PROPOSED RULEMAKING
DEPARTMENT OF
PUBLIC WELFARE
[ 55 PA. CODE CHS. 1187 AND 1189 ]
Supplemental Ventilator Care Payment for Medical Assistance Nursing Facilities
[43 Pa.B. 4855]
[Saturday, August 24, 2013]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 add § 1187.117 (relating to supplemental ventilator care payments) and amend § 1189.105 (relating to incentive payments) to read as set forth in Annex A.
Purpose of Proposed Rulemaking
The purpose of this proposed rulemaking is to change the Department's methods and standards for payment of Medical Assistance (MA) nursing facility services to offer a new category of supplemental payment to qualified MA nursing facilities effective July 1, 2012.
The proposed rulemaking is needed to address the financial impact that the implementation of the current Resource Utilization Group III (RUG-III) version 5.12 (RUG v. 5.12) resident classification system and the phase-out of the older RUG v. 5.01 is having on nursing facilities that care for a significant number of MA ventilator care residents.
Background
The Department is proposing to offer a new category of supplemental ventilator care payment to qualified MA nonpublic and county nursing facilities that provide medically necessary ventilator care for a significant portion of their MA-recipient resident population. The Department published a public notice announcing this proposed change at 42 Pa.B. 3824 (June 30, 2012). On September 27, 2012, the Department submitted State Plan Amendment (SPA) 12-030 regarding supplemental ventilator care payments to nonpublic and county nursing facilities to the Centers for Medicare and Medicaid Services (CMS). CMS approved the SPA on December 13, 2012.
Currently, the Department pays for nursing facility services provided to MA-eligible recipients in nonpublic nursing facilities at per diem rates that are computed using the case-mix payment system in Chapter 1187, Subchapter G (relating to rate setting). Beginning July 1, 2010, the payment methodology was changed to phase in, over a 3-year period, use of the RUG v. 5.12 classification system. Prior to July 1, 2010, RUG v. 5.01, an earlier version of the RUG-III classification system, was used.
The RUG-III classification systems were developed by the CMS to provide a patient-specific means of identifying the variable health care resources required to care for individuals with different needs by placing residents into groups based on their characteristics and clinical needs. Each group is then assigned a case-mix index (CMI) which is a numerical score intended to reflect the relative resource use of the average resident assigned to the group. See Chapter 1187, Appendix A (relating to resource utilization group index scores for case-mix adjustment in the nursing facility reimbursement system). A resident placed in a group which is assigned a higher CMI has greater needs and, therefore, requires more nursing resources than a resident in a group assigned a lower CMI. The data source used to classify each resident into a RUG-III group is the Federally-approved, Pennsylvania-specific minimum data set (MDS) assessment completed at a minimum upon admission and quarterly thereafter for each resident. Once each quarter (February 1, May 1, August 1 and November 1), the residents in the nursing facility's census are identified and the latest classifiable assessment is used to assign each resident to a RUG-III group. See §§ 1187.2 and 1187.33 (relating to definitions; and resident data and picture date reporting requirements). A facility average MA CMI is then calculated and used in the determination of each nonpublic nursing facility's per diem rate as specified in § 1187.96(a)(5) (relating to price- and rate-setting computations). In general, nursing facilities with a high facility average MA CMI receive a higher per diem rate because the residents in their care require more nursing resources.
Under § 1187.96, nursing facility case-mix per diem rates are a combination of a blended resident care rate, other resident-related rate, an administrative rate and a capital rate. The blended resident care rate uses a portion of both RUG-III versions as it phases in fully to RUG v. 5.12. For rate year 2010-2011, the resident care portion of the per diem rate was calculated using 75% of the RUG v. 5.01 resident care rate and 25% of the RUG v. 5.12 resident care rate. For rate year 2011-2012, the percent split was 50% and 50% and for rate year 2012-2013, the last year of the phase in, only 25% of the older RUG v. 5.01 resident care rate is used in the rate calculation.
Now that RUG v. 5.12 has been implemented and the phase-out of the older RUG v. 5.01 is nearing completion, the Department is addressing concerns regarding reimbursement of nursing facilities that serve ventilator care residents.
Although county nursing facilities do not have the same concerns relating to the CMI because their rates are calculated differently under Chapter 1189 (relating to county nursing facility services), the Department is nonetheless making the payment available to county nursing facilities to promote the growth of ventilator care. Making these additional funds available is part of the Department's ongoing efforts to ensure that MA recipients continue to receive access to medically necessary nursing facility services and that those services result in quality care that improves the lives of those who receive them.
Requirements
The Department is proposing to offer a new category of supplemental ventilator care payment under § 1187.117. The supplemental ventilator care payment will be calculated on a quarterly basis and paid to nursing facilities caring for a minimum of ten MA-recipient residents who receive medically necessary ventilator care, with at least 10% of the facility's MA-recipient resident population receiving medically necessary ventilator care. For those nursing facilities meeting both of the threshold criteria on the appropriate picture date, the total supplemental ventilator care payment will be the nursing facility's supplemental ventilator care per diem multiplied by the number of paid MA facility days and therapeutic leave days. If the Department grants a nursing facility a waiver to the 180-day billing requirement, the MA-paid days billed under the waiver and after the authorization date of the waiver will not be included in the calculation of the supplemental ventilator care payment and the supplemental ventilator care payment amount will not be retroactively revised. Since this payment is a supplemental payment and not part of the case-mix per diem rates, it will not be subject to the budget adjustment factor under § 1187.96.
A nursing facility's supplemental ventilator care per diem would be calculated as follows: ((number of MA-recipient residents who receive medically necessary ventilator care ÷ total MA-recipient residents) × $69) × (the number of MA-recipient residents who receive medically necessary ventilator care ÷ total MA-recipient residents).
The maximum supplemental ventilator care per diem would be $69 for nursing facilities whose percent of MA-recipient residents who received medically necessary ventilator care to total MA-recipient residents equals 100%. This formula results in the provision of higher supplemental ventilator care payments to facilities with the highest percent of MA-recipient residents who received medically necessary ventilator care. These payments are based on the proportion of MA-recipients who received medically necessary ventilator care to total MA-recipient residents.
Affected Individuals and Organizations
This proposed rulemaking affects nonpublic and county nursing facilities enrolled in the MA Program.
Accomplishments and Benefits
This proposed rulemaking will benefit MA nursing facility residents in this Commonwealth by ensuring they will continue to have access to medically necessary nursing facility services and that those services result in quality care that improves the lives of those who receive them.
Fiscal Impact
This change will result in an estimated annual payment of $2.1 million in total funds ($0.956 million in State funds) in Fiscal Year 2012-2013.
Paperwork Requirements
There are no new or additional paperwork requirements. The CMI Report used to determine the number of MA-recipient residents who receive ventilator care is an existing report.
Effective Date
The effective date will be July 1, 2012.
Public Comment
Interested persons are invited to submit written comments, suggestions or objections regarding the proposed rulemaking to Marilyn Yocum, Department of Public Welfare, Office of Long-Term Living, Bureau of Policy and Regulatory Management, P. O. Box 8025, Harrisburg, PA 17805-8025 within 30 calendar days after the date of publication of this proposed rulemaking in the Pennsylvania Bulletin. Reference Regulation No. 14-535 when submitting comments.
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).
Regulatory Review Act
Under section 5(a) of the Regulatory Review Act (71 P. S. § 745.5(a)), on August 14, 2013, 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 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 must 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 Department, the General Assembly and the Governor of comments, recommendations or objections raised.
BEVERLY D. MACKERETH,
SecretaryFiscal Note: 14-535. (1) General Fund; (2) Implementing Year 2012-13 is $956,000; (3) 1st Succeeding Year 2013-14 is $956,000; 2nd Succeeding Year 2014-15 is $956,000; 3rd Succeeding Year 2015-16 is $956,000; 4th Succeeding Year 2016-17 is $956,000; 5th Succeeding Year 2017-18 is $956,000; (4) 2011-12 Program—$737,356,000; 2010-11 Program—$728,907,000; 2009-10 Program—$540,266,000; (7) Long-Term Care; (8) recommends adoption. Funds have been included in the budget to cover this increase.
Annex A
TITLE 55. PUBLIC WELFARE
PART III. MEDICAL ASSISTANCE MANUAL
CHAPTER 1187. NURSING FACILITY SERVICES
Subchapter H. PAYMENT CONDITIONS, LIMITATIONS AND ADJUSTMENTS (Editor's Note: The following section is new and printed in regular type to enhance readability.)
§ 1187.117. Supplemental ventilator care payments.
(a) A supplemental ventilator care payment will be made each calendar quarter, effective July 1, 2012, to nursing facilities subject to the following:
(1) To qualify for the supplemental ventilator care payment, the nursing facility shall satisfy both of the following threshold criteria on the applicable picture date:
(i) The nursing facility shall have a minimum of ten MA-recipient residents who receive medically necessary ventilator care.
(ii) The nursing facility shall have a minimum of 10% of their MA-recipient resident population receiving medically necessary ventilator care.
(2) Under paragraph (1), the percentage of the nursing facility's MA-recipient residents who require medically necessary ventilator care will be calculated by dividing the total number of MA-recipient residents who receive medically necessary ventilator care by the total number of MA-recipient residents. The result of this calculation will be rounded to two percentage decimal points.
(3) To qualify as an MA-recipient resident who receives medically necessary ventilator care, the resident shall be listed as an MA resident and have a positive response for the MDS item for ventilator use on the Federally-approved PA-specific MDS assessment listed on the nursing facility's CMI report for the applicable picture date.
(4) The number of total MA-recipient residents is the number of MA-recipient residents listed on the nursing facility's CMI report for the applicable picture date.
(5) The applicable picture dates and the authorization of a quarterly supplemental ventilator care payment are as follows:
Picture Dates Authorization
ScheduleFebruary 1 September May 1 December August 1 March November 1 June (6) If a nursing facility fails to submit a valid CMI report for the picture date as provided under § 1187.33(a)(5) (relating to resident data and picture date reporting requirements), the facility cannot qualify for a supplemental ventilator care payment.
(b) A nursing facility's supplemental ventilator care payment is calculated as follows:
(1) The supplemental ventilator care per diem is ((number of MA-recipient residents who receive medically necessary ventilator care/total MA-recipient residents) × $69) × (the number of MA-recipient residents who receive medically necessary ventilator care/total MA-recipient residents).
(2) The amount of the total supplemental ventilator care payment is the supplemental ventilator care per diem multiplied by the number of paid MA facility and therapeutic leave days.
(c) If the Department grants a nursing facility a waiver to the 180-day billing requirement, then the MA-paid days that may be billed under the waiver and after the authorization date of the waiver will not be included in the calculation of the supplemental ventilator care payment. The Department will not retroactively revise the supplemental ventilator care payment amount.
(d) The paid MA facility and therapeutic leave days used to calculate a qualifying facility's supplemental ventilator care payment under subsection (b)(2) will be obtained from the calendar quarter that contains the picture date used in the qualifying criteria as described in subsection (a).
(e) The supplemental ventilator care payments will be made quarterly in each month listed in subsection (a).
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.
(c) Supplemental ventilator care payments.
(1) A supplemental ventilator care payment will be made each calendar quarter, effective July 1, 2012, to county nursing facilities subject to the following:
(i) To qualify for the supplemental ventilator care payment, the county nursing facility shall satisfy both of the following threshold criteria on the applicable picture date:
(A) The county nursing facility shall have a minimum of ten MA-recipient residents who receive medically necessary ventilator care.
(B) The county nursing facility shall have a minimum of 10% of its MA-recipient resident population receiving medically necessary ventilator care.
(ii) For purposes of paragraph (1), the percentage of the county nursing facility's MA-recipient residents who require medically necessary ventilator care will be calculated by dividing the total number of MA-recipient residents who receive medically necessary ventilator care by the total number of MA-recipient residents. The result of this calculation will be rounded to two percentage decimal points.
(iii) To qualify as an MA-recipient resident who receives medically necessary ventilator care, the resident shall be listed as an MA resident and have a positive response for the MDS item for ventilator use on the Federally-approved PA-specific MDS assessment listed on the county nursing facility's CMI report for the applicable picture date.
(iv) The number of total MA-recipient residents is the number of MA-recipient residents listed on the county nursing facility's CMI report for the applicable picture date.
(v) The applicable picture dates and the authorization of a quarterly supplemental ventilator care payment are as follows:
Picture Dates Authorization
ScheduleFebruary 1 September May 1 December August 1 March November 1 June (vi) If a county nursing facility fails to submit a valid CMI report for the picture date as provided under § 1187.33(a)(5) (relating to resident data and picture date reporting requirements), the facility cannot qualify for a supplemental ventilator care payment.
(2) A county nursing facility's supplemental ventilator care payment is calculated as follows:
(i) The supplemental ventilator care per diem is ((number of MA-recipient residents who receive medically necessary ventilator care/total MA-recipient residents) × $69) × (the number of MA-recipient residents who receive medically necessary ventilator care/total MA-recipient residents).
(ii) The amount of the total supplemental ventilator care payment is the supplemental ventilator care per diem multiplied by the number of paid MA facility and therapeutic leave days.
(3) If the Department grants a county nursing facility a waiver to the 180-day billing requirement, the MA-paid days that may be billed under the waiver and after the authorization date of the waiver will not be included in the calculation of the supplemental ventilator care payment. The Department will not retroactively revise the supplemental ventilator care payment amount.
(4) The paid MA facility and therapeutic leave days used to calculate a qualifying facility's supplemental ventilator care payment under paragraph (2)(ii) will be obtained from the calendar quarter that contains the picture date used in the qualifying criteria as described in paragraph (1).
(5) The supplemental ventilator care payments will be made quarterly in each month listed in paragraph (1).
[Pa.B. Doc. No. 13-1584. Filed for public inspection August 23, 2013, 9:00 a.m.]
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