§ 1187.117. Supplemental ventilator care and tracheostomy care payments.
(a) Supplemental ventilator care payments.
(1) A supplemental ventilator care payment will be made each calendar quarter, effective July 1, 2012, through June 30, 2014, to nursing facilities subject to the following:
(i) To qualify for the supplemental ventilator care payment, the nursing facility shall satisfy both of the following threshold criteria on the applicable picture date:
(A) The nursing facility shall have a minimum of ten MA-recipient residents who receive medically necessary ventilator care.
(B) The nursing facility shall have a minimum of 10% of their MA-recipient resident population receiving medically necessary ventilator care.
(ii) Under subparagraph (i), 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 as described in paragraph (2)(i). The result of this calculation will be rounded to two percentage decimal points. (For example, 0.0945 will be rounded to 0.09 (or 9%); 0.1262 will be rounded to 0.13 (or 13%).)
(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 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 nursing facility’s CMI report for the applicable picture date. MA-pending individuals or those individuals found to be MA eligible after the nursing facility submits a valid CMI report for the picture date as provided under § 1187.33(a)(5) (relating to resident data and picture date reporting requirements) may not be included in the count and may not result in an adjustment of the percent of ventilator dependent MA residents.
(v) The applicable picture dates and the authorization of a quarterly supplemental ventilator care payment are as follows:
Picture Dates Authorization Schedule February 1 September May 1 December August 1 March November 1 June (vi) If a nursing facility fails to submit a valid CMI report for the picture date as provided under § 1187.33(a)(5), the facility cannot qualify for a supplemental ventilator care payment.
(2) A 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) x $69) x (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.
(b) Supplemental ventilator care and tracheostomy care payment.
(1) A supplemental ventilator care and tracheostomy care payment will be made each calendar quarter, effective July 1, 2014, to nursing facilities subject to the following:
(i) To qualify for the supplemental ventilator care and tracheostomy care payment, the nursing facility shall satisfy both of the following threshold criteria on the applicable picture date:
(A) The nursing facility shall have a minimum of ten MA-recipient residents who receive medically necessary ventilator care or tracheostomy care.
(B) The nursing facility shall have a minimum of 10% of their MA-recipient resident population receiving medically necessary ventilator care or tracheostomy care.
(ii) Under subparagraph (i), the percentage of the nursing facility’s MA-recipient residents who require medically necessary ventilator care or tracheostomy care will be calculated by dividing the total number of MA-recipient residents who receive medically necessary ventilator care or tracheostomy care by the total number of MA-recipient residents as described in paragraph (2)(i). The result of this calculation will be rounded to two percentage decimal points. (For example, 0.0945 will be rounded to 0.09 (or 9%); 0.1262 will be rounded to 0.13 (or 13%).)
(iii) To qualify as an MA-recipient resident who receives medically necessary ventilator care or tracheostomy care, the resident shall be listed as an MA resident and have a positive response for the MDS item for ventilator use or tracheostomy care on the Federally-approved PA-specific MDS assessment listed on the 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 nursing facility’s CMI report for the applicable picture date. MA-pending individuals or those individuals found to be MA eligible after the nursing facility submits a valid CMI report for the picture date as provided under § 1187.33(a)(5) may not be included in the count and may not result in an adjustment of the percent of ventilator dependent or tracheostomy care MA residents.
(v) The applicable picture dates and the authorization of a quarterly supplemental ventilator care and tracheostomy care payment are as follows:
Picture Dates Authorization Schedule February 1 September May 1 December August 1 March November 1 June (vi) If a nursing facility fails to submit a valid CMI report for the picture date as provided under § 1187.33(a)(5), the facility cannot qualify for a supplemental ventilator care and tracheostomy care payment.
(2) A nursing facility’s supplemental ventilator care and tracheostomy care payment is calculated as follows:
(i) The supplemental ventilator care and tracheostomy care per diem is ((number of MA-recipient residents who receive medically necessary ventilator care or tracheostomy care/total MA-recipient residents) x $69) x (the number of MA-recipient residents who receive medically necessary ventilator care or tracheostomy care/total MA-recipient residents).
(ii) The amount of the total supplemental ventilator care and tracheostomy care payment is the supplemental ventilator care and tracheostomy care per diem multiplied by the number of paid MA facility and therapeutic leave days.
(c) Waiver to 180-day billing requirement. 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 under subsection (a) or the supplemental ventilator care and tracheostomy care payment under subsection (b). The Department will not retroactively revise the supplemental payment amount under subsections (a) and (b).
(d) Calculation of quarterly payments. The paid MA facility and therapeutic leave days used to calculate a qualifying facility’s supplemental ventilator care or supplemental ventilator care and tracheostomy care payments under subsections (a)(2)(ii) and (b)(2)(ii) will be obtained from the calendar quarter that contains the picture date used in the qualifying criteria as described in subsections (a) and (b).
(e) Quarterly payments. The supplemental ventilator care or supplemental ventilator care and tracheostomy care payments will be made quarterly in each month listed in subsections (a) and (b).
Authority The provisions of this § 1187.117 issued under 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).
Source The provisions of this § 1187.117 adopted June 13, 2014, section 1187(a) shall take effect upon publication and apply retroactively from July 1, 2012, through June 30, 2014, section 1187.117(c)—(e) shall take effect upon publication and apply retroactively from July 1, 2012, section 1187.117(b) takes effect July 1, 2014, 44 Pa.B. 3565.
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