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 16.03.10.270 - NURSING FACILITY: SPECIAL RATES

Current through August 31, 2023
A special rate consists of a facility's daily reimbursement
				  rate for a patient plus an add-on amount. Section
				  56-117, Idaho Code, provides
				  authority for the Department to pay facilities an amount in addition to the
				  daily rate when a patient has needs that are beyond the scope of facility
				  services and when the cost of providing for those additional needs is not
				  adequately reflected in the rates calculated. This special rate add-on amount
				  for such specialized care is in addition to any payments made in accordance
				  with other provisions of this chapter and is excluded from the computation of
				  payments or rates under other provisions in these rules. (3-17-22)
01.
Determination
. The
				Department determines to approve a special rate on a patient-by-patient basis.
				No rate will be allowed if reimbursement for these needs is available from a
				non-Medicaid source. A special rate request will be based on an identified
				condition that will continue for a period greater than thirty (30) days.
				(3-17-22)
02.
Effective
				Date
. Upon approval, a special rate is effective on the date the
				application was received. (3-17-22)
03.
Reporting
. Costs equivalent
				to payments for special rate add-on amounts must be removed from the cost
				components subject to limits, and be reported separately by the provider.
				(3-17-22)
04.
Limitation
. A special rate cannot exceed the provider's charges to other
				patients for similar services. (3-17-22)
05.
Prospective Rate Treatment
.
				Prospective treatment of special rates became effective July 1, 2000.
				Subsections 270.06 and
				270.07 of this rule provide
				clarification of how special rates are paid under the prospective payment
				system. (3-17-22)
06.
Determination of Payment for Qualifying Residents
. Special rate
				add-on amounts are calculated using one (1) of the methods described in
				Subsections 270.06.a. through 270.06.c. of
				this rule. (3-17-22)
a. One Hundred Percent
				(100%) Special Care Facility Existing July 1, 2000. If on July 1, 2000, an
				entire facility was a special care unit that included Medicaid residents, the
				facility's direct care cost per diem will not be subject to the direct care
				cost limit. However, the direct care costs are case mix adjusted based on the
				ratio of the facility's Medicaid CMI for the rate period to the facility-wide
				CMI for the cost reporting period. (3-17-22)
b. Equipment and Non-Therapy Supplies.
				Equipment and non-therapy supplies not addressed in Section
				225 of these rules as determined by
				the Department, are reimbursed in accordance with IDAPA 16.03.09, "Medicaid
				Basic Plan Benefits," Section
				755, as an add-on amount.
				(3-17-22)
c. Ventilator Dependent
				Residents and Residents Receiving Tracheostomy Care. Nursing facilities
				providing care to residents who are ventilator-dependent or who receive
				tracheostomy care are eligible to submit requests for the fixed add-on amount,
				in addition to the facility's rate for residents receiving this type of care.
				Approved requests are effective the date the type of care is needed by the
				participant, or no earlier than sixty (60) days prior to the date the request
				is received by the Department. The rate includes the cost for equipment and
				supplies and for additional registered nurse and certified nursing assistant
				hours, as appropriate for each type of care. Costs for equipment and supplies
				will be adjusted annually for inflation, and registered nursing and certified
				nursing assistant costs will be adjusted according to the annual Weighted
				Average Hourly Rates (WAHR) survey results. (3-17-22)
i. Approved add-on rates for
				ventilator-dependent residents and residents receiving tracheostomy care are
				subject to annual reviews by the Department to ensure that the add-on rate
				remains necessary for the type of care needed by the resident.
				(3-17-22)
ii. The provider must
				inform the department if an approved add-on rate is no longer needed or if the
				resident requires a change from one type of care to another.
				(3-17-22)
d. Ventilator
				Dependent Residents and Residents Receiving Tracheostomy Care in Out-of-State
				Nursing Facilities. For residents who are ventilator-dependent or receive
				tracheostomy care in an out-of-state facility, the add-on amount to the
				facility's rate is effective the date this type of care is needed by the
				participant or no earlier than sixty (60) days prior to the date the request is
				received by the Department. The add-on rate will include: (3-17-22)
i. Calculation of a staffing add-on for the
				cost, if any, for additional direct care staff required in meeting the
				exceptional needs of these residents. The hourly add-on rate is equal to the
				current WAHR CNA or current WAHR RN wage rate plus a benefits allowance based
				on annual cost report data, then weighted to remove the CNA minimum daily
				staffing time adjusted for the appropriate skill level of care staff; and
				(3-17-22)
ii. Calculation of an
				add-on for equipment and non-therapy supplies following the provisions in
				Subsection 270.06.b. of this rule.
				(3-17-22)