Missouri Code of State Regulations › Title 13 - DEPARTMENT OF SOCIAL SERVICES › Division 70 - MO HealthNet Division › Chapter 10 - Nursing Home Program › Section 13 CSR 70-10.020 - Prospective Reimbursement Plan for Nursing Facility and HIV Nursing Facility Services

Current through Register Vol. 49, No. 14, July 15, 2024
PURPOSE: This amendment provides for an increase to
				  nursing facility and HIV nursing facility per diem reimbursement rates of ten
				  dollars and zero cents ($10.00) and an increase to the Value Based Purchasing
				  per diem adjustments of eighty-seven cents ($0.87) for qualifying facilities,
				  effective for dates of service beginning July 1, 2023. These per diem
				  adjustments correspond to the state fiscal year (SFY) 2024 appropriation for
				  nursing facilities and was contingent upon approval by the Centers for Medicare
				  & Medicaid Services (CMS).
(1) Authority. This regulation is established
				pursuant to the authorization granted to the Department of Social Services
				(department), MO HealthNet Division (division), to promulgate rules and
				regulations.
(2) Purpose. This
				regulation establishes a methodology for determination of reimbursement rates
				for nursing facilities and human immunodeficiency virus (HIV) nursing
				facilities participating in the MO HealthNet Program, which is Missouri's
				Medicaid program. Hereinafter, the term nursing facility/ies shall refer to
				both nursing facilities and HIV nursing facilities unless specifically stated
				otherwise. Subject to limitations prescribed elsewhere in this regulation, a
				facility's reimbursement rate shall be determined by the division as described
				in this regulation. Any reimbursement rate determined by the division shall be
				a final decision and will be implemented as set forth in the division's
				decision letter. The decisions of the division may be subject to review upon
				properly filing a complaint with the Administrative Hearing Commission (AHC). A
				nursing facility seeking review by the AHC must obtain a stay from the AHC to
				stop the division from implementing its final decision if the AHC determines
				the facility meets the criteria for a stay and so orders. If the facility
				appeals the division's decision, it is the responsibility of the nursing
				facility to notify any interested parties, including but not limited to,
				hospice providers, that the rate being received is not a final rate and is
				subject to change. Federal financial participation is available on expenditures
				for services provided within the scope of the federal Medicaid Program and made
				under a court order in accordance with
				42 CFR
				431.250.
(3) General Principles.
(A) Provisions of this reimbursement
				regulation shall apply only to facilities certified for participation in the MO
				HealthNet (Medicaid) Program.
(B)
				The reimbursement rates determined by this regulation shall apply only to
				services provided on or after July 1, 2022.
(C) The effective date of this regulation
				shall be July 1, 2022.
(D) The
				Medicaid Program shall provide reimbursement for nursing facility services
				based solely on the individual Medicaid-eligible participant's covered days of
				care, within benefit limitations as determined in subsections (5)(D),
				multiplied by the facility's Medicaid reimbursement rate. No payments may be
				collected or retained in addition to the Medicaid reimbursement rate for
				covered services, unless otherwise provided for in this regulation. Where
				third-party payment is involved, Medicaid will be the payer of last resort with
				the exception of state programs such as vocational rehabilitation and the
				Missouri Crippled Children's Services.
(E) The Medicaid reimbursement rate shall be
				the lower of-
1. The Medicare (Title XVIII)
				rate, if applicable; or
2. The
				reimbursement rate as determined in accordance with this regulation.
(F) Medicaid reimbursements shall
				not be paid for services provided to Medicaid-eligible participants during any
				time period in which the facility failed to have a Medicaid participation
				agreement in effect. A reimbursement rate may not be established for a facility
				if a Medicaid participation agreement is not in effect.
(G) When a nursing facility is found not in
				compliance with federal requirements for participation in the Medicaid Program,
				sections 1919(b), (c), and (d) of the Social Security Act (42 U.S.C.
				1396r), it may be terminated from the
				Medicaid Program or it may have imposed upon it an alternative remedy, pursuant
				to section 1919(h) of the Social Security Act (42 U.S.C. 1396r). In
				accordance with section 1919(h)(3)(D) of the Social Security Act, the
				alternative remedy, denial of payment for new admission, is contingent upon
				agreement to repay payments received if the corrective action is not taken in
				accordance with the approved plan and timetable. It is also required that the
				nursing facility establish a directed plan of correction in conjunction with
				and acceptable to the Department of Health and Senior Services.
(H) Upon execution of a Medicaid
				participation agreement, a qualified facility not previously certified for
				participation in the Medicaid Program shall be assigned a provider number by
				the Missouri Medicaid Audit and Compliance division of the Department of Social
				Services.
(I) The division shall
				recover liabilities, sanctions, and penalties pertaining to the Medicaid
				Program associated with the provider number, regardless of when the services
				were rendered.
(J) Changes in
				ownership, management, control, operation, leasehold interest by any form for
				any facility previously certified for participation in the Medicaid Program at
				any time that results in increased costs for the successor owner, management,
				or leaseholder shall not be recognized for purposes of reimbursement.
(K) A facility with certified and
				noncertified beds shall allocate allowable costs related to the provision of
				nursing facility services on the cost report, in accordance with the cost
				report instructions. The methods for allocation must be supported by adequate
				accounting and/or statistical data necessary to evaluate the allocation method
				and its application.
(L) Any
				facility which is involuntarily terminated from participation in the Medicare
				Program shall also be terminated from participation in the MO HealthNet Program
				on the same date as the Medicare termination.
(M) No restrictions nor limitations shall,
				unless precluded by federal or state law, be placed on a participant's right to
				select providers of his/her own choice.
(N) A nursing facility's Medicaid
				reimbursement rate shall not be limited by its average private pay
				rate.
(O) The reimbursement rates
				authorized by this regulation may be reevaluated in light of the provider's
				cost experience to determine any adjustments needed.
(P) Covered supplies, such as food, laundry
				supplies, housekeeping supplies, linens, medical supplies, but not limited to,
				must be accounted for through inventory accounts. Purchases shall be recorded
				as inventory and shall be expensed in the fiscal year the items are used.
				Inventory shall be counted at least annually to coincide with the end of the
				cost report period. Expensing of items shall be recorded by adding purchases to
				the beginning period inventory and subtracting the end of the period inventory.
				This inventory control shall begin the first fiscal year ending after the
				effective date of this plan.
(Q)
				Medicaid reimbursement will not be paid for a Medicaid-eligible resident while
				placed in a non-certified bed in a nursing facility.
(R) All illustrations and examples provided
				throughout this regulation are for illustration purposes only and are not meant
				to be actual calculations.
(S)
				Reimbursement of Medicare/Medicaid crossover claims (crossover claims) for
				Medicare Part A and Medicare Advantage/Part C inpatient skilled nursing
				facility benefits shall be as follows:
1.
				Crossover claims for Medicare Part A inpatient skilled nursing facility
				benefits in which Medicare was the primary payer and the MO HealthNet Division
				is the payer of last resort for the coinsurance must meet the following
				criteria to be eligible for MO HealthNet reimbursement:
A. The crossover claim must be related to
				Medicare Part A inpatient skilled nursing facility benefits that were provided
				to MO HealthNet participants also having Medicare coverage; and
B. The crossover claim must contain approved
				coinsurance days. The amount indicated by Medicare to be the coinsurance due on
				the Medicare allowed amount is the crossover amount eligible for MO HealthNet
				reimbursement. The coinsurance amount is based on the days for which Medicare
				is not the sole payer. These days are referred to as coinsurance days and are
				days twenty-one (21) through one hundred (100) of each Medicare benefit period;
				and
C. The Other Payer paid amount
				field on the claim must contain the actual amount paid by Medicare. The MO
				HealthNet provider is responsible for accurate and valid reporting of crossover
				claims submitted to MO HealthNet for payment. Providers submitting crossover
				claims for Medicare Part A inpatient skilled nursing facility benefits to the
				MO HealthNet program must be able to provide documentation that supports the
				information on the claim upon request. The documentation must match the
				information on the Medicare Part A plan's remittance advice. Any amounts paid
				by MO HealthNet that are determined to be based on inaccurate data will be
				subject to recoupment; and
D. The
				nursing facility's Medicaid reimbursement rate multiplied by the approved
				coinsurance days exceeds the amount paid by Medicare for the same approved
				coinsurance days;
2.
				Crossover claims for Medicare Advantage/Part C (Medicare Advantage) inpatient
				skilled nursing facility benefits in which a Medicare Advantage plan was the
				primary payer and the MO HealthNet Division is the payer of last resort for the
				copay (coinsurance) must meet the following criteria to be eligible for MO
				HealthNet reimbursement:
A. The crossover
				claim must be related to Medicare Advantage inpatient skilled nursing facility
				benefits that were provided to MO HealthNet participants who also are either a
				Qualified Medicare Beneficiary (QMB Only) or Qualified Medicare Beneficiary
				Plus (QMB Plus); and
B. The
				crossover claim must be submitted as a Medicare UB-04 Part C Institutional
				Crossover claim through the division's online Internet billing system;
				and
C. The crossover claim must
				contain approved coinsurance days. The amount indicated by the Medicare
				Advantage plan to be the coinsurance due on the Medicare Advantage plan allowed
				amount is the crossover amount eligible for MO HealthNet reimbursement. The
				coinsurance amount is based on the days for which the Medicare Advantage plan
				is not the sole payer. These days are referred to as coinsurance days and are
				established by each Medicare Advantage plan; and
D. The Other Payer paid amount field on the
				claim must contain the actual amount paid by the Medicare Advantage plan. The
				MO HealthNet provider is responsible for accurate and valid reporting of
				crossover claims submitted to MO HealthNet for payment. Providers submitting
				crossover claims for Medicare Advantage inpatient skilled nursing facility
				benefits to the MO HealthNet program must be able to provide documentation that
				supports the information on the claim upon request. The documentation must
				match the information on the Medicare Advantage plan's remittance advice. Any
				amounts paid by MO HealthNet that are determined to be based on inaccurate data
				will be subject to recoupment; and
E. The nursing facility's Medicaid
				reimbursement rate multiplied by the approved coinsurance days exceeds the
				amount paid by the Medicare Advantage plan for the same approved coinsurance
				days;
3. MO HealthNet
				reimbursement will be the lower of-
A. The
				difference between the nursing facility's Medicaid reimbursement rate
				multiplied by the approved coinsurance days and the amount paid by either
				Medicare or the Medicare Advantage plan for those same coinsurance days;
				or
B. The coinsurance amount;
				and
4. Nursing facility
				providers may not submit a MO HealthNet fee-for-service nursing facility claim
				for the same dates of service on the crossover claim for Medicare Part A and
				Medicare Advantage inpatient skilled nursing facility benefits. If it is
				determined that a MO HealthNet fee-for-service nursing facility claim is
				submitted and payment is made, it will be subject to recoupment.