reglab/statecodes huggingface dataset:
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 1 - MEDICAID PROVIDERS AND SERVICES › Rule 14.6 - Rate-Setting Criteria for Nursing Facilities › Section 14.6-15 - Valuation; sale or lease among family members

Current through July 10, 2024
Authority: IC
				  12-15-1-10; IC
				  12-15-21-2
Affected: IC
				  12-13-7-3; IC 12-15
Sec. 15.
(a) If a
				provider rents, leases, or purchases facilities or equipment from a related
				party, the historical cost to the related party, not to exceed fair market
				value, shall be utilized in computing the average historical cost of property
				of the median bed except as described in this section for the sale of
				facilities between family members.
(b) If a sale of facilities between family
				members meets the following conditions, the cost basis of the facility shall be
				recognized for the purpose of computing the average historical cost of property
				of the median bed in accordance with this rule as a bona fide sale arising from
				an arm's-length transaction, subject to the limitations of subsection (c):
(1) There is no spousal relationship between
				parties.
(2) The following persons
				are considered family members:
(A) Natural
				parent, child, and sibling.
(B)
				Adopted child and adoptive parent.
(C) Stepparent, stepchild, stepsister, and
				stepbrother.
(D) Father-in-law,
				mother-in-law, sister-in-law, brother-in-law, son-in-law, and
				daughter-in-law.
(E) Grandparent
				and grandchild.
(3) The
				transfer is recognized and reported by all parties as a sale for federal income
				tax purposes.
(4) The seller is not
				associated with the facility in any way after the sale other than as a passive
				creditor.
(5) The buyer is actively
				engaged in the operation of the facility after the sale with earnings from the
				facility accruing to at least one (1) principal buyer primarily as salaries or
				self-employment income and not as leases, rents, or other passive
				income.
(6) This family sale
				exception has not been utilized during the previous eight (8) years on this
				facility.
(7) None of the entities
				involved is a publicly held corporation as defined by the Securities and
				Exchange Commission.
(8) If any of
				the entities involved are corporations, they must be family owned corporations,
				where members of the same family control the corporations through ownership of
				fifty percent (50%) or more of the voting stock.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 1 - MEDICAID PROVIDERS AND SERVICES › Rule 14.6 - Rate-Setting Criteria for Nursing Facilities › Section 14.6-17 - Allowable costs; wages; costs of employment; record keeping; owner or related party compensation

Current through July 10, 2024
Authority: IC
				  12-15-1-10; IC
				  12-15-21-2
Affected: IC
				  12-13-7-3; IC 12-15
Sec. 17.
(a)
				Reasonable compensation of individuals employed by a provider is an allowable
				cost, provided such employees are engaged in patient care-related functions and
				that compensation amounts are reasonable and allowable under this section and
				section 18 of this rule.
(b) The
				provider shall report on the forms prescribed by the office, all
				patient-related staff costs and hours incurred to perform the function for
				which the provider was certified. Both total compensation and total hours
				worked shall be reported for all employees.
(c) Payroll records shall be maintained by
				the provider to substantiate the staffing costs reported to the office. The
				records shall indicate each employee's classification, hours worked, rate of
				pay, and the department or functional area to which the employee was assigned
				and actually worked. If an employee performs duties in more than one (1)
				department or functional area, the payroll records shall indicate the time
				allocations to the various assignments.
(d) When an owner or related party work
				assignment is at or below a department head level, the hours and compensation
				shall be included in the staffing hours reported using the forms prescribed by
				the office. Such hours and compensation must be reported separately and so
				identified. Compensation paid to owners or related parties for performing such
				duties shall be allowed if the compensation paid to owner/related parties does
				not exceed the price paid in the open market to obtain such services by
				nonowners or nonrelated parties. Such compensation to owner/related parties is
				not subject to the limitation found in section 18 of this rule.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 1 - MEDICAID PROVIDERS AND SERVICES › Rule 14.6 - Rate-Setting Criteria for Nursing Facilities › Section 14.6-18 - Allowable costs; calculation of allowable owner or related party compensation; wages; salaries; fees

Current through July 10, 2024
Authority: IC
				  12-15-1-10; IC
				  12-15-21-2
Affected: IC
				  12-13-7-3; IC 12-15
Sec. 18.
(a)
				Compensation for:
(1) an owner, a related
				party, management, general line personnel, and consultants who perform
				management functions; or
(2) any
				individual or entity rendering services above the department head level;
shall be subject to the annual limitations described in this
				  section. All compensation received by the parties as described in this
				  subsection shall be reported and separately identified on the financial report
				  form even though such payment may exceed the limitations. This compensation is
				  allowed to cover costs for all administrative, policymaking, decision making,
				  and other management functions above the department head level. Through June
				  30, 2019, compensation subject to this limitation includes wages, salaries, and
				  fees for the owner, management, contractors, and consultants who actually
				  perform management functions as well as any other individual or entity
				  performing such tasks. Beginning July 1, 2019, and thereafter, wages, salaries,
				  and fees paid for the owner, administrator, assistant administrator,
				  management, contractors, and consultants who actually perform management
				  functions as well as any other individual or entity performing such tasks are
				  subject to this limitation.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 1 - MEDICAID PROVIDERS AND SERVICES › Rule 14.6 - Rate-Setting Criteria for Nursing Facilities › Section 14.6-19 - Medical or nonmedical supplies and equipment

Current through July 10, 2024
Authority: IC
				  12-15-1-10; IC
				  12-15-21-2
Affected: IC
				  12-13-7-3; IC 12-15
Sec. 19.
The approved per diem rate in nursing facilities includes
				  the cost of both medical and nonmedical supply items, and the provider shall
				  not bill Medicaid for such items in addition to the established rate. Under no
				  circumstances shall medical or nonmedical supplies and equipment for nursing
				  facility residents be billed through a pharmacy or other provider. Medical and
				  nonmedical supply items for nursing facility residents that are reimbursed by
				  other payor sources shall not be reimbursed by Medicaid.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 1 - MEDICAID PROVIDERS AND SERVICES › Rule 14.6 - Rate-Setting Criteria for Nursing Facilities › Section 14.6-20 - Nursing facilities reimbursement for therapy services

Current through July 10, 2024
Authority: IC
				  12-15-1-10; IC
				  12-15-21-2
Affected: IC
				  12-13-7-3; IC 12-15
Sec. 20.
(a) Therapy
				services provided to Medicaid members by nursing facilities are included in the
				established rate. Under no circumstances shall therapies for nursing facility
				residents be billed to Medicaid through any provider. Therapy services for
				nursing facility residents that are reimbursed by other payor sources shall not
				be reimbursed by Medicaid.
(b) For
				purposes of determining allowable therapy costs, the office shall adjust each
				provider's cost of therapy services reported on the Nursing Facility Financial
				Report, including any employee benefits prorated based on total salaries and
				wages, to account for non-Medicaid payers, including Medicare, of therapy
				services provided to nursing facility residents. Such adjustment shall be
				applied to each cost report in order to remove reported costs attributable to
				therapy services reimbursed by other payers. The adjustment shall be calculated
				based on an allocation of reported therapy revenues and shall be subject to
				field audit verification.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 1 - MEDICAID PROVIDERS AND SERVICES › Rule 14.6 - Rate-Setting Criteria for Nursing Facilities › Section 14.6-21 - Allocation of expenses

Current through July 10, 2024
Authority: IC
				  12-15-1-10; IC
				  12-15-21-2
Affected: IC
				  12-13-7-3; IC 12-15
Sec. 21.
(a) Except
				as provided in subsection (b), the detailed basis for allocation of expenses
				between nursing facility services and other services in a facility shall remain
				a prerogative of the provider as long as the basis is reasonable and consistent
				between accounting periods.
(b) The
				following relationships shall be followed:
(1)
				Reported expenses and patient census information must be for the same reporting
				period.
(2) Nursing salary
				allocations must be on the basis of nursing hours worked and must be for the
				reporting period except when specific identification is used based on the
				actual salaries paid for the reporting period.
(3) No allocation of costs between annual
				financial report line items shall be permitted.
(4) Any changes in the allocation or
				classification of costs must be approved by the office prior to the changes
				being implemented, unless implementing prior period audit adjustments. Proposed
				changes in allocation or classification methods must be submitted to the office
				for approval at least ninety (90) days prior to the provider's reporting year
				end.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 1 - MEDICAID PROVIDERS AND SERVICES › Rule 14.6 - Rate-Setting Criteria for Nursing Facilities › Section 14.6-24 - Nursing facility quality assessment

Current through July 10, 2024
Authority: IC
				  12-15-1-10; IC
				  12-15-21-2
Affected: IC 4-21.5-3; IC 12-13-7-3; IC 12-15-21-3; IC 16-21;
				  IC 16-28-15-2; IC 16-28-15-7; IC 23-2-4
Sec. 24.
(a) Through
				June 30, 2019, the office shall collect a quality assessment from each nursing
				facility licensed under IC 16-28 as a comprehensive care facility. The census
				days utilized in the calculation shall be based on the most recently completed
				annual financial report or quality assessment data collection form, and the
				organization type shall be determined based on the organizations type at the
				rate effective date being established. The rate utilized is as follows:
(1) Privately owned or operated nursing
				facilities with total annual nursing facility census days fewer than sixty-two
				thousand (62,000), sixteen dollars and thirty-seven cents ($16.37) per
				non-Medicare day.
(2) Privately
				owned or operated and nonstate government owned or operated nursing facilities
				with total annual nursing facility census days equal to or greater than
				sixty-two thousand (62,000), four dollars and nine cents ($4.09) per
				non-Medicare day.
(3) Nonstate
				government owned or operated nursing facilities that became nonstate government
				owned or operated before July 1, 2003, four dollars and nine cents ($4.09) per
				non-Medicare day.
(4) Nonstate
				government owned or operated nursing facilities that became nonstate government
				owned or operated on or after July 1, 2003, with total annual nursing facility
				census fewer than sixty-two thousand (62,000), sixteen dollars and thirty-seven
				cents ($16.37) per non-Medicare day.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 1 - MEDICAID PROVIDERS AND SERVICES › Rule 14.6 - Rate-Setting Criteria for Nursing Facilities › Section 14.6-26 - Rate reduction

Current through July 10, 2024
Authority: IC
				  12-15-1-10; IC
				  12-15-21-2
Affected: IC
				  12-13-7-3; IC 12-15
Sec. 26.
Notwithstanding all other provisions of this rule,
				  reimbursement rates shall be reduced by three percent (3%) per resident day,
				  through June 30, 2021.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 1 - MEDICAID PROVIDERS AND SERVICES › Rule 15 - Nursing Facilities; Electronic Transmission of Minimum Data Set › Section 15-1 - Scope

Current through July 10, 2024
Authority: IC
				  12-15-1-10; IC
				  12-15-21-2
Affected: IC
				  12-13-7-3; IC 12-15
Sec. 1.
Nursing facilities certified to provide nursing facility
				  care to Medicaid members are required to electronically transmit minimum data
				  set (MDS) information for all nursing facility residents to the office. Such
				  MDS information shall include the resident's room number on all comprehensive
				  or quarterly MDS assessments and tracking forms. The MDS data is used to
				  establish and maintain a case mix system for Medicaid reimbursement to nursing
				  facilities and other Medicaid program management purposes.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 1 - MEDICAID PROVIDERS AND SERVICES › Rule 15 - Nursing Facilities; Electronic Transmission of Minimum Data Set › Section 15-2 - Definitions

Current through July 10, 2024
Authority: IC
				  12-15-1-10; IC
				  12-15-21-2
Affected: IC
				  12-13-7-3; IC 12-15
Sec. 2.
(a) The
				definitions in this section apply throughout this rule.
(b) "Case mix reimbursement" means a system
				of paying nursing facilities according to the mix of residents in each facility
				as measured by resident characteristics and service needs. Its function is to
				provide payment for resources needed to serve different types of
				residents.
(c) "Minimum data set"
				or "MDS" means a core set of screening and assessment elements, including
				common definitions and coding categories, that forms the foundation of the
				comprehensive assessment for all residents of long-term care facilities
				certified to participate in Medicaid. The items in the MDS standardize
				communication about resident problems, strengths, and conditions within the
				facilities, between facilities, and between facilities and outside agencies.
				The Indiana system will employ the MDS 3.0 or subsequent revisions as approved
				by CMS.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 1 - MEDICAID PROVIDERS AND SERVICES › Rule 15 - Nursing Facilities; Electronic Transmission of Minimum Data Set › Section 15-4 - MDS supporting documentation requirements

Current through July 10, 2024
Authority: IC
				  12-15-1-10; IC
				  12-15-21-2
Affected: IC
				  12-13-7-3; IC
				  12-15-13-6
Sec. 4.
(a) The
				office shall publish supporting documentation requirements for all MDS data
				elements that are utilized to classify nursing facility residents in accordance
				with the RUG-IV resident classification system. The requirements shall be
				published as a provider bulletin and may be updated by the office as needed.
				Any such updates shall be made effective no earlier than permitted under IC
				12-15-13-6(a).
(b) Nursing facilities shall maintain
				supporting documentation in the resident's medical chart for all MDS data
				elements that are utilized to classify nursing facility residents in accordance
				with the RUG-IV resident classification system. Such supporting documentation
				shall be maintained by the nursing facility for all residents in a manner that
				is accessible and conducive to review.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 1 - MEDICAID PROVIDERS AND SERVICES › Rule 15 - Nursing Facilities; Electronic Transmission of Minimum Data Set › Section 15-5 - MDS review requirements

Current through July 10, 2024
Authority: IC
				  12-15-1-10; IC
				  12-15-21-2
Affected: IC
				  12-13-7-3; IC 12-15
Sec. 5.
(a) The
				office shall periodically review the MDS supporting documentation maintained by
				nursing facilities for all residents, regardless of payer type. The reviews
				shall be conducted as frequently as deemed necessary by the office, and each
				nursing facility shall be reviewed no less frequently than every thirty-six
				(36) months. Advance notification of up to seventy-two (72) hours shall be
				provided by the office for all MDS reviews, except for follow-up reviews that
				are intended to ensure compliance with validation improvement plans. Advance
				notification for follow-up reviews shall not be required.
(b) All MDS assessments, regardless of payer
				type, are subject to an MDS review.
(c) When conducting the MDS reviews, the
				office shall consider all MDS supporting documentation that is provided by the
				nursing facility and is available to the reviewers prior to the exit
				conference. MDS supporting documentation that is provided by the nursing
				facility after the exit conference begins shall not be considered by the
				office.
(d) The nursing facility
				shall be required to produce, upon request by the office, a computer generated
				copy of the MDS assessment that is transmitted in accordance with section 1 of
				this rule, which shall be the basis for the MDS review.
(e) Suspected intentional alteration of
				clinical documentation, or creation of documentation after MDS assessments have
				been transmitted, shall be referred to the IMFCU for investigation of possible
				fraud. Such an investigation could result in a felony or misdemeanor criminal
				conviction.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 1 - MEDICAID PROVIDERS AND SERVICES › Rule 16 - Reimbursement for Hospice Services › Section 16-1 - Policy

Current through July 10, 2024
Authority: IC
				  12-15-1-10; IC
				  12-15-21-2; IC
				  12-15-40
Affected: IC 12-15
Sec. 1.
(a) This rule
				sets forth procedures for payment for services rendered to Medicaid members by
				duly certified hospice providers that provide hospice care. All payments
				referred to within this rule for the provider groups and levels of care are
				contingent upon the following:
(1) Proper and
				current certification.
(2)
				Compliance with applicable state and federal statutes and
				regulations.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 1 - MEDICAID PROVIDERS AND SERVICES › Rule 16 - Reimbursement for Hospice Services › Section 16-2 - Levels of care

Current through July 10, 2024
Authority: IC
				  12-15-1-10; IC
				  12-15-21-2; IC
				  12-15-40
Affected: IC 12-15
Sec. 2.
(a)
				Reimbursement for hospice care shall be made according to the methodology and
				amounts calculated by CMS. Medicaid hospice reimbursement rates are based on
				Medicare reimbursement rates and methodologies, adjusted to disregard offsets
				attributable to Medicare coinsurance amounts. The rates will be adjusted for
				regional differences in wages using the hospice wage index published by
				CMS.
(b) Medicaid reimbursement for
				hospice services will be made at one (1) of five (5) all-inclusive per diem
				rates for each day in which a Medicaid member is under the care of the hospice
				provider. The reimbursement amounts are determined within each of the following
				categories:
(1) Routine home care: Days one
				(1) - sixty (60).
(2) Routine home
				care: Days over sixty (60).
(3)
				Continuous home care.
(4) Inpatient
				respite care.
(5) General inpatient
				hospice care.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 1 - MEDICAID PROVIDERS AND SERVICES › Rule 16 - Reimbursement for Hospice Services › Section 16-3 - Limitation on payments for inpatient care

Current through July 10, 2024
Authority: IC
				  12-15-1-10; IC
				  12-15-21-2; IC
				  12-15-40
Affected: IC 12-15
Sec. 3.
(a) Payments
				to a hospice for inpatient care must be limited according to the number of days
				of inpatient care furnished to Medicaid members. During the twelve (12) month
				period beginning November 1 of each year and ending October 31 of the next
				year, the aggregate number of inpatient days (both general inpatient days and
				inpatient respite care days) for any given hospice provider may not exceed
				twenty percent (20%) of the total number of days of hospice care provided to
				all Medicaid members during the same period by the designated hospice provider
				or its contracted agent or agents. For purposes of this computation, if it is
				determined that the inpatient rate should not be paid, any days for which the
				hospice provider receives payment at a home care rate will not be counted as
				inpatient days.
(b) The limitations
				on payment for inpatient days are as follows:
(1) The maximum number of allowable inpatient
				days will be calculated by multiplying the total number of a provider's
				Medicaid hospice days by twenty percent (20%).
(2) If the total number of days of inpatient
				care to Medicaid hospice members is less than or equal to the maximum number of
				inpatient days computed in subdivision (1), then no adjustment is
				made.
(3) If the total number of
				days of inpatient care to Medicaid hospice members is greater than the maximum
				number of inpatient days computed in subdivision (1), then the payment
				limitation will be determined by the following method:
(A) Calculating the ratio of the maximum
				allowable inpatient days to the number of actual days of inpatient care, and
				multiplying this ratio by the total reimbursement for inpatient care that was
				made.
(B) Multiplying excess
				inpatient care days by the routine home care rate.
(C) Adding together the amounts calculated in
				clauses (A) and (B).
(D) Comparing
				the amount in clause (C) with total reimbursement made to the hospice provider
				for inpatient care during the cap period. The amount by which total
				reimbursement made to the hospice provider for inpatient care for Medicaid
				members exceeds the amount calculated in clause (C) is due from the hospice
				provider.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 1 - MEDICAID PROVIDERS AND SERVICES › Rule 16 - Reimbursement for Hospice Services › Section 16-4 - Additional amount for nursing facility residents

Current through July 10, 2024
Authority: IC
				  12-15-1-10; IC
				  12-15-21-2; IC
				  12-15-40
Affected: IC 12-15
Sec. 4.
(a) An
				additional per diem amount will be paid directly to the hospice provider for
				room and board of hospice residents in a certified nursing facility receiving
				routine or continuous care services, when the office has determined that the
				member requires nursing facility level of care. Medicaid reimbursement is
				available for hospice services rendered to a nursing facility resident only if,
				prior to services being rendered, the hospice and the nursing facility enter
				into a written agreement under which the hospice takes full responsibility for
				the professional care management of the resident's hospice care and the nursing
				facility agrees to provide room and board to the individual. In this context,
				"room and board" includes all assistance in the activities of daily living,
				socializing activities, administration of medication, maintaining the
				cleanliness of a resident's room, and supervision and assisting in the use of
				durable medical equipment and prescribed therapies.
(b) The room and board rate will be
				ninety-five percent (95%) of the lowest per diem reimbursement rate Medicaid
				would have paid to the nursing facility for any resident for those dates of
				service on which the member was a resident of that facility.
(c) Medicaid payment to the nursing facility
				for nursing facility care for the hospice resident is discontinued when the
				resident makes an election to receive hospice care. Any payment to the nursing
				facility for furnishing room and board to hospice patients is made by the
				hospice provider under the terms of its agreement with the nursing
				facility.
(d) The additional amount
				for room and board is not available for members receiving inpatient respite
				care or general inpatient care.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 1 - MEDICAID PROVIDERS AND SERVICES › Rule 16 - Reimbursement for Hospice Services › Section 16-5 - Reimbursement for physician services

Current through July 10, 2024
Authority: IC
				  12-15-1-10; IC
				  12-15-21-2; IC
				  12-15-40
Affected: IC 12-15
Sec. 5.
(a) The basic
				payment rates for hospice care represent full reimbursement to the hospice
				provider for the costs of all covered services related to the treatment of the
				member's terminal illness, including the administrative and general activities
				performed by physicians who are employees of or working under arrangements made
				with the hospice provider. These activities would generally be performed by the
				physician serving as the medical director and the physician member of the
				hospice interdisciplinary group. Group activities include participation in the
				establishment of plans of care, supervision of care and services, periodic
				review and updating of plans of care, and establishment of governing policies.
				The costs for these services are included in the reimbursement rates for
				hospice care.
(b) Reimbursement for
				a hospice employed physician's direct patient services that are not rendered by
				a hospice volunteer is made in accordance with the usual Medicaid reimbursement
				methodology for physician services. These services will be billed by the
				hospice provider under the Medicaid hospice provider number. The only physician
				services to be billed separately from the hospice per diem are direct patient
				care services. Laboratory and x-ray services relating to the terminal condition
				are included in the hospice daily rate.
(c) Reimbursement for an independent
				physician's direct patient services that are not rendered by a hospice
				volunteer is made in accordance with the usual Medicaid reimbursement
				methodology for physician services. These services will not be billed by the
				hospice provider under the hospice provider number. The only services to be
				billed by an attending physician are the physician's personal professional
				services. Costs for services such as laboratory or x-rays are not to be
				included on the attending physician's billed charges to Medicaid when those
				services relate to the terminal condition. These costs are included in the
				daily rates paid and are expressly the responsibility of the hospice
				provider.
(d) Volunteer physician
				services are excluded from Medicaid reimbursement. However, a physician who
				provides volunteer services to a hospice may be reimbursed for nonvolunteer
				services provided to hospice patients. In determining which services are
				furnished on a volunteer basis and which are not, a physician must treat
				Medicaid patients on the same basis as other hospice patients. For example, a
				physician may not designate all physician services rendered to non-Medicaid
				patients as volunteered and at the same time seek payment for all physician
				services rendered to Medicaid patients.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 1 - MEDICAID PROVIDERS AND SERVICES › Rule 17 - Rate-Setting Criteria for State-Owned Intermediate Care Facilities for the Mentally Retarded › Section 17-1 - Policy; scope

Current through July 10, 2024
Authority: IC
				  12-15-1-10; IC
				  12-15-21-2
Affected: IC
				  12-13-7-3; IC
				  12-15-13-3.5; IC
				  12-15-13-4; IC
				  24-4.6-1-101
Sec. 1.
(a) This rule
				sets forth procedures for payment for services rendered to Medicaid members by
				duly certified state-owned ICFs/IID, state-owned nursing facilities, and
				state-owned psychiatric hospitals. All payments referred to within this rule
				for the provider groups and levels of care are contingent upon the following:
(1) Proper and current
				certification.
(2) Compliance with
				applicable state and federal statutes and regulations.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 1 - MEDICAID PROVIDERS AND SERVICES › Rule 17 - Rate-Setting Criteria for State-Owned Intermediate Care Facilities for the Mentally Retarded › Section 17-2 - Definitions

Current through July 10, 2024
Authority: IC
				  12-15-1-10; IC
				  12-15-1-15; IC
				  12-15-21-2
Affected: IC
				  12-13-7-3; IC 12-15
Sec. 2.
(a) The
				definitions in this section apply throughout this rule.
(b) "All-inclusive rate" means a per diem
				rate which, at a minimum, reimburses for all:
(1) nursing care;
(2) room and board;
(3) supplies; and
(4) ancillary therapy services; within a
				single, comprehensive amount.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 1 - MEDICAID PROVIDERS AND SERVICES › Rule 17 - Rate-Setting Criteria for State-Owned Intermediate Care Facilities for the Mentally Retarded › Section 17-3 - Accounting records; retention schedule; audit trail; cash basis; segregation of accounts by nature of business and by location

Current through July 10, 2024
Authority: IC
				  12-15-1-10; IC
				  12-15-21-2
Affected: IC
				  12-13-7-3; IC 12-15
Sec. 3.
(a) The basis
				of accounting used under this rule is a comprehensive basis of accounting other
				than generally accepted accounting principles. However, generally accepted
				accounting principles as prescribed by the Governmental Accounting Standards
				Board pronouncements shall be followed in the preparation and presentation of
				all financial reports and all reports detailing proposed change of provider
				transactions unless otherwise prescribed by this rule.
(b) Each provider must maintain financial
				records for a period of three (3) years after the date of submission of
				financial reports to the office. State accounting records are maintained on a
				cash basis, which shall be used in all data submitted to the office. The
				provider's accounting records must establish an audit trail from those records
				to the financial reports submitted to the office.
(c) In the event that a field audit visit
				indicates that the provider's records are inadequate to support data submitted
				to the office, and the auditor is unable to complete the audit and issue an
				opinion, the provider shall be given, in writing, a list of the deficiencies
				and allowed sixty (60) days from the date of receipt of this notice to correct
				the deficiencies. In the event the deficiencies are not corrected within the
				sixty (60) day period, the office shall not grant any rate increase to the
				provider until the cited deficiencies are corrected and certified to the office
				by the provider. However, the office may:
(1)
				make appropriate adjustments to the applicable cost reports of the provider
				resulting from inadequate records;
(2) document the adjustments in a finalized
				exception report; and
(3)
				incorporate the adjustments in prospective rate calculations under section 1(d)
				of this rule.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 1 - MEDICAID PROVIDERS AND SERVICES › Rule 17 - Rate-Setting Criteria for State-Owned Intermediate Care Facilities for the Mentally Retarded › Section 17-4 - Financial report to office; annual schedule; prescribed form; extensions

Current through July 10, 2024
Authority: IC
				  12-15-1-10; IC
				  12-15-1-15; IC
				  12-15-21-2
Affected: IC
				  12-13-7-3; IC 12-15
Sec. 4.
(a) Each
				provider shall submit an annual financial report to the office not later than
				ninety (90) days after the close of the provider's reporting year. The annual
				financial report shall coincide with the fiscal year used by the provider to
				report federal income taxes for the operation unless the provider requests in
				writing that a different reporting period be used. Such a request shall be
				submitted within sixty (60) days after the initial certification of a provider.
				This option may be exercised only one (1) time by a provider. If a reporting
				period other than the tax year is established, audit trails between the periods
				are required, including reconciliation statements between the provider's
				records and the annual financial report.
(b) The provider's annual financial report
				shall be submitted using forms prescribed by the office. All data elements and
				required attachments shall be completed so as to provide full financial
				disclosure and shall include the following as a minimum:
(1) Patient census data.
(2) Statistical data.
(3) Ownership and related party
				information.
(4) Statement of all
				expenses and all income.
(5) Detail
				of fixed assets and patient related interest bearing debt.
(6) Schedule of Medicaid and private pay
				charges; private pay charges shall be lowest usual and customary charge on the
				last day of the reporting period.
(7) Certification by the provider that the
				data are true, accurate, related to patient care, and that expenses not related
				to patient care have been clearly identified.
(8) Certification by the preparer, if
				different from the provider, that the data were compiled from all information
				provided to the preparer by the provider and as such are true and accurate to
				the best of the preparer's knowledge.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 1 - MEDICAID PROVIDERS AND SERVICES › Rule 17 - Rate-Setting Criteria for State-Owned Intermediate Care Facilities for the Mentally Retarded › Section 17-5 - New provider; initial financial report to office; criteria for establishing initial rates; supplemental report

Current through July 10, 2024
Authority: IC
				  12-15-1-10; IC
				  12-15-1-15; IC
				  12-15-21-2
Affected: IC
				  12-13-7-3; IC 12-15
Sec. 5.
(a) Rate
				requests to establish initial rates for a new operation or a new type of
				certified service shall be filed by completing the budget financial report form
				and submitting it to the office on or before thirty (30) days after
				notification of the certification date or establishment of a new service or new
				operation. The budget financial report shall reflect the forecasted data of
				operating for the first twelve (12) months and shall be subject to appropriate
				reasonableness tests. Initial rates shall be effective upon certification, or
				the date that a service is established, whichever is later.
(b) The methodology, set out in this rule,
				used to compute rates for active providers shall be followed to compute initial
				rates for new providers, except that historical data are not available.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 1 - MEDICAID PROVIDERS AND SERVICES › Rule 17 - Rate-Setting Criteria for State-Owned Intermediate Care Facilities for the Mentally Retarded › Section 17-6 - Active providers; rate review; annual request; additional requests; requests due to change in law

Current through July 10, 2024
Authority: IC
				  12-15-1-10; IC
				  12-15-1-15; IC
				  12-15-21-2
Affected: IC
				  12-13-7-3; IC 12-15
Sec. 6.
(a) As a
				normal practice, rates shall be reviewed once each year using the annual
				financial report as the basis of the review. The rate effective date shall be
				the first day of the month following the provider's reporting year end,
				provided the annual financial report is submitted within ninety (90) days of
				the end of the provider's reporting period. If the provider requests that the
				interim rate be reviewed, a budget financial report covering the twelve (12)
				month period immediately following the expected rate effective date shall be
				prepared by the provider and submitted with the annual financial
				report.
(b) A provider shall not be
				granted an additional interim rate review until the review indicated in
				subsection (a) has been completed. A provider may request no more than one (1)
				additional interim rate review during its budget reporting year when the
				provider can reasonably demonstrate the need for a change in rate based on more
				recent historical and forecasted data. This additional interim rate review
				shall be completed in the same manner as the annual interim rate review, using
				all other limitations in effect at the time the annual interim review took
				place.
(c) To request the
				additional interim review, the provider shall submit, on forms prescribed by
				the office, a minimum of six (6) months of historical data of which at least
				four (4) months must be subsequent to the fiscal year end of the annual
				financial report. In addition, a budget financial report covering the twelve
				(12) month period immediately following the expected rate effective date shall
				be submitted. Any new rate resulting from this additional interim review shall
				be effective on the first day of the month following the submission of data to
				the office.
(d) The office may
				consider changes in federal or state law or regulation during a calendar year
				to determine whether a significant rate increase is mandated. This review will
				be considered separately by the office and will not be considered as an
				additional interim rate review.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 1 - MEDICAID PROVIDERS AND SERVICES › Rule 17 - Rate-Setting Criteria for State-Owned Intermediate Care Facilities for the Mentally Retarded › Section 17-7 - Request for rate review; budget component; occupancy level assumptions; effect of inflation assumptions

Current through July 10, 2024
Authority: IC
				  12-15-1-10; IC
				  12-15-1-15; IC
				  12-15-21-2
Affected: IC
				  12-13-7-3; IC 12-15
Sec. 7.
Under this rate setting system, emphasis is placed on proper
				  planning, budgeting, and cost control by the provider. To establish consistency
				  in the submission and review of forecasted costs, the following apply:
(1) Each interim rate review request shall
				include a budget financial report. If a budget financial report is not
				submitted, the interim rate review will not result in an increase in Medicaid
				rates but may result in a rate decrease based on historical or annual financial
				reports submitted.
(2) All budget
				financial reports shall be submitted using forms prescribed by the office. All
				forecasted data and required attachments shall be completed to provide full
				financial disclosure and will include as a minimum the following:
(A) Patient census data.
(B) Statistical data.
(C) Ownership and related party
				information.
(D) Statement of all
				expenses and all income.
(E) Detail
				of fixed assets and patient related interest bearing debt.
(F) Schedule of Medicaid and private pay
				charges; charges shall be the lowest usual and customary charge on the rate
				effective date of the rate review.
(G) Certification by the provider that
				forecasted data has been prepared in good faith, with appropriate care by
				qualified personnel, using appropriate accounting principles and assumptions,
				and that the process to develop the forecasted data uses the best information
				that is reasonably available and is consistent with the plans of the provider.
				The certification shall state that all expenses not related to patient care
				have been clearly identified or removed.
(H) Certification by the preparer, if the
				preparer is different from the provider, that the forecasted data were compiled
				from all information provided to the preparer and that the preparer has read
				the forecasted data with its summaries of significant assumptions and
				accounting policies and has considered them to be not obviously
				inappropriate.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 1 - MEDICAID PROVIDERS AND SERVICES › Rule 17 - Rate-Setting Criteria for State-Owned Intermediate Care Facilities for the Mentally Retarded › Section 17-8 - Limitations or qualifications to Medicaid reimbursement; advertising

Current through July 10, 2024
Authority: IC
				  12-15-1-10; IC
				  12-15-1-15; IC
				  12-15-21-2
Affected: IC
				  12-13-7-3; IC 12-15
Sec. 8.
Advertising is not an allowable cost under this rule except
				  for those advertising costs incurred in the recruitment of facility personnel
				  necessary for compliance with facility certification requirements. Advertising
				  costs are not allowable in connection with public relations, fundraising, or to
				  encourage patient utilization.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 1 - MEDICAID PROVIDERS AND SERVICES › Rule 17 - Rate-Setting Criteria for State-Owned Intermediate Care Facilities for the Mentally Retarded › Section 17-9 - Criteria limiting rate adjustment granted by office

Current through July 10, 2024
Authority: IC
				  12-15-1-10; IC
				  12-15-1-15; IC
				  12-15-21-2
Affected: IC
				  12-13-7-3; IC 12-15
Sec. 9.
The Medicaid reimbursement system is based on recognition of
				  the provider's allowable costs. Providers reimbursed under this rule will be
				  reimbursed with a retrospective payment system. The annual financial reports
				  filed by the providers will be used to determine the actual cost per day for
				  services. A retroactive settlement will be determined for the time period
				  covered by the annual financial report. The total allowable costs will be
				  divided by the actual client days to determine the actual per diem rate. The
				  variance between the actual per diem rate and the interim per diem rates based
				  on the projected budget and paid during the report period will be multiplied by
				  the paid client days to arrive at the annual settlement.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 1 - MEDICAID PROVIDERS AND SERVICES › Rule 17 - Rate-Setting Criteria for State-Owned Intermediate Care Facilities for the Mentally Retarded › Section 17-10 - Computation of rate; allowable costs; review of cost reasonableness

Current through July 10, 2024
Authority: IC
				  12-15-1-10; IC
				  12-15-21-2
Affected: IC
				  12-13-7-3; IC 12-15
Sec. 10.
(a) The rate
				for a room with two (2) beds, which is the basic per diem room rate, shall be
				established as a ratio between total allowable costs and patient days, subject
				to all other limitations described in this rule.
(b) Costs and revenues shall be reported as
				required on the financial report forms. Patient care costs shall be clearly
				identified.
(c) The provider shall
				report as patient care costs only costs that have been incurred in the
				providing of patient care services. The provider shall certify on all financial
				reports that costs not related to patient care have been separately identified
				on the financial report.
(d) In
				determining reasonableness of costs, the office may compare line items, cost
				centers, or total costs of providers with like levels of care. The office may
				request satisfactory documentation from providers whose costs do not appear to
				be reasonable.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 1 - MEDICAID PROVIDERS AND SERVICES › Rule 17 - Rate-Setting Criteria for State-Owned Intermediate Care Facilities for the Mentally Retarded › Section 17-11 - Allowable costs; capital reimbursement; depreciable life

Current through July 10, 2024
Authority: IC
				  12-15-1-10; IC
				  12-15-1-15; IC
				  12-15-21-2
Affected: IC
				  12-13-7-3; IC 12-15
Sec. 11.
(a)
				Providers shall be reimbursed for the use of facilities and equipment,
				regardless of whether they are owned or leased. Such reimbursement shall
				include all depreciation, interest, lease, rent, or other consideration paid
				for the use of property. This includes all central office facilities and
				equipment whose patient care-related depreciation, interest, or lease expense
				is allocated to the facility.
(b)
				The straight line method will be used to calculate the allowance for
				depreciation. For depreciation purposes, the following will be used:
Property
Depreciable Life
Land improvements
20 years
Buildings and building components
40 years
Building improvements
20 years
Movable equipment
10 years
Vehicles
4 years
Software
3 years
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 1 - MEDICAID PROVIDERS AND SERVICES › Rule 17 - Rate-Setting Criteria for State-Owned Intermediate Care Facilities for the Mentally Retarded › Section 17-12 - Capital reimbursement; basis; historical cost; mandatory record keeping; valuation

Current through July 10, 2024
Authority: IC
				  12-15-1-10; IC
				  12-15-1-15; IC
				  12-15-21-2
Affected: IC
				  12-13-7-3; IC 12-15
Sec. 12.
(a) The
				basis used in computing the capital reimbursement shall be the historical cost
				of all assets used to deliver patient related services, provided the following:
(1) They are in use.
(2) They are identifiable to patient
				care.
(3) They are available for
				physical inspection.
(4) They are
				recorded in provider records.
If an asset does not meet all of the requirements prescribed
				  in this section, the cost shall not be included in computing the
				  reimbursement.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 1 - MEDICAID PROVIDERS AND SERVICES › Rule 17 - Rate-Setting Criteria for State-Owned Intermediate Care Facilities for the Mentally Retarded › Section 17-13 - Unallowable costs; cost adjustments; charity and courtesy allowances; discounts; rebates; refunds of expenses

Current through July 10, 2024
Authority: IC
				  12-15-1-10; IC
				  12-15-1-15; IC
				  12-15-21-2
Affected: IC
				  12-13-7-3; IC 12-15
Sec. 13.
(a) Charity,
				courtesy allowances, discounts, refunds, rebates, and other similar items
				granted by a provider shall not be included in allowable costs. Bad debts
				incurred by a provider shall not be an allowable cost.
(b) Payments that must be reported on the
				annual financial report form that are received by a provider, an owner, or
				other official of a provider in any form from a vendor shall be considered a
				reduction of the provider's costs for the goods or services from that
				vendor.
(c) The cost of goods or
				services sold to nonpatients shall be offset against the total cost of such
				service to determine the allowable patient related expenses. If the provider
				has not determined the cost of such items, the revenue generated from such
				sales shall be used to offset the total cost of such services.