Code of Maine Rules › 10 - DEPARTMENT OF HEALTH AND HUMAN SERVICES › 144 - DEPARTMENT OF HEALTH AND HUMAN SERVICES - GENERAL › Chapter 101 - MAINECARE BENEFITS MANUAL (FORMERLY MAINE MEDICAL ASSISTANCE MANUAL) › Chapter III - Allowances for Services › Section 144-101-III-67 - Principles of Reimbursement for Nursing Facilities › Subsection 144-101-III-67-22 - ESTABLISHMENT OF PROSPECTIVE PER DIEM RATE

Current through 2024-29, July 17, 2024
22.1
Principle.
For services provided on or after July 1, 2014, the
					 Department will establish a prospective per diem rate to be paid to each
					 facility until the end of its fiscal year. Each nursing facility's cost
					 components for the base year, as determined from the as filed cost report will
					 be the basis for the base year computations (subject to upper limits).
					 Allowable costs are separated into three (3) components - direct, routine and
					 fixed costs.
The base year direct and routine cost component costs
						will be trended forward using the guidelines as described in Principles 22.3
						and 22.4, respectively. Thereafter, inflation will be based on Principle 31.
						The prospective rate shall consist of three (3) components: the direct care
						cost component as defined in Principle 16, the routine cost component as
						defined in Principle 17, and the fixed cost component as defined in Principle
						18.
22.2
Fixed Cost
					 Component
The fixed cost component shall be determined from the
						most recent audited or, if more recent information is approved by the
						Department, it shall be based on that more recent information using allowable
						costs as identified in Principle 18. As described in Principle 18, fixed costs
						will be adjusted for providers whose annual level of occupancy is less than
						seventy percent (70%). The adjustment to fixed costs shall be based upon a
						theoretical level of occupancy of seventy percent (70%).
For all new providers coming into the program, the
						seventy percent (70%) occupancy adjustment will not apply for the first ninety
						(90) days of operation. It will, however, apply to the remaining months of
						their initial operating periods. To the extent that fixed costs are allowable,
						such cost will be adjusted for providers with sixty (60) or fewer beds whose
						annual level of occupancy is less than seventy percent (70%). The adjustment to
						the fixed cost component shall be based upon a theoretical level of occupancy
						of seventy percent (70%). The seventy percent (70%) occupancy rate adjustment
						will be applied to fixed costs and shall be cost settled at the time of audit.
						For all new providers of sixty (60) or fewer beds coming into the program, the
						seventy percent (70%) occupancy adjustment will not apply for the first thirty
						(30) days of operation. It will, however, apply to the remaining months of
						their initial operating period.
22.3
Direct Care Cost Component
22.3.1
Case Mix Reimbursement
					 System
22.3.1.1 The direct care cost
					 component utilizes a case mix reimbursement system. Case mix reimbursement
					 takes into account the fact that some residents are more costly to care for
					 than others. Thus the system requires:
(a)
					 the assessment of residents on the Department's approved form -MDS as specified
					 in Principle 16.2;
(b) the
					 classification of residents into groups which are similar in resource
					 utilization by use of the case mix resident classification groups as defined in
					 Principle 22.3.2;
(c) a weighting
					 system which quantifies the relative costliness of caring for different classes
					 of residents by direct care staff to determine a facility's case mix
					 index.