reglab/statecodes huggingface dataset:
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.10 - MEDICAID ENHANCED PLAN BENEFITS › SUB AREA: LONG-TERM CARE › Section 16.03.10.256 - NURSING FACILITY: PRINCIPLE FOR RATE SETTING

Current through August 31, 2023
Reimbursement rates will be set based on projected cost data
				  from cost reports and audit reports. Reimbursement is to be set for
				  freestanding and hospital-based facilities. In general, the methodology will be
				  a cost-based prospective reimbursement system with an acuity adjustment for
				  direct care costs, allowances for margin payments related to the indirect and
				  direct care costs, and subject to the application of a BAF. (3-17-22)
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.10 - MEDICAID ENHANCED PLAN BENEFITS › SUB AREA: LONG-TERM CARE › Section 16.03.10.257 - NURSING FACILITY: DEVELOPMENT OF THE RATE

Current through August 31, 2023
Nursing facility rates are prospective, with new rates
				  effective July 1st of each year, and are recalculated annually with quarterly
				  adjustments for case mix. In no case will the rate be set higher than the
				  charge for like services to private pay patients in effect for the period for
				  which payment is made as computed by the lower of costs or customary charges.
				  For the rate year of July 1, 2021, through June 30, 2022, rates will be
				  calculated using audited cost reports ended in the calendar year 2019,
				  including an inflation factor applied from the mid-point of the cost reporting
				  period to the mid-point of the rate period. Inflation will be applied to all
				  rate components, with the exception of property costs. For the rate years
				  beginning July 1, 2022, and annually thereafter, rates will be calculated using
				  audited cost reports for the periods ending in the calendar year two (2) years
				  prior to each July 1 (July 1, 2022, rates will use cost reports ended in
				  calendar year 2020 and so forth), including inflation adjustments from the
				  midpoint of the cost report period to the mid-point of the rate period, with
				  the exception of property costs. (3-17-22)
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.10 - MEDICAID ENHANCED PLAN BENEFITS › SUB AREA: LONG-TERM CARE › Section 16.03.10.259 - NURSING FACILITY: TREATMENT OF NEW BEDS

Current through August 31, 2023
Facilities that add beds after July 1, 1999, will have their
				  reimbursement rate subjected to an additional limitation for the next three (3)
				  years. This limitation will apply beginning with the first rate setting period
				  that utilizes a cost report that includes the date when the beds were added.
				  This provision will be the same for either behavioral care unit facilities or
				  non-behavioral care units. (3-17-22)
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.10 - MEDICAID ENHANCED PLAN BENEFITS › SUB AREA: LONG-TERM CARE › Section 16.03.10.262 - NURSING FACILITY: OUT-OF-STATE NURSING HOMES

Current through August 31, 2023
The Idaho Medicaid Program will reimburse for out-of-state
				  nursing home placements when services are not available in Idaho to meet the
				  participant's medical need, or in a temporary situation for a limited period of
				  time required to safely transport the participant to an Idaho facility.
				  Reimbursement for out-of-state nursing homes will be at the per diem rate set
				  by the Medicaid Program in the state where the nursing home is located. Special
				  rates will be allowed according to Section
				  270 of these rules.
				  (3-17-22)
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.10 - MEDICAID ENHANCED PLAN BENEFITS › SUB AREA: LONG-TERM CARE › Section 16.03.10.263 - NURSING FACILITY: DISTRESSED FACILITY

Current through August 31, 2023
01.
Determination
. If the Department determines that a facility is located
				in an under-served area, or addresses an under-served need, the Department may
				negotiate a reimbursement rate different than the rate then in effect for that
				facility. (3-17-22)
02.
Discretionary Factors
. The fact that a facility may be located in an
				under-served area or meets an under-served need does not guarantee increased
				reimbursement. In exercising its discretion to apply a higher rate, the
				Department will consider the factors as described in Subsections
				263.02.a. through 263.02.e. of
				this rule. (3-17-22)
a. Prudent Spending
				Patterns. The facility has exercised prudent spending and cost allocation
				practices, as evidenced by a thorough and comprehensive review of the
				facility's accounts by the Department. (3-17-22)
b. Reasonable Attempts to Remedy Problems.
				The facility must persuade the Department that it has conscientiously and
				diligently attempted to cover its costs of care, hire qualified staff and
				otherwise operate effectively and efficiently, but for causes beyond the
				facility's reasonable control, it has not been able to do so.
				(3-17-22)
c. Facility Already
				Receives Special Rates. When a facility already receives special rates for
				certain difficulty-of-care patients from the Department, the same costs of care
				that were used to determine special rates will not be applied toward a
				determination of distressed facility status, because the special rate meets
				that need. (3-17-22)
d. Direct and
				Indirect Costs of Care Apportioned to Patient Care. The Department reimburses
				the costs of patient care, and does not pay for indirect costs not associated
				with patient care. The determination of distressed status will focus on whether
				the facility's distress stems from patient care costs, or whether the distress
				arises from expenses unrelated to patient care costs. (3-17-22)
e. Existing Cost Limits. Under no
				circumstances may a facility's reimbursement exceed the lower of its actual
				costs or customary charge to private-pay patients, as required by federal law,
				subject to the exceptions in federal law. The Department's cost caps can be
				exceeded through the distressed facility process, but to an amount no greater
				than the federal upper payment limit. (3-17-22)
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.10 - MEDICAID ENHANCED PLAN BENEFITS › SUB AREA: LONG-TERM CARE › Section 16.03.10.264 - NURSING FACILITY: INTERIM ADJUSTMENTS TO RATES AS A RESULT OF NEW MANDATES

Current through August 31, 2023
Certain costs may be excluded from the cost limit
				  calculations, may be subject to retrospective settlement at the discretion of
				  the Department, and may result in changes to the prospective rates as provided
				  in this Section to assure equitable reimbursement: (3-17-22)
01.
Changes of More Than Fifty Cents
				Per Patient Day in Costs
. Changes of more than fifty cents ($.50) per
				patient day in costs otherwise subject to the cost limitations incurred by a
				facility as a result of changes in state or federal laws or rules will be
				reported separately on the cost report until such time as they can be properly
				reflected in the cost limits. (3-17-22)
a. The
				provider will report these costs on a separate schedule or by notations on the
				cost report so that these costs can be identified and reconciled to the
				provider's general ledger. These costs will be reported separately and will not
				be reimbursed through the rate setting process until the costs are fully
				represented in the cost data used to establish the cost limitations and rates.
				(3-17-22)
b. If more than one (1)
				increase occurs as a result of one (1) or more law or rule changes, the costs
				from each event are to be reported separately. (3-17-22)
c. The computation of the cost increase
				amount or amounts is to be presented in detail on a supplementary schedule or
				schedules unless the Department states otherwise. (3-17-22)
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.10 - MEDICAID ENHANCED PLAN BENEFITS › SUB AREA: LONG-TERM CARE › Section 16.03.10.265 - NURSING FACILITY: MDS REVIEWS

Current through August 31, 2023
The following Minimum Data Set (MDS) reviews will be
				  conducted: (3-17-22)
01.
Facility Review
. Subsequent to the picture date, each facility will be
				sent a copy of its resident roster (a listing of residents, their RUG
				classification, case mix index, and identification as Medicaid or other). It
				will be the facility's responsibility at that time to review the roster for
				accuracy. If the roster is accurate, the facility will sign and return the
				roster for rate setting. If any errors are detected, those errors will be
				communicated to the Department in writing along with any supporting
				documentation. If the signed resident roster is not returned and no errors are
				communicated to the Department, the original resident roster will be used for
				rate setting. Once the resident roster has been used for rate setting, it will
				be considered final unless modified by subsequent Departmental review.
				(3-17-22)
02.
Departmental
				Review
. If a departmental review of the MDS data reveals errors that
				result in an incorrect case mix index, the provider's rate will be
				retroactively adjusted, for all quarters containing the incorrect assessment,
				and an amount due to or from the Department will be calculated. This does not
				include residents who received the default classification due to incomplete or
				inconsistent MDS data. (3-17-22)
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.10 - MEDICAID ENHANCED PLAN BENEFITS › SUB AREA: LONG-TERM CARE › Section 16.03.10.266 - NURSING FACILITY: BEHAVIORAL CARE UNIT (BCU) AND RATE STRUCTURE

Current through August 31, 2023
Effective October 1, 2012, the additional direct care costs
				  associated with BCU residents will remain in direct care costs subject to the
				  direct care cost limitation. Those qualifying BCU nursing facility providers
				  may have a direct care cost limitation higher than non-BCU nursing facility
				  providers. BCU nursing facility providers will not receive an increased
				  indirect care cost limitation. (3-17-22)
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.10 - MEDICAID ENHANCED PLAN BENEFITS › SUB AREA: LONG-TERM CARE › Section 16.03.10.267 - NURSING FACILITY: TREATMENT OF NEWLY LICENSED FACILITIES WITH BEHAVIORAL CARE UNITS

Current through August 31, 2023
Facilities licensed on or after September 1, 2017, must meet
				  the qualifications for a BCU described in Idaho Medicaid Provider Agreement
				  Additional Terms - Behavioral Care Units. BCU facilities existing prior to this
				  date that receive a new license due to a change in ownership will not be
				  subject to the provisions of this rule. (3-17-22)
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.10 - MEDICAID ENHANCED PLAN BENEFITS › SUB AREA: LONG-TERM CARE › Section 16.03.10.268 - NURSING FACILITY: EXISTING PROVIDER ELECTS TO ADD BEHAVIORAL CARE UNIT (BCU)

Current through August 31, 2023
An existing nursing facility provider that elects to add a
				  BCU on or after September 1, 2017, may be deemed eligible after meeting the
				  following requirements: (3-17-22)
01.
Meet Criteria for BCU
. The nursing facility provider must meet the
				criteria for a BCU described in Section
				266 of these rules.
				(3-17-22)
02.
BCU Eligible
				Days
. The provider must demonstrate that BCU days from a minimum of
				sixty (60) calendar days, regardless of payer source, divided by total census
				days for that same sixty (60) day period, equals or exceeds a minimum of thirty
				percent (30%). (3-17-22)
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.10 - MEDICAID ENHANCED PLAN BENEFITS › SUB AREA: LONG-TERM CARE › Section 16.03.10.269 - NURSING FACILITY: NEW OWNER OF AN EXISTING NURSING FACILITY WITH A BEHAVIORAL CARE UNIT (BCU)

Current through August 31, 2023
01.
New Owner
				Elects to Continue BCU
. An existing nursing facility that is considered
				a BCU will continue to be a BCU, if the new owner elects to continue to provide
				these services. The new owner will receive a rate calculated according to the
				current change of ownership rules in Section
				261 of these rules. The prior
				owner's cost report will be used until the new owner has a qualifying cost
				report. They BCU will continue to qualify for the higher direct care cost limit
				the previous owner was allowed. (3-17-22)
02.
New Owner Does Not Elect to
				Continue BCU
. If the new owner does not elect to operate the BCU, the
				prior owner's cost report will be used. The direct care cost limit will be
				adjusted down to that of the non-BCU nursing facility. (3-17-22)
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.10 - MEDICAID ENHANCED PLAN BENEFITS › SUB AREA: LONG-TERM CARE › Section 16.03.10.272 - NURSING FACILITY: LEGAL CONSULTANT FEES AND LITIGATION COSTS

Current through August 31, 2023
Costs of legal consultant fees and litigation costs incurred
				  by the provider will be handled in accordance with the following:
				  (3-17-22)
01.
In General
.
				Legal consultant fees unrelated to the preparation for or the taking of an
				appeal of an audit performed by the Department of Health and Welfare, or
				litigation costs incurred by the provider in an action unrelated to litigation
				with the Department of Health and Welfare, will be allowed as a part of the
				total per diem costs of which the Medicaid Program will reimburse a portion
				according to the percentage of Medicaid patient days. (3-17-22)
02.
Administrative Appeals
. In
				the case of the provider contesting in administrative appeal the findings of an
				audit performed by the Department of Health and Welfare, the costs of the
				provider's legal counsel will be reimbursed by the Medicaid Program only to the
				extent that the provider prevails on the issues involved. The determination of
				the extent that the provider prevails will be based on the ratio of the total
				dollars at issue for the audit period at issue in the hearing to the total
				dollars ultimately awarded to the provider for that audit period by the hearing
				officer or subsequent adjudicator. (3-17-22)
03.
Other
. All other litigation
				costs incurred by the provider in actions against the Department of Health and
				Welfare will not be reimbursable either directly or indirectly by the Medicaid
				Program except where specifically ordered by a court of law.
				(3-17-22)
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.10 - MEDICAID ENHANCED PLAN BENEFITS › SUB AREA: LONG-TERM CARE › Section 16.03.10.273 - NURSING FACILITY: PATIENT FUNDS

Current through August 31, 2023
The safekeeping of patient funds, under the program, is the
				  responsibility of the provider. Accordingly, the administration of these funds
				  requires scrupulous care in recording all transactions for the patient.
				  (3-17-22)
01.
Use
.
				Generally, funds are provided for personal needs of the patient to be used at
				the patient's discretion. The provider agrees to manage these funds and render
				an accounting but may not use them in any way. (3-17-22)
02.
Provider Liability
. The
				provider is subject to legal and financial liabilities for committing any of
				the following acts. This is only a partial listing of the acts contrary to
				federal regulations: (3-17-22)
a. Management
				fees may not be charged for managing patient trust funds. These charges
				constitute double payment as management is normally performed by an employee of
				the provider and their salary is included in reasonable cost reimbursement.
				(3-17-22)
b. Nothing is to be
				deducted from these funds, unless such deductions are authorized by the patient
				or their agent in writing. (3-17-22)
c. Interest accruing to patient funds on
				deposit is the property of the patients and is part of the personal funds of
				each patient. The interest from these funds is not available to the provider
				for any use, including patient benefits. (3-17-22)
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.10 - MEDICAID ENHANCED PLAN BENEFITS › SUB AREA: LONG-TERM CARE › Section 16.03.10.274 - NURSING FACILITY: IDAHO OWNER-ADMINISTRATIVE COMPENSATION

Current through August 31, 2023
Allowable compensation to owners and persons related to
				  owners who provide any administrative services will be limited based on the
				  schedule in this section. (3-17-22)
01.
Allowable Owner Administrative
				Compensation
. The following schedule will be used in determining the
				maximum amount of owner administrative compensation allowable for the calendar
				year ending December 31, 2002.
Licensed Bed
								Range
Upper limit
51 - 100
86,951
101 - 150
95,641
151 - 250
129,878
251 - up
186,435
(3-17-22)
02.
The Administrative Compensation
				Schedule
. The administrative compensation schedule in this Section will
				be adjusted annually based upon the change in average hourly earnings in
				nursing and personal care facilities as published by IHS Markit, its successor
				organization or, if unavailable, another nationally recognized forecasting
				firm. (3-17-22)
03.
The
				Maximum Allowable Compensation
. The maximum allowable compensation for
				an owner providing administrative services is determined from the schedule in
				Subsection 274.01 of these
				rules
.
Allowable compensation will be determined as follows:
				(3-17-22)
a. In determining the number of beds
				applicable on the schedule, all licensed beds for which the individual provides
				administrative services will be counted, regardless of whether they are in the
				same facility. (3-17-22)
b. For an
				owner providing services to more than fifty (50) beds, the amounts shown on the
				schedule for the applicable number of beds will determine the upper limit for
				allowable compensation. (3-17-22)
c. For owners providing services to less than
				fifty-one (51) beds, such services related to administrative duties will be
				reimbursed at the hourly rate allowable if the owner was providing services to
				fifty-one (51) beds. Additionally, services other than administrative services
				may be performed by the owner and will be allowable at the reasonable market
				rate for such services. To be allowable, hours for each type of service will be
				documented. In no event will the total compensation for administrative and
				non-administrative duties paid to an owner or related party to an owner of a
				facility or facilities with fifty (50) licensed beds or less exceed the limit
				that would be applicable to an owner with the same number of points providing
				administrative services to facilities with fifty-one (51) beds as set forth in
				the schedule of Subsection
				274.01 of these rules.
				(3-17-22)
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.10 - MEDICAID ENHANCED PLAN BENEFITS › SUB AREA: LONG-TERM CARE › Section 16.03.10.278 - NURSING FACILITY: OCCUPANCY ADJUSTMENT FACTOR

Current through August 31, 2023
In order to equitably allocate fixed costs to the Medicaid
				  patients in cases where a facility is not maintaining reasonable occupancy
				  levels, an adjustment will be made. No occupancy adjustment will be made
				  against the costs that are used to calculate the property rental rate; however
				  adjustment will be made against all other property costs. The adjustment will
				  be made as follows: (3-17-22)
01.
Occupancy Levels
. If a facility maintains an average occupancy of
				less than eighty percent (80%) of a facility's capacity, the total property
				costs not including cost paid under the property rental rate, will be prorated
				based upon an eighty percent (80%) occupancy rate. Property costs and property
				rental rates are defined in Section
				013 of these rules. The facility's
				average occupancy percentage will be subtracted from eighty percent (80%) and
				the resultant percentage will be taken times the total fixed costs to determine
				the nonallowable fixed costs. (3-17-22)
02.
Occupancy Adjustment
. For
				purposes of an occupancy adjustment, facility capacity will be computed based
				upon the greater of the largest number of beds for which the facility was
				licensed during the period being reported on or the largest number of beds for
				which the facility was licensed during calendar year 1981, except where a
				portion of the facility has been converted to use for nonroutine nursing home
				activities or the facility is newly constructed and has entered the Medicaid
				Program subsequent to January 1, 1982. If the facility's designed capacity has
				been changed, the number of beds used to determine occupancy will be lowered by
				the amount of capacity being converted to nonroutine nursing home activities.
				Facility capacity for a new facility will be based on the number of beds
				approved by the certificate of need process less any capacity converted to
				nonroutine nursing home activities. (3-17-22)
03.
Fixed Costs
. For purposes of
				an occupancy adjustment fixed costs will be considered all allowable and
				reimbursable costs reported under the property cost categories.
				(3-17-22)
04.
Change in
				Designed Capacity
. In cases where a provider changes the designed
				capacity of a facility, the average occupancy for the period prior to the
				change and subsequent to the change will be computed and each period will be
				adjusted separately. If the designed capacity is increased, the increased
				number of beds will not be subject to this adjustment for the first six (6)
				months following their licensure. (3-17-22)
05.
New Facility
. In the case of
				a new facility being licensed and occupied, the first six (6) months occupancy
				level will not be subject to this adjustment. (3-17-22)
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.10 - MEDICAID ENHANCED PLAN BENEFITS › SUB AREA: LONG-TERM CARE › Section 16.03.10.279 - NURSING FACILITY: RECAPTURE OF DEPRECIATION

Current through August 31, 2023
Where depreciable assets that were reimbursed based on cost
				  and were used in the Medicaid Program by a facility subsequent to January 1,
				  1982, and for which depreciation has been reimbursed by the Program, are sold
				  for an amount in excess of their net book value, depreciation so reimbursed
				  will be recaptured from the buyer of the facility in an amount equal to
				  reimbursed depreciation after January 1, 1982, or gain on the sale, whichever
				  is less. (3-17-22)
01.
Amount
				Recaptured
. Depreciation will be recaptured in full if a sale of a
				depreciated facility takes place within the first five (5) years of a seller's
				ownership. Credit will be given for the period of ownership prior to January 1,
				1982. For every year the asset is held beyond the first five (5) years, the
				total depreciation recaptured will be reduced by ten percent (10%) per year of
				the total depreciation taken. (3-17-22)
02.
Time Frame
. Depreciation
				will be recaptured by the Medicaid Program from the buyer of the facility over
				a period of time not to exceed five (5) years from the date of sale, with not
				less than one-fifth (1/5) of the total amount being recaptured for each year
				after such date. (3-17-22)
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.10 - MEDICAID ENHANCED PLAN BENEFITS › SUB AREA: LONG-TERM CARE › Section 16.03.10.283 - NURSING FACILITY: FILING DATES

Current through August 31, 2023
01.
Deadlines
. Deadlines for annual cost reports will be the last day of the
				third month following the fiscal year end or the deadline imposed by Medicare
				if the provider is required to file a Medicare cost report. (3-17-22)
02.
Waivers
. A delay of thirty
				(30) days may be granted for annual cost reports in unusual circumstances.
				Requests for such deferrals and reasons therefore must be in writing and should
				be made prior to the deadline. A written decision will be rendered in writing
				within ten (10) days. (3-17-22)
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.10 - MEDICAID ENHANCED PLAN BENEFITS › SUB AREA: LONG-TERM CARE › Section 16.03.10.284 - NURSING FACILITY: FAILURE TO FILE

Current through August 31, 2023
Failure to submit timely reports may result in a reduction in
				  the interim rate. Failure to file the required cost reports, including required
				  supplemental information, unless a waiver is granted, may result in a reduction
				  of ten percent (10%) in the provider's rate(s) the first day of the month
				  following the deadline date. Continued failure to comply will result in
				  complete payment suspension on the first day of the following month. When
				  suspension or reduction has occurred and the provider has filed the required
				  cost reports, amounts accruing to the provider during the period of suspension
				  or reduction will be restored. Loss of license or certification will result in
				  immediate termination of reimbursement, full scope audit and settlement for the
				  cost period. (3-17-22)
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.10 - MEDICAID ENHANCED PLAN BENEFITS › SUB AREA: LONG-TERM CARE › Section 16.03.10.285 - NURSING FACILITY: ACCOUNTING SYSTEM

Current through August 31, 2023
Reports must be filed using the accrual basis and conform
				  with generally accepted accounting principles or within provisions of the
				  guidelines as specified. In any case, the recorded transaction must be capable
				  of verification by Departmental audit. (3-17-22)
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.10 - MEDICAID ENHANCED PLAN BENEFITS › SUB AREA: LONG-TERM CARE › Section 16.03.10.286 - NURSING FACILITY: AUDITS

Current through August 31, 2023
All financial reports are subject to audit by Departmental
				  representatives. (3-17-22)
01.
Accuracy of Recording
. To determine whether the transactions recorded in
				the books of record are substantially accurate and reliable as a basis for
				determining reasonable costs. (3-17-22)
02.
Reliability of Internal
				Control
. To determine that the facilities internal control is
				sufficiently reliable to disclose the results of the to the provider's
				operations. (3-17-22)
03.
Economy and Efficiency
. To determine if Title XIX and Title XXI
				participants have received the required care on the a basis of economy and
				efficiency. (3-17-22)
04.
Application of GAAP
. To determine if GAAP is applied on a consistent
				basis in conformance with applicable federal and state regulations.
				(3-17-22)
05.
Patient Trust
				Fund Evaluation
. To evaluate the provider's policy and practice
				regarding their fiduciary responsibilities for patients, funds and property.
				(3-17-22)
06.
Enhancing
				Financial Practices
. To provide findings and recommendations aimed at
				better financial practices to allow the most economical delivery of patient
				care. (3-17-22)
07.
Compliance
. To provide recommendations that will enable the provider to
				conform more closely with state and federal regulations in the delivery of
				health care to program participants. (3-17-22)
08.
Final Settlement
. To effect
				final settlement when required by
Sections
250 through 296 of
				these rules. (3-17-22)
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.10 - MEDICAID ENHANCED PLAN BENEFITS › SUB AREA: LONG-TERM CARE › Section 16.03.10.287 - NURSING FACILITY: AUDIT APPLICATION

Current through August 31, 2023
01.
Annual
				Audits
. Normally, all annual statements will be audited within the
				following year. (3-17-22)
02.
Limited Scope Audit
. Other statements and some annual audit
				recommendations may be subject to limited scope audits to evaluate provider
				compliance. (3-17-22)
03.
Additional Audits
. In addition, audits may be required where: (3-17-22)
a. A significant change of ownership occurs.
				(3-17-22)
b. A change of management
				occurs. (3-17-22)
c. An overpayment
				of twenty-five percent (25%) or more has resulted for a completed cost period.
				(3-17-22)
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.10 - MEDICAID ENHANCED PLAN BENEFITS › SUB AREA: LONG-TERM CARE › Section 16.03.10.288 - NURSING FACILITY: AUDIT STANDARDS AND REQUIREMENTS

Current through August 31, 2023
01.
Review of New Provider Fiscal
				Records
. Before any program payments can be made to a prospective
				provider the intermediary will review the provider's accounting system and its
				capability of generating accurate statistical cost data. Where the provider's
				record keeping capability does not meet program requirements the intermediary
				will offer limited consultative services or suggest revisions of the provider's
				system to enable the provider to comply with program requirements.
				(3-17-22)
02.
Requirements
. Providers Reimbursement Manual (PRM), Section
				2404.3, states: "Examination of
				Pertinent Data and Information -- Providers asking to participate as well as
				those currently participating must permit the intermediary to examine such
				records and documents as are deemed necessary. (3-17-22)
03.
Examination of Records
.
				Examination of records and documents may include: (3-17-22)
a. Corporate charters or other documents of
				ownership including those of a parent or related companies. (3-17-22)
b. Minutes and memos of the governing body
				including committees and its agents. (3-17-22)
c. All contracts. (3-17-22)
d. Tax returns and records, including
				workpapers and other supporting documentation. (3-17-22)
e. All insurance contracts and policies
				including riders and attachments. (3-17-22)
f. Leases. (3-17-22)
g. Fixed asset records (see audit section -
				Capitalization of Assets). (3-17-22)
h. Schedules of patient charges.
				(3-17-22)
i. Notes, bonds and other
				evidences of liability. (3-17-22)
j. Capital expenditure records.
				(3-17-22)
k. Bank statements,
				cancelled checks, deposit slips and bank reconciliations. (3-17-22)
l. Evidence of litigations the facility and
				its owners are involved in. (3-17-22)
m. Documents of ownership including
				attachments that describe the property. (3-17-22)
n. All invoices, statements and claims.
				(3-17-22)
o. Providers Accounting
				Firm. Where a provider engages an accounting firm to maintain its fiscal
				records, the financial audit work papers prepared by the accounting firm are
				considered to be the property of the provider and must be made available to the
				intermediary upon request, under PRM, Subparagraph 2404.4(Q).
				(3-17-22)
p. Ledgers, journals, all
				working papers, subsidiary ledgers, records and documents relating to financial
				operation. (3-17-22)
q. All patient
				records, including trust funds and property. (3-17-22)
r. Time studies and other cost determining
				information. (3-17-22)
s. All other
				sources of information needed to form an audit opinion.
				(3-17-22)
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.10 - MEDICAID ENHANCED PLAN BENEFITS › SUB AREA: LONG-TERM CARE › Section 16.03.10.291 - NURSING FACILITY: COSTS FOR THE COMPLETION OF NURSE AIDE TRAINING AND COMPETENCY EVALUATION PROGRAMS (NATCEPS) AND FOR COMPLYING WITH CERTAIN OTHER REQUIREMENTS

Current through August 31, 2023
Provisions of federal law require the state to give special
				  treatment to costs related to the completion of training and competency
				  evaluation of nurse aides and to increase rates related to other new
				  requirements. Treatment will be as follows: (3-17-22)
01.
Cost Reimbursement
.
				Effective for cost reports filed and for payments made after April 1, 1990,
				NATCEP costs will be outside the content of nursing facility care and will be
				reported separately as exempt costs. (3-17-22)
02.
Costs Subject to Audit
. Such
				NATCEP costs are subject to audit, and must be reported by all nursing
				facilities, including those that are hospital-based, and are not included in
				the percentile cap. (3-17-22)
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.10 - MEDICAID ENHANCED PLAN BENEFITS › SUB AREA: LONG-TERM CARE › Section 16.03.10.292 - NURSING FACILITY: PAYMENTS FOR PERIODS OF TEMPORARY ABSENCE

Current through August 31, 2023
Payments may be made for reserving beds in long-term care
				  facilities for participants during their temporary absence if the facility
				  charges private paying patients for reserve bed days, subject to the following
				  limitations: (3-17-22)
01.
Facility Occupancy Limits
. Payment for periods of temporary absence from
				long term care facilities will not be made when the number of unoccupied beds
				in the facility on the day preceding the period of temporary absence in
				question is equal to or greater than: (3-17-22)
a. If licensed beds are less than one hundred
				(<100) and they have five (5) or more beds unoccupied, leave of absence
				payments are not allowed. (3-17-22)
b. If licensed beds are greater than or equal
				to one hundred (>100), they must have a minimum occupancy rate of
				ninety-five percent (95%) for leave of absence payments to be allowed.
				(3-17-22)
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.10 - MEDICAID ENHANCED PLAN BENEFITS › SUB AREA: LONG-TERM CARE › Section 16.03.10.300 - PERSONAL CARE SERVICES (PCS)

Current through August 31, 2023
01.
Description of Personal Care Services (PCS)
. Under Sections
				39-5601 through
				39-5607, Idaho Code, it is the
				intent of the Department to provide personal care services (PCS) to eligible
				participants in their own homes or personal residences to prevent unnecessary
				institutional placement, to provide for the greatest degree of independence
				possible, to enhance quality of life, to encourage individual choice, and to
				maintain community integration. (3-17-22)
02.
Temporary Changes to PCS Rules
				During Declared State of Emergency Related to Novel Coronavirus Disease
				(COVID-19)
. In response to Idaho's declaration on 3/13/20 of a state of
				emergency related to COVID-19, the Department reserves the right to temporarily
				alter requirements and processes related to PCS services, currently and through
				the duration of the emergency state, in order to mitigate spread of disease and
				to ensure the health and safety of our participants under the guidance and
				authority of the provisions in a CMS approved 1135 waiver. Guidance for
				approved flexibilities is posted on the Medicaid Information Releases website
				at
https://healthandwelfare.idaho.gov/providers/idaho-medicaid-providers/information-medicaid-providers
.
				(3-17-22)
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.10 - MEDICAID ENHANCED PLAN BENEFITS › SUB AREA: LONG-TERM CARE › Section 16.03.10.301 - PERSONAL CARE SERVICES: DEFINITIONS

Current through August 31, 2023
01.
Children's PCS Assessment
. A set of standardized criteria adopted by the
				Department to assess functional and cognitive abilities of children to
				determine eligibility for children's PCS. (3-17-22)
02.
Natural Supports
. Personal
				associations and relationships that enhance the quality and security of life
				for people, such as family, friends, neighbors, volunteers, church, or others.
				(3-17-22)
03.
Personal Care
				Services (PCS)
. A range of medically-oriented care services related to a
				participant's physical or functional requirements. These services are provided
				in the participant's home or personal residence, but do not include
				housekeeping or skilled nursing care. (3-17-22)
04.
PCS Family Alternate Care
				Home
. The private home of an individual licensed by the Department to
				provide PCS to one (1) or two (2) children, who are unable to reside in their
				own home and require assistance with medically-oriented tasks related to the
				child's physical or functional needs. (3-17-22)
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.10 - MEDICAID ENHANCED PLAN BENEFITS › SUB AREA: LONG-TERM CARE › Section 16.03.10.302 - PERSONAL CARE SERVICES: ELIGIBILITY

Current through August 31, 2023
01.
Financial Eligibility
. The participant must be financially eligible for
				medical assistance under IDAPA 16.03.01, "Eligibility for Health Care
				Assistance for Families and Children," or 16.03.05, "Eligibility for Aid to the
				Aged, Blind, and Disabled (AABD)." (3-17-22)
02.
Other Eligibility
				Requirements
. Bureau of Long Term Care (BLTC) will prior authorize
				payment for the amount and duration of all services when all of the following
				conditions are met: (3-17-22)
a. The BLTC
				finds that the participant is capable of being maintained safely and
				effectively in their own home or personal residence using PCS.
				(3-17-22)
b. The participant is an
				adult for whom a Uniform Assessment Instrument (UAI) has been completed, or a
				child for whom a children's PCS assessment has been completed;
				(3-17-22)
c. The BLTC reviews the
				documentation for medical necessity; and (3-17-22)
d. The participant has a plan of care that
				meets the person-centered planning requirements described in Sections
				316 and
				317 of these rules.
				(3-17-22)
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.10 - MEDICAID ENHANCED PLAN BENEFITS › SUB AREA: LONG-TERM CARE › Section 16.03.10.303 - PERSONAL CARE SERVICES: COVERAGE AND LIMITATIONS

Current through August 31, 2023
01.
Medical Care and Services
.
				PCS services include medically-oriented tasks related to a participant's
				physical or functional requirements, as opposed to housekeeping or skilled
				nursing care, provided in the participant's home or personal residence. The
				provider must deliver at least one (1) of the following services: (3-17-22)
a. Basic personal care and grooming to
				include bathing, care of the hair, assistance with clothing, and basic skin
				care; (3-17-22)
b. Assistance with
				bladder or bowel requirements that may include helping the participant to and
				from the bathroom or assisting the participant with bedpan routines;
				(3-17-22)
c. Assistance with food,
				nutrition, and diet activities including preparation of meals if incidental to
				medical need; (3-17-22)
d. The
				continuation of active treatment training programs in the home setting to
				increase or maintain participant independence for the participant with
				developmental disabilities; (3-17-22)
e. Assisting the participant with
				physician-ordered medications that are ordinarily self-administered, in
				accordance with IDAPA 24.34.01, "Rules of the Idaho Board of Nursing,"
				Subsection 490.05; (3-17-22)
f. Non-nasogastric gastrostomy tube feedings
				if authorized by BLTC prior to implementation and if the following requirements
				are met: (3-17-22)
i. The task is not complex
				and can be safely performed in the given participant care situation;
				(3-17-22)
ii. A Licensed Registered
				Nurse (RN) has assessed the participant's nursing care needs and has developed
				a written standardized procedure for gastrostomy tube feedings, individualized
				for the participant's characteristics and needs; (3-17-22)
iii. Individuals to whom the procedure can be
				delegated are identified by name. The RN must provide proper instruction in the
				performance of the procedure, supervise a return demonstration of safe
				performance of the procedure, state in writing the strengths and weaknesses of
				the individual performing the procedure, and evaluate the performance of the
				procedure at least monthly; (3-17-22)
iv. Any change in the participant's status or
				problem related to the procedure must be reported immediately to the RN;
				(3-17-22)
v. The individualized
				procedure, the supervised performance of the procedure, and follow-up
				evaluation of the performance of the procedure must be documented in writing by
				the supervising RN and must be readily available for review, preferably with
				the participant's record; and (3-17-22)
vi. Routine medication may be given by the
				personal assistant through the non-nasogastric tube if authorized by the
				supervising RN. (3-17-22)
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.10 - MEDICAID ENHANCED PLAN BENEFITS › SUB AREA: LONG-TERM CARE › Section 16.03.10.304 - PERSONAL CARE SERVICES: PROCEDURAL REQUIREMENTS

Current through August 31, 2023
01.
Service Delivery Based on Plan of Care or NSA
. All PCS services
				are provided based on a written plan of care or a negotiated service agreement
				(NSA). The requirements for the NSA for participants in Residential Assisted
				Living Facilities are described in IDAPA 16.03.22, "Residential Assisted Living
				Facilities." The requirements for the NSA for participants in Certified Family
				Homes are described in IDAPA 16.03.19, "Certified Family Homes." The Personal
				Assistance Agency and the participant who lives in their own home are
				responsible to prepare the plan of care. (3-17-22)
a. The plan of care for participants who live
				in their own homes or in a PCS Family Alternate Care Home is based on:
				(3-17-22)
i. The physician's or authorized
				provider's information if applicable; (3-17-22)
ii. The results of the UAI for adults, the
				children's PCS assessment and, if applicable, the QIDP's assessment and
				observations of the participant; and (3-17-22)
iii. Information obtained from the
				participant. (3-17-22)
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.10 - MEDICAID ENHANCED PLAN BENEFITS › SUB AREA: LONG-TERM CARE › Section 16.03.10.305 - PERSONAL CARE SERVICES: PROVIDER QUALIFICATIONS

Current through August 31, 2023
01.
Provider Qualifications for Personal Assistants
. All personal
				assistants must have at least one (1) of the following qualifications:
				(3-17-22)
a. Licensed Registered Nurse (RN). A
				person currently licensed by the Idaho State Board of Nursing as a licensed
				registered nurse; (3-17-22)
b.
				Licensed Practical Nurse (LPN). A person currently licensed by the Idaho State
				Board of Nursing as a licensed practical nurse; or (3-17-22)
c. Personal Assistant. A person who meets the
				standards of Section
				39-5603, Idaho Code, and receives
				training to ensure the quality of services. The assistant must be at least age
				eighteen (18) years of age. The BLTC may require a certified nursing assistant
				(CNA) if, in their professional judgment, the participant's medical condition
				warrants a CNA. (3-17-22)
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.10 - MEDICAID ENHANCED PLAN BENEFITS › SUB AREA: LONG-TERM CARE › Section 16.03.10.306 - PERSONAL ASSISTANCE AGENCY (PAA): QUALIFICATIONS AND DUTIES

Current through August 31, 2023
01.
Provider Agreement Required
.
				A Personal Assistance Agency is an organization that has signed the Medicaid
				Provider General Agreement and the Additional Terms-Personal Assistance
				Agencies, Aged and Disabled Waiver Provider Agreement with the Department. The
				PAA agrees to comply with all conditions within the agreements. A Personal
				Assistance Agency may also provide fiscal intermediary services in accordance
				with Section 329 of these
				rules. Each Personal Assistance Agency must direct, control, and monitor the
				work of each of its personal assistants. (3-17-22)
02.
Responsibilities of a Personal
				Assistance Agency
. A Personal Assistance Agency must be capable of and
				is responsible for all of the following, no matter how the PAA is organized or
				the form of the business entity it has chosen: (3-17-22)
a. Recruitment, hiring, firing, training,
				supervision, scheduling and payroll for personal assistants and the assurance
				that all providers are qualified to provide quality service;
				(3-17-22)
b. Participation in the
				provision of worker's compensation, unemployment compensation and all other
				state and federal tax withholdings; (3-17-22)
c. Maintenance of liability insurance
				coverage. Termination of either worker's compensation or professional liability
				insurance by the provider is cause for termination of the provider's provider
				agreement; (3-17-22)
d. Provision
				of a licensed registered nurse (RN) or, where applicable, a QIDP supervisor to
				develop and complete plans of care and provide ongoing supervision of a
				participant's care; (3-17-22)
e.
				Assignment of qualified personal assistants to eligible participants after
				consultation with and approval by the participants; (3-17-22)
f. Assuring that all personal assistants meet
				the qualifications in Subsection
				305.01 of these rules;
				(3-17-22)
g. Billing Medicaid for
				services approved and authorized by the BLTC; (3-17-22)
h. Collecting any participant contribution
				due; (3-17-22)
i. Conducting, at
				least annually, participant satisfaction or quality control reviews that are
				available to the Department and the general public; and
				(3-17-22)