Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 2 › Subtitle 09 - MEDICAL CARE PROGRAMS › Chapter 10.09.10 - Nursing Facility Services › Section 10.09.10.01 - Definitions

Current through Register Vol. 51, No. 14, July 12, 2024
A. In this chapter,
				  the following terms have the meanings indicated.
B. Terms Defined.
(1) "Accrual basis" means recording revenue
				  in the period when earned, regardless of when collected, and recording expenses
				  in the period when incurred, regardless of when paid.
(2) "Administrative day" means a day of care
				  rendered to a recipient who no longer requires the level of care being
				  provided.
(3) "Allowable cost"
				  means costs that are includable in the per diem rate and that represent the
				  provider's actual cost as verified by the Department or the Department's
				  designee.
(4) "Appropriate
				  facility" means a facility located within a 25-mile radius of the location of
				  the facility currently rendering care to the recipient or a more distant
				  facility if acceptable to the recipient, which facility is licensed and
				  certified to render the recipient's required level of care.
(5) "Bad debts" means amounts considered to
				  be uncollectible from accounts and notes receivable that were created or
				  acquired in providing services. "Accounts receivable" and "notes receivable"
				  are designations for claims arising from rendering services which, when made or
				  entered, were considered collectible in money in the relatively near
				  future.
(6) "Case mix index (CMI)"
				  means a numeric score that identifies the average relative nursing resource
				  needs for the residents classified under the Resource Utilization Group (RUG)
				  based on the assessed nursing needs of the resident, whose values are set forth
				  as CMI Set F01, located at
https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-
				  Instruments/NursingHomeQualityInits/NHQMDS30TechnicalInform ation.html
.
(7) "Centers for Medicare and
				  Medicaid Services (CMS) " means the federal agency that is located in the U.S.
				  Department of Health and Human Services that administers the Medicare and
				  Medicaid programs.
(8) "Change of
				  ownership" means:
(a) One of the following
				  occurs:
(i) The merger of the provider into
				  the acquiring entity and the acquiring entity's tax identification number
				  remains;
(ii) The assignment,
				  transfer, disposition, lease, or sale of all or substantially all of a
				  provider's assets to another entity;
(iii) The consolidation of two or more
				  providers, resulting in the creation of a new entity; or
(iv) The merger of the provider into another
				  entity, or the consolidation of two or more entities, resulting in the creation
				  of a new entity;
(b) A
				  provider's Medical Assistance participating provider number dissolves or will
				  no longer be utilized for purposes of billing the Program for covered services;
				  and
(c) A new Medical Assistance
				  participating provider number or tax identification number is used
				  instead.
(9) "Cost
				  center" means one of the groups into which similar categories of costs are
				  assigned for reimbursement rate determination: Administrative and Routine,
				  Other Patient Care, Nursing Service, and Capital.
(10) "Cost report period case mix index"
				  means the simple average of the day weighted facility case mix indices for
				  residents of all payer sources from the final quarterly resident rosters for a
				  nursing facility, carried to four decimal places, for the quarterly resident
				  roster periods that most closely match a cost reporting period
(11) "Credit balance" means:
(a) A third party payment, which is in
				  addition to the Medicaid payment;
(b) The Medicaid payment in excess of the
				  amount due the provider; or
(c) A
				  duplicate payment.
(12)
				  "Department" means the State Department of Health and Mental Hygiene, which is
				  the single State agency designated to administer the Maryland Medical
				  Assistance Program pursuant to Title XIX of the Social Security Act,
				  42 U.S.C. §
												1396 et seq.
(13) "Facility" means a facility licensed
				  under COMAR 10.07.02 and certified as meeting the requirements of Title XIX of
				  the Social Security Act, 42
				  U.S.C. §
												1396 et seq., for participation
				  as a nursing facility.
(14)
				  "Facility average Medicaid case mix index" means the day-weighted average case
				  mix index for all identified Medicaid days from each nursing facility's final
				  resident roster for each resident roster quarter calculated as the sum of the
				  number of days each assessment associated with a Medicaid payer source is
				  active times the assessment CMI divided by the sum of all Medicaid payer source
				  days.
(15) "Final report" means the
				  third party liability audit report issued to a provider stating the total
				  amount due to the Department as a result of the completed audit.
(16) "Fiscal year" means a 12-month reporting
				  period covering the same period as the facility's tax return, unless waived by
				  the Department according to standards found in Medicare Provider Reimbursement
				  Manual, HCFA Publication 15-1.
(17)
				  "Indemnity bond" means a bond posted by the provider to ensure that the
				  provider is able to fulfill any financial obligations to the Department upon
				  sale of the facility.
(18) "Interim
				  Working Capital Fund" means funding made available to providers on a temporary
				  basis that shall be repaid to the Department.
(19) "Market basket index" means inflation
				  indices from the latest Skilled Nursing Home without Capital Market Basket
				  Index, published 2 months before the period in which rates are being calculated
				  and which is available from CMS at
www.cms.gov
, or a comparable index available
				  from, and used by, CMS, if this index ceases to be published by Global Insight,
				  Inc. or its successor
(20)
				  "Maryland Health Care Commission" means the agency established by
				  Health-General Article, Title 19, Subtitle 1, Annotated Code of
				  Maryland.
(21) "Medicaid" means
				  Medical Assistance provided under the State Plan approved under Title XIX of
				  the Social Security Act.
(22)
				  "Medical Assistance Program" means a program of comprehensive medical and other
				  health-related care for indigent and medically indigent persons.
(23) "Medicare upper payment limit" means
				  that aggregate payments to nursing facilities may not exceed the limits
				  established for such payment in
				  42 CFR §
												447.272.
(24) "Minimum Data Set (MDS) " means the MDS
				  required by 42 CFR §
												483.20 and set forth in the Resident
				  Assessment Instrument published by CMS, and available at
www.cms.gov
, incorporated herein by
				  reference, as amended and supplemented, a core set of screening, clinical, and
				  functional status elements, including common definitions and coding categories
				  that forms the foundation of the assessment required for all residents in
				  Medicare-certified or Medicaid-certified nursing facilities.
(25) "New facility" means:
(a) A facility that has not been a provider
				  during the previous 12-month period or, for rates effective January 1, 2015 and
				  after, does not have a cost report in the price database as set forth in
				  Regulation .09B(1) of this chapter; and
(b)A facility not defined as a replacement
				  facility.
(26)
				  "Noncompliant" means:
(a) A provider fails to
				  submit to the Department the required quarterly report of credit
				  balances;
(b) A provider fails to
				  submit a quarterly report which provides sufficient data relating to the credit
				  balances it maintained during that quarter; or
(c) A random audit by the Department reveals
				  errors or omissions in a provider's credit balance report.
(27) Nursing Facility (NF).
(a) "Nursing facility" means an institution
				  which is primarily engaged in providing to residents:
(i) Skilled nursing care and related services
				  for residents who require medical or nursing care;
(ii) Rehabilitation services for the
				  rehabilitation of injured, disabled, or sick persons; or
(iii) On a regular basis, health-related care
				  and services to individuals who, because of their mental or physical condition,
				  require care and services (above the level of room and board) which can be made
				  available to them only through institutional facilities.
(b) "Nursing facility" means an institution
				  which is licensed by the Department under COMAR 10.07.02.
(c) "Nursing facility" does not include an
				  institution which is primarily for the care and treatment of mental diseases,
				  an intellectually disability or a developmental disability.
(28) "Nursing facility services"
				  means services provided to individuals who do not require hospital care, but
				  who, because of their mental or physical condition, require skilled nursing
				  care and related services, rehabilitation services, or, on a regular basis,
				  health-related care and services (above the level of room and board) which can
				  be made available to them only through institutional facilities.
(29) "Owner" means a party or entity having
				  any ownership interest in the facility.
(30) "Patient day" means care of one patient
				  for 1 day of service. The day of admission is counted as 1 day of care, but the
				  day of discharge is not counted. If a patient is discharged on his day of
				  admission, 1 patient day will be counted.
(31) "Payroll-Based Journal" means a system
				  for facilities to submit staffing information to meet the requirements of
				  § 6106 of the Affordable Care Act (ACA) that requires facilities to
				  electronically submit direct care staffing information (including agency and
				  contract staff) based on payroll and other auditable data.
(32) "Predischarge plan" means:
(a) A written document describing who has
				  operational responsibility for discharge planning;
(b) The manner in and methods by which that
				  person will function;
(c) The time
				  period in which each recipient's need for discharge planning will be
				  determined;
(d) The maximum time
				  period after which a reevaluation of each recipient's discharge plan will be
				  made;
(e) The local resources
				  available to the provider, the individual, and the attending physician to
				  assist in developing and implementing individual discharge plans; and
(f) Provisions for periodic review and
				  reevaluation of the provider's discharge planning program.
(33) "Program" means the Medical Assistance
				  Program.
(34) "Prospective rate"
				  means a facility-specific quarterly per diem rate based on the RUG
				  classification system, and calculated as the sum of:
(a) Administrative and Routine rate as
				  calculated in accordance with Regulation .09 of this chapter;
(b) Other Patient Care Rate as calculated in
				  accordance with Regulation .10 of this chapter;
(c) Capital Rate as calculated in accordance
				  with Regulation .11 of this chapter; and
(d) Nursing Rate as calculated in accordance
				  with Regulation .12 of this chapter.
(35) "Provider" means a facility which has in
				  effect a provider agreement with the Department.
(36) "Provider agreement" means the contract
				  between the Department and the provider covering the obligations of the parties
				  under the Medical Assistance Program.
(37) "Purchaser" means an entity that
				  participates in a change of ownership with a provider by:
(a) Having a provider merge into the
				  entity;
(b) Accepting the
				  assignment, transfer, disposition, or sale of all or substantially all of a
				  provider's assets; or
(c) Being a
				  new entity that results from the consolidation of the provider with a third
				  party.
(38) "Quality
				  measure" means a specific performance criterion, as described in Regulation .15
				  of this chapter, used to assess a facility's performance level.
(39) "Random sample" means the selection for
				  audit by the Department of representative share of the providers complying with
				  the requirement of submitting a quarterly report of credit balances to the
				  Department.
(40) "Recipient" means
				  a person who is certified as eligible for, and is receiving, Medical Assistance
				  benefits.
(41) "Recreational
				  services" means those organized activities provided for the enjoyment of the
				  patients that are designed to promote their physical, social, and mental
				  well-being.
(42) "Reimbursement
				  class" means the group of providers for which a separate per diem rate will be
				  prepared in the Administrative and Routine, Other Patient Care, and Nursing
				  Service cost centers based on geographic region as set forth in Regulation .30
				  of this chapter.
(43) "Relative of
				  the owner" means the owner's husband, wife, natural parent, natural child,
				  sibling, adopted child, adoptive parent, stepparent, stepchild, stepbrother,
				  stepsister, father-in-law, mother-in-law, son-in-law, daughter-in-law,
				  brother-in-law, sister-in-law, grandparent, or grandchild.
(44) "Replacement facility" means:
(a) A newly constructed nursing facility that
				  replaces an existing licensed and certified facility; or
(b)A facility that was closed for significant
				  renovation that reopens and is approved by the Department as a replacement
				  facility.
(45) "Resident
				  roster" means a list of all residents in a nursing facility for a calendar
				  quarter based on MDS assessments and tracking forms, accurately and
				  successfully transmitted by the nursing facility into the CMS-approved
				  submission system, used for the calculated day-weighted case mix indices for
				  Medicaid, Medicare, and other payment sources.
(46) "Resource" means that portion of a
				  recipient's income available toward the cost of medical and remedial care as
				  determined by the Department or its designee.
(47) "Resource Utilization Group (RUG) "
				  means the version IV (RUG-IV), 48-Group classification system, that has been
				  developed by CMS and set forth at
https://www.cms.gov/Medicare/Quality-Initiatives-Patient-
				  [File Link Not
				  Available]Assessment-Instruments/NursingHomeQualityInits/NHQIMDS30TechnicalInform
				  ation.html
for grouping nursing facility residents according to the
				  residents' functional status and anticipated uses of services and resources as
				  identified from data supplied by the MDS.
(48) "Secretary" means the Secretary of
				  Health and Mental Hygiene.
(49)
				  "Special focus facility" means a facility identified by the Centers for
				  Medicare and Medicaid Services as having:
(a)
				  More problems than other nursing homes;
(b) More serious problems than other nursing
				  homes; and
(c) A pattern of serious
				  problems that has persisted over a long period of time.
(50) "Specialized rehabilitative therapy
				  services" means those services furnished by a provider as an integral part of a
				  patient's care plan ordered by a physician and provided in conjunction with
				  continuous nursing care for the purpose of the restoration of normal form and
				  function after injury or illness. The services shall be performed by a licensed
				  physical therapist, licensed physical therapy assistant, or registered
				  occupational therapist.
(51)
				  "Standby letter of credit" means a written instrument prepared by a provider's
				  bank authorizing the Department to draw on the bank, upon sale of the
				  facility.
(52) "Statewide average
				  case mix index" means the simple average of all of the cost report period case
				  mix indices for the rate year
(53)
				  "Statewide average Medicaid case mix index" means the Medicaid day weighted
				  average of all nursing facilities' case mix indices for the Medicaid days
				  identified on the final resident rosters for each resident roster
				  quarter
(54) "Substandard quality
				  of care" means that one or more requirements under 42 CFR § 483.13,
				  42 CFR §
												483.15, or
				  42 CFR
				  483.25 were not met, to a degree constituting
				  immediate jeopardy to resident health or safety, and a pattern of actual harm,
				  widespread actual harm, or a widespread potential for more than minimal
				  harm.
(55) "Substandard quality of
				  care" means a finding of substandard care in accordance with
				  42 CFR §
												488.301.
(56) "Third party liability audit" means a
				  financial review of Medical Assistance payments to a provider to ascertain the
				  legal liability of third parties to pay for care and services available under
				  the Medical Assistance Program.
(57) "Third party liability review" means a
				  financial review of the credit balances of a nursing facility to ascertain the
				  legal liability of third parties to pay for care and services available under
				  the Medical Assistance Program.
(58) "Uniform cost report" means the cost
				  report format which each facility is required to use in the submission of its
				  fiscal year cost and utilization data, including supplemental schedules and
				  other balance sheet and administrative data.