Florida Administrative Code › 59 - AGENCY FOR HEALTH CARE ADMINISTRATION › 59G - Medicaid › Chapter 59G-6 - REIMBURSEMENT TO PROVIDERS › Section 59G-6.010 - Payment Methodology for Nursing Home Services

Current through Reg. 50, No. 138; July 16, 2024
(1) This rule applies to all nursing facility
				providers rendering Florida Medicaid nursing facility services in accordance
				with Rule 59G-4.200, F.A.C.
(2) Definitions.
(a) Adjusted Facility Sq Ft - Component of
				the Fair Rental Value System (FRVS) Calculation, the Minimum, Maximum, or
				Actual Sq. Ft per bed, defined in Section 409.908(2)(b)1.g., Florida Statutes
				(F.S.).
(b) Allowable Medicaid
				Costs - Are defined in CMS Publication 15-1 chapter 21 under reasonable costs
				and costs related and not related to patient care.
(c) Budget Neutrality Factor - Budget
				neutrality multipliers shall be incorporated into the Prospective Payment
				System (PPS) and exempt provider rate setting to ensure that total
				reimbursement is as required through the General Appropriations Act. Quality
				Incentive Payments, Direct Care Staffing and Ventilator add-ons, and the
				Nursing Facility Quality Assessment are excluded.
(d) Depreciation Factor - Component of the
				FRVS Calculation, referred to as Obsolescence Factor, defined in Section
				409.908(2)(b)1.g., F.S.
(e) Direct
				Care Cost Component - The direct patient care component shall include the
				Medicaid allowable portion of salaries and benefits of direct care staff
				providing nursing services including registered nurses, licensed practical
				nurses, and certified nursing assistants who deliver care directly to residents
				in the nursing facility, allowable therapy costs, and dietary costs adjusted
				for inflation. Direct care staff does not include nursing administration,
				Minimum Data Set (MDS) and care plan coordinators, staff development, infection
				control preventionist, risk managers, and staffing coordinators. There shall be
				no costs directly or indirectly allocated to the direct care component from a
				home office or management company for staff who do not deliver care directly to
				residents in the nursing facility.
(f) Equipment Cost - Component of the FRVS
				Calculation, referred to as moveable equipment allowance, defined in Section
				409.908(2)(b)1.g., F.S.
(g) Exempt
				Providers - Pediatric, facilities operated by the Florida Department of
				Veterans Affairs, and government-operated facilities are exempt from
				reimbursement under the prospective payment methodology and shall be reimbursed
				on a cost-based prospective payment system, in accordance with Section
				409.908(2)(b)8., Florida Statutes (F.S.). Reimbursement of direct care,
				indirect care, and operating costs are subject to reimbursement ceilings and
				targets.
(h) Fair Rental Rate -
				Component of the FRVS Calculation defined in Section 409.908(2)(b)1.g.,
				F.S.
(i) Floors - Floors are
				calculated for the direct care and indirect care cost components for each peer
				group and are equal to the price times the floor percentage as defined in
				Section 409.908(2)(b)1.c., F.S.
(j)
				Floor Reduction - The difference between the floor and the provider's inflated
				per day cost component, if a provider's cost is below the floor.
(k) Fair Rental Value System (FRVS) Rate - A
				FRVS is used to reimburse providers for their facility related capital costs. A
				provider must submit an FRVS survey to the Agency for Health Care
				Administration (AHCA) using the electronic form and instructions on the Florida
				Nursing Home: Fair Rental Value Survey web page. The survey information is used
				to compute an adjusted age for each provider, based on the most recent survey
				received by April 30 of each year for the subsequent rate period. The nursing
				facility provider's FRVS survey will be used to calculate the rate for a future
				rate period
(l) High Medicaid
				Utilization and High Direct Patient Care Add-On - Providers who meet the
				minimum Medicaid utilization and staffing criteria outlined in Section
				409.908(2)(b)6., F.S. and have a prospective payment per diem rate that is
				lower than their per diem rate effective September 1, 2016, shall receive the
				lesser of a $20 per diem increase or a per diem increase sufficient to set
				their rate equal to their September 1, 2016 rate.
(m) Indirect Care Cost Component - All other
				allowable Medicaid patient care costs, that are not listed in the operating or
				direct care components, are adjusted for inflation and shall be included in the
				indirect patient care component.
(n) Land Allocation Percentage - Component of
				the FRVS Calculation, referred to as Land Valuation, defined in Section
				409.908(2)(b)1.g., F.S.
(o) Medians
				- The mid-points of the inflated per diems for direct care, indirect care, and
				operating cost components of all included providers in a peer group. Beginning
				October 1, 2018 separate medians shall be calculated for operating, direct, and
				indirect cost components based on the most recent cost reports received for the
				September 2016 rate setting by the rate setting acceptance cut-off date, per
				Section 409.908(2)(b)1.b., F.S. Beginning October 1, 2021 medians shall be
				calculated based on the most recently finalized, audited cost report, every 4th
				year.
(p) Medicaid Adjustment Rate
				(MAR) - An add-on to the direct care and indirect care cost components of
				exempt providers with greater than 50 percent Medicaid utilization.
(q) Medicaid Bad Debt - Amounts considered to
				be uncollectible from accounts and notes receivable which are created or
				acquired in providing services per CMS publication 15-1 chapter 3 section
				302.1.
(r) Nursing Facility Quality
				Assessment (NFQA) - An assessment imposed on each nursing facility provider
				used to obtain Federal financial participation through the Medicaid program and
				partially fund the quality incentive payment program for nursing facilities
				that exceed quality benchmarks. The per diem Florida Medicaid share of the NFQA
				is calculated as follows:
1. Total patient
				days minus Medicare days (exclusive of Medicare Part A resident days) is equal
				to total non-Medicare days.
2. The
				product of total non-Medicare days, NFQA rate and Florida Medicaid days as a
				percentage of total days is equal to the total NFQA Florida Medicaid
				share.
3. Total NFQA Florida
				Medicaid share divided by Florida Medicaid days is equal to the per diem
				Florida Medicaid Share of the NFQA.
(s) Occupancy Percentage - Component of the
				Fair Rental Value System (FRVS) Calculation, the Minimum Occupancy, defined in
				Section 409.908(2)(b)1.g., F.S.
(t)
				Offense - Full Quality Assessment Payment not received by the 20th day of the
				next succeeding calendar month.
(u)
				Operating Cost Component - The operating component shall include the costs for
				medical records, plant operation, housekeeping, administration, Medicaid bad
				debt and laundry and linen.
(v)
				Quality Assessment Payment - Timely submission of one month's total number of
				resident days and rendering of Quality Assessment Fee Payment equal to the
				assessment rate times the reported number of days.
(w) Peer Group - Providers are divided into
				two peer groups defined in section 409.908(2)(b)1.a., F.S.
(x) Price - The standardized rate for each
				peer group that is calculated for the direct care, indirect care and operating
				cost components as the median times the price percentage as defined in Section
				409.908(2)(b)1.b., F.S.
(y) Quality
				Incentive Payment - A provider is awarded points for process, outcome,
				structural and credentialing measures using most recently reported data on May
				31 of the rate period year. To qualify for a quality incentive payment, a
				provider must meet the minimum threshold defined in Section 409.908(2)(b)1.f.,
				F.S. The Quality Incentive budget is defined in Section 409.908(2)(b)1.e., F.S.
1. Process Measures - Includes Flu Vaccine,
				Antipsychotic Medication, and Restraint quality metrics. For each rate period,
				data to calculate these quality metrics is from the Medicare Nursing Home
				Compare datasets using the most recent four quarter average available on May 31
				of the rate period year. Providers are ranked based on the percentage of
				residents who have, or do not have, a particular condition. Providers whose
				fourth quarter measure score is at or above the 90th percentile for a
				particular measure will be awarded 3 points, those scoring from the 75th up to
				90th percentiles will be awarded 2 points, and those scoring from the 50th up
				to 75th percentiles will receive 1 point. Providers who score below the 50th
				percentile and achieve a 20 percent improvement from the previous year will
				receive 0.5 points. The quality measure percentiles that are used to award the
				points will be recalculated during rebase years starting October 2021 and every
				subsequent 4th year. During non rebase years the quality measure percentiles
				will be frozen.
2. Outcome Measures
				- Includes Urinary Tract Infections, Pressure Ulcers, Falls, Incontinence, and
				Decline in Activities of Daily Living quality metrics. Outcome Measures are
				scored and percentiles are calculated using the same methodology as Process
				Measures. Data to calculate these metrics is from the Medicare Nursing Home
				Compare datasets.
3. Structure
				Measures - Includes Direct Care Staffing from the Medicaid cost report received
				by the rate setting cutoff date and Social Work and Activity Staff as reported
				on CMS Facility Staffing Payroll-Based Journal data for the four most recent
				quarters as of May 31 of the year in which the rate period begins. Structure
				Measures are scored and percentiles are calculated using the same methodology
				as Process Measures and Outcome Measures. Structure Measure percentiles are
				recalculated annually.
4.
				Credentialing Measures - Includes CMS Overall 5-Star, Florida Gold Seal, Joint
				Commission Accreditation, and American Health Care Association National Quality
				Award. Facilities assigned a rating of 3, 4, or 5 stars in the CMS 5- Star
				program will receive 1, 3, or 5 points, respectively. For each rate period, the
				CMS 5-Star Rating Measure will be calculated using the most recent overall
				rating from the Star Ratings dataset from the Nursing Home Compare datasets
				provided by CMS as of May 31 of the year in which the rate period begins.
				Facilities that have either a Florida Gold Seal, Joint Commission
				Accreditation, or the silver or gold American Health Care Association National
				Quality Award on May 31 of the current year will be awarded 5 points.
				Recipients of the Florida Gold Seal Award can be viewed on Florida Health
				Finder website, recipients of the Joint Commission Accreditation can be viewed
				on the Joint Commission website, and recipients of the American Health Care
				Association National Quality Award can be viewed on the American Health Care
				Association website.
(z)
				Rate Period - October 1 - September 30.
(aa) Rate Setting Acceptance Cost Report
				Cutoff Date - The cost report cutoff date is April 30, or the next business day
				if April 30 falls on a weekend or State of Florida observed holiday, of the
				year in which the rate period beings. A link to the Cost Report template Web
				site can be found at
http://ahca.myflorida.com/Medicaid/cost_reim/ecr.shtml
.
(bb) Rebase Rate Semester - Direct care,
				indirect care, and operating cost components will be rebased beginning October
				1, 2021 and every subsequent fourth year by using the most recently finalized,
				audited cost report available by the rate setting acceptance cut-off
				date.
(cc) Reimbursement Ceiling -
				The upper rate limits, calculated based on all Medicaid Nursing Facility
				providers, for operating, direct care, and indirect care components applicable
				to exempt nursing facility providers in a peer group.
(dd) Reimbursement Targets - Provider
				specific per diem limitations, for the operating and indirect care cost
				components for exempt providers.
(ee) RSMeans Data - The industry-standard for
				materials, labor, and equipment cost information database used by contractors
				and other professionals to accurately estimate construction project
				costs.
(ff) Subsequent Offense -
				any offense within a period of five years preceding the most recent quality
				assessment due date.
(gg) Unit Cost
				Rate Increase - Effective July 1, 2020, a unit cost increase was established as
				an equal percentage for each nursing home. For the period beginning on October
				1, 2020, and ending on September 30, 2021, providers are reimbursed the greater
				of their September 2016 cost-based rate plus the July 1, 2020, unit cost
				increase or their prospective payment rate plus the July 1, 2020, unit cost
				increase.
(hh) Ventilator
				Supplemental Payment - Effective October 1, 2019, claims and encounter data
				with diagnosis code Z99.11, dependence on respirator (ventilator) status, with
				dates of service in the prior calendar year will be used to calculate the
				ventilator supplemental payment. The sum of claims and encounters with
				diagnosis code Z99.11 for the facility will be divided by annualized Medicaid
				days from the most recently submitted cost report received by the Rate Setting
				Acceptance Cost Report Cutoff Date, then multiplied by $200.00. The result will
				be added to the rate setting per diem.