. § 745.5a(j.2)), on July 20, 2011, the final-form rulemaking was deemed approved by the House and Senate Committees. Under section 5.1(e) of the Regulatory Review Act, IRRC met on July 21, 2011, and approved the final-form rulemaking.
Findings
The Department finds that:
(1) Public notice of intention to amend the administrative regulation by this order has been given sections 201 and 202 of the act of July 31, 1968 (P. L. 769, No. 240) (45 P. S. §§ 1201 and 1202) and the regulations promulgated thereunder, 1 Pa. Code §§ 7.1 and 7.2.
(2) Adoption of this final-form rulemaking in the manner provided by this order is necessary and appropriate for the administration and enforcement of the code.
Order
The Department, acting under sections 201(2), 206(2), 403(b) and 443.1 of the code, orders that:
(a) The regulations of the Department, 55 Pa. Code Chapters 1187 and 1189, are amended by amending §§ 1187.2, 1187.33 and 1187.93 and Chapter 1187, Appendix A to read as set forth at 40 Pa.B. 6525 and by amending §§ 1187.96, 1187.97 and 1189.105 to read as set forth in Annex A, with ellipses referring to the existing text of the regulations.
(b) The Secretary of the Department shall submit this order, 40 Pa.B. 6525 and Annex A to the Offices of General Counsel and Attorney General for approval as to legality and form as required by law.
(c) The Secretary of the Department shall certify and deposit this order, 40 Pa.B. 6525 and Annex A with the Legislative Reference Bureau as required by law.
(d) This order shall take effect retroactive to July 1, 2010.
GARY D. ALEXANDER,
Secretary(Editor's Note: For the text of the order of the Independent Regulatory Review Commission relating to this document, see 41 Pa.B. 4265 (August 6, 2011).)
Fiscal Note: Fiscal Note 14-520 remains valid for the final adoption of the subject regulation.
Annex A
TITLE 55. PUBLIC WELFARE
PART III. MEDICAL ASSISTANCE MANUAL
CHAPTER 1187. NURSING FACILITY SERVICES
Subchapter G. RATE SETTING § 1187.96. Price- and rate-setting computations.
(a) Using the NIS database in accordance with this subsection and § 1187.91 (relating to database), the Department will set prices for the resident care cost category.
(1) The Department will use each nursing facility's cost reports in the NIS database to make the following computations:
(i) The total resident care cost for each cost report will be divided by the total facility CMI from the available February 1 picture date closest to the midpoint of the cost report period to obtain case-mix neutral total resident care cost for the cost report year.
(ii) The case-mix neutral total resident care cost for each cost report will be divided by the total actual resident days for the cost report year to obtain the case-mix neutral resident care cost per diem for the cost report year.
(iii) The Department will calculate the 3-year arithmetic mean of the case-mix neutral resident care cost per diem for each nursing facility to obtain the average case-mix neutral resident care cost per diem of each nursing facility.
(2) The average case-mix neutral resident care cost per diem for each nursing facility will be arrayed within the respective peer groups, and a median determined for each peer group.
(3) For rate years 2006-2007, 2007-2008, 2009-2010, 2010-2011 and 2011-2012, the median used to set the resident care price will be the phase-out median as determined in accordance with § 1187.98 (relating to phase-out median determination).
(4) The median of each peer group will be multiplied by 1.17, and the resultant peer group price assigned to each nursing facility in the peer group.
(5) The price derived in paragraph (4) for each nursing facility will be limited by § 1187.107 (relating to limitations on resident care and other resident related cost centers) and the amount will be multiplied each quarter by the respective nursing facility MA CMI to determine the nursing facility resident care rate. The MA CMI picture date data used in the rate determination are as follows: July 1 rate—February 1 picture date; October 1 rate—May 1 picture date; January 1 rate—August 1 picture date; and April 1 rate—November 1 picture date.
(6) For rate years 2010-2011, 2011-2012 and 2012-2013, unless the nursing facility is a new nursing facility, the resident care rate used to establish the nursing facility's case-mix per diem rate will be a blended resident care rate.
(i) The nursing facility's blended resident care rate for the 2010-2011 rate year will equal 75% of the nursing facility's 5.01 resident care rate calculated in accordance with subparagraph (iv) plus 25% of the nursing facility's 5.12 resident care rate calculated in accordance with subparagraph (iv).
(ii) The nursing facility's blended resident care rate for the 2011-2012 rate year will equal 50% of the nursing facility's 5.01 resident care rate calculated in accordance with subparagraph (v) and 50% of the nursing facility's 5.12 resident care rate calculated in accordance with subparagraph (v).
(iii) The nursing facility's blended resident care rate for the 2012-2013 rate year will equal 25% of the nursing facility's 5.01 resident care rate calculated in accordance with subparagraph (v) and 75% of the nursing facility's 5.12 resident care rate calculated in accordance with subparagraph (v).
(iv) For the rate year 2010-2011, each nursing facility's blended resident care rate will be determined based on the following calculations:
(A) For the first quarter of the rate year (July 1, 2010—September 30, 2010), the Department will calculate each nursing facility's blended resident care rate as follows:
(I) The Department will calculate a 5.12 resident care rate for each nursing facility in accordance with paragraphs (1)—(5). The CMI values the Department will use to determine each nursing facility's total facility CMIs and facility MA CMI, computed in accordance with § 1187.93 (relating to CMI calculations), will be the RUG-III version 5.12 44 group values as set forth in Appendix A. The resident assessment that will be used for each resident will be the most recent classifiable resident assessment of any type.
(II) The Department will calculate a 5.01 resident care rate for each nursing facility in accordance with paragraphs (1)—(5). The CMI values the Department will use to determine each nursing facility's total facility CMIs and facility MA CMI, computed in accordance with § 1187.93, will be the RUG-III version 5.01 44-group values as set forth in Appendix A. The resident assessment that will be used for each resident will be the most recent comprehensive resident assessment.
(III) The nursing facility's blended resident care rate for the quarter beginning July 1, 2010, and ending September 30, 2010, will be the sum of the nursing facility's 5.01 resident care rate multiplied by 0.75 and the nursing facility's 5.12 resident care rate multiplied by 0.25.
(B) For the remaining 3 quarters of the 2010-2011 rate year (October 1 through December 31; January 1 through March 31; April 1 through June 30), the Department will calculate each nursing facility's blended resident care rate as follows:
(I) The Department will calculate a quarterly adjusted 5.12 resident care rate for each nursing facility in accordance with paragraph (5). The CMI values used to determine each nursing facility's MA CMI, computed in accordance with § 1187.93, will be the RUG-III version 5.12 44 group values as set forth in Appendix A. The resident assessment that will be used for each resident will be the most recent classifiable resident assessment of any type.
(II) The Department will calculate a quarterly adjusted 5.01 resident care rate for each nursing facility by multiplying the nursing facility's prior quarter 5.01 resident care rate by the percentage change between the nursing facility's current quarter 5.12 resident care rate and the nursing facility's previous quarter 5.12 resident care rate. The percentage change will be determined by dividing the nursing facility's current quarter 5.12 resident care rate by the nursing facility's previous quarter 5.12 resident care rate.
(III) The nursing facility's blended resident care rate for the 3 remaining quarters of the rate year will be the sum of the nursing facility's quarterly adjusted 5.01 resident care rate multiplied by 0.75 and the nursing facility's quarterly adjusted 5.12 resident care rate multiplied by 0.25.
(v) For rate years 2011-2012 and 2012-2013, each nursing facility's blended resident care rate will be determined based on the following calculations:
(A) For the first quarter of each rate year (July 1—September 30), the Department will calculate each nursing facility's blended resident care rate as follows:
(I) The Department will calculate a 5.12 resident care rate for each nursing facility in accordance with paragraphs (1)—(5). The CMI values used to determine each nursing facility's total facility CMIs and facility MA CMI, computed in accordance with § 1187.93, will be the RUG-III version 5.12 44 group values as set forth in Appendix A. The resident assessment that will be used for each resident will be the most recent classifiable resident assessment of any type.
(II) The Department will calculate a 5.01 resident care rate for each nursing facility by multiplying the nursing facility's prior April 1st quarter 5.01 resident care rate by the percentage change between the nursing facility's current 5.12 resident care rate and the nursing facility's prior April 1st quarter 5.12 resident care rate. The percentage change will be determined by dividing the nursing facility's current 5.12 resident care by the nursing facility's April 1st quarter 5.12 resident care rate.
(III) The nursing facility's blended resident care rate for the quarter beginning July 1, 2011, and ending September 30, 2011, will be the sum of the nursing facility's 5.01 resident care rate multiplied by 0.50 and the nursing facility's 5.12 resident care rate multiplied by 0.50.
(IV) The nursing facility's blended resident care rate for the quarter beginning July 1, 2012, and ending September 30, 2012, will be the sum of the nursing facility's 5.01 resident care rate multiplied by 0.25 and the nursing facility's 5.12 resident care rate multiplied by 0.75.
(B) For the remaining 3 quarters of each rate year (October 1 through December 31; January 1 through March 31; April 1 through June 30), the Department will calculate each nursing facility's blended resident care rate as follows:
(I) The Department will calculate a quarterly adjusted 5.12 resident care rate for each nursing facility in accordance with paragraph (5). The CMI values used to determine each nursing facility's MA CMI, computed in accordance with § 1187.93, will be the RUG-III version 5.12 44 group values as set forth in Appendix A. The resident assessment that will be used for each resident will be the most recent classifiable resident assessment of any type.
(II) The Department will calculate a quarterly adjusted 5.01 resident care rate for each nursing facility by multiplying the nursing facility's prior quarter 5.01 resident care rate by the percentage change between the nursing facility's current quarter 5.12 resident care rate and the nursing facility's previous quarter 5.12 resident care rate. The percentage change will be determined by dividing the nursing facility's current quarter 5.12 resident care rate by the nursing facility's previous quarter 5.12 resident care rate.
(III) For the remaining 3 quarters of rate year 2011-2012 (October 1 through December 31; January 1 through March 31; April 1 through June 30), each nursing facility's blended resident care rate will be the sum of the nursing facility's quarterly adjusted 5.01 resident care rate multiplied by 0.50 and the nursing facility's quarterly adjusted 5.12 resident care rate multiplied by 0.50.
(IV) For the remaining 3 quarters of rate year 2012-2013 (October 1 through December 31; January 1 through March 31; April 1 through June 30), each nursing facility's blended resident care rate will be the sum of the nursing facility's quarterly adjusted 5.01 resident care rate multiplied by 0.25 and the facility's quarterly adjusted 5.12 resident care rate multiplied by 0.75.
(7) Beginning with rate year 2013-2014, and thereafter, the Department will calculate each nursing facility's resident care rate in accordance with paragraphs (1)—(5). The CMI values used to determine each nursing facility's total facility CMIs and facility MA CMI, computed in accordance with § 1187.93, will be the RUG-III version 5.12 44 group values as set forth in Appendix A. The resident assessment that will be used for each resident will be the most recent classifiable resident assessment of any type.
* * * * * (e) The following applies to the computation of nursing facilities' per diem rates:
(1) The nursing facility per diem rate will be computed by adding the resident care rate, the other resident related rate, the administrative rate and the capital rate for the nursing facility.
(2) For each quarter of the 2006-2007 and 2007-2008 rate-setting years, the nursing facility per diem rate will be computed as follows:
(i) Generally. If a nursing facility is not a new nursing facility or a nursing facility experiencing a change of ownership during the rate year, that nursing facility's resident care rate, other resident related rate, administrative rate and capital rate will be computed in accordance with subsections (a)—(d) and the nursing facility's per diem rate will be the sum of those rates multiplied by a budget adjustment factor determined in accordance with subparagraph (iv).
(ii) New nursing facilities. If a nursing facility is a new nursing facility for purposes of § 1187.97(1) (relating to rates for new nursing facilities, nursing facilities with a change of ownership, reorganized nursing facilities and former prospective payment nursing facilities) that nursing facility's resident care rate, other resident related rate, administrative rate and capital rate will be computed in accordance with § 1187.97(1), and the nursing facility's per diem rate will be the sum of those rates multiplied by a budget adjustment factor determined in accordance with subparagraph (iv).
(iii) Nursing facilities with a change of ownership and reorganized nursing facilities. If a nursing facility undergoes a change of ownership during the rate year, that nursing facility's resident care rate, other resident related rate, administrative rate and capital rate will be computed in accordance with § 1187.97(2), and the nursing facility's per diem rate will be the sum of those rates multiplied by a budget adjustment factor determined in accordance with subparagraph (iv).
(iv) Budget adjustment factor. The budget adjustment factor for the rate year will be determined in accordance with the formula set forth in the Commonwealth's approved State Plan.
(3) For rate years 2010-2011, 2011-2012 and 2012-2013, unless the nursing facility is a new nursing facility, the nursing facility per diem rate will be computed by adding the blended resident care rate, the other resident related rate, the administrative rate and the capital rate for the nursing facility.
§ 1187.97. Rates for new nursing facilities, nursing facilities with a change of ownership, reorganized nursing facilities and former prospective payment nursing facilities.
The Department will establish rates for new nursing facilities, nursing facilities with a change of ownership, reorganized nursing facilities and former prospective payment nursing facilities as follows:
(1) New nursing facilities.
(i) The net operating portion of the case-mix rate is determined as follows:
(A) A new nursing facility, unless a former county nursing facility, will be assigned the Statewide average MA CMI until assessment data submitted by the nursing facility under § 1187.33 (relating to resident data and picture date reporting requirements) is used in a rate determination under § 1187.96(a)(5) (relating to price- and rate-setting computations). Beginning, July 1, 2010, the Statewide average MA CMI assigned to a new nursing facility will be calculated using the RUG-III version 5.12 44 group values in Appendix A and the most recent classifiable assessments of any type. When a new nursing facility has submitted assessment data under § 1187.33, the CMI values used to determine the new nursing facility's total facility CMIs and MA CMI will be the RUG-III version 5.12 44 group values and the resident assessment that will be used for each resident will be the most recent classifiable assessment of any type.
(B) For a former county nursing facility, the county nursing facility's assessment data and MA CMI will be transferred to the new nursing facility.
(C) The nursing facility will be assigned to the appropriate peer group. The peer group price for resident care, other resident related and administrative costs will be assigned to the nursing facility until there is at least one audited nursing facility cost report used in the rebasing process. Beginning July 1, 2010, a new nursing facility will be assigned the peer group price for resident care that will be calculated using the RUG-III version 5.12 44 group values in Appendix A and the most recent classifiable assessments of any type.
* * * * *
CHAPTER 1189. COUNTY NURSING FACILITY SERVICES
Subchapter E. PAYMENT CONDITIONS, LIMITATIONS AND ADJUSTMENTS § 1189.105. Incentive payments.
* * * * * (b) Pay for performance incentive payment. The Department will establish pay for performance measures that will qualify a county nursing facility for additional incentive payments in accordance with the formula and qualifying criteria in the Commonwealth's approved State Plan. For pay for performance payment periods beginning on or after July 1, 2010, in determining whether a county nursing facility qualifies for a quarterly pay for performance incentive, the facility's MA CMI for a picture date will equal the arithmetic mean of the individual CMIs for MA residents identified in the facility's CMI report for the picture date. An MA resident's CMI will be calculated using the RUG-III version 5.12 44 group values in Chapter 1187, Appendix A (relating to resource utilization group index scores for case-mix adjustment in the nursing facility reimbursement system) and the most recent classifiable assessment of any type for the resident.
[Pa.B. Doc. No. 11-1459. Filed for public inspection August 26, 2011, 9:00 a.m.]
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