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 4 - Rate-Setting Criteria for State-Owned Intermediate Care Facilities for the Mentally Retarded › Section 4-17 - Capital return factor; basis; sale or capital lease of facility; valuation; sale or lease among family members (Repealed)

Current through July 10, 2024
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 1 - MEDICAID PROVIDERS AND SERVICES › Rule 4 - Rate-Setting Criteria for State-Owned Intermediate Care Facilities for the Mentally Retarded › Section 4-18 - Unallowable costs; cost adjustments; charity and courtesy allowances; discounts; rebates; refunds of expenses (Repealed)

Current through July 10, 2024
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 1 - MEDICAID PROVIDERS AND SERVICES › Rule 4 - Rate-Setting Criteria for State-Owned Intermediate Care Facilities for the Mentally Retarded › Section 4-19 - Allowable costs; wages; costs of employment; record keeping; owner or related party compensation (Repealed)

Current through July 10, 2024
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 1 - MEDICAID PROVIDERS AND SERVICES › Rule 4 - Rate-Setting Criteria for State-Owned Intermediate Care Facilities for the Mentally Retarded › Section 4-20 - Allowable costs; calculation of allowable owner or related party compensation; wages; salaries; fees; fringe benefits (Repealed)

Current through July 10, 2024
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 1 - MEDICAID PROVIDERS AND SERVICES › Rule 4 - Rate-Setting Criteria for State-Owned Intermediate Care Facilities for the Mentally Retarded › Section 4-21 - Nursing facilities providing intermediate or skilled care; staffing costs; incentive for cost efficiency (Repealed)

Current through July 10, 2024
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 1 - MEDICAID PROVIDERS AND SERVICES › Rule 4 - Rate-Setting Criteria for State-Owned Intermediate Care Facilities for the Mentally Retarded › Section 4-23 - Nursing facilities providing intermediate and skilled care; reimbursement for therapy services (Repealed)

Current through July 10, 2024
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 1 - MEDICAID PROVIDERS AND SERVICES › Rule 4 - Rate-Setting Criteria for State-Owned Intermediate Care Facilities for the Mentally Retarded › Section 4-24 - Nursing facilities providing intermediate care and skilled care; allocation of intermediate and skilled care costs (Repealed)

Current through July 10, 2024
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 1 - MEDICAID PROVIDERS AND SERVICES › Rule 4 - Rate-Setting Criteria for State-Owned Intermediate Care Facilities for the Mentally Retarded › Section 4-25 - State-owned intermediate care facilities for the mentally retarded; allowable costs; compensation; per diem rate (Repealed)

Current through July 10, 2024
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 1 - MEDICAID PROVIDERS AND SERVICES › Rule 4 - Rate-Setting Criteria for State-Owned Intermediate Care Facilities for the Mentally Retarded › Section 4-26 - Community residential facilities for the developmentally disabled; allowable costs; compensation; per diem rate; incentive payment rate (Repealed)

Current through July 10, 2024
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 1 - MEDICAID PROVIDERS AND SERVICES › Rule 4 - Rate-Setting Criteria for State-Owned Intermediate Care Facilities for the Mentally Retarded › Section 4-26.1 - Community residential facilities for the developmentally disabled; allowable costs; compensation; per diem rate; incentive payment rate (Repealed)

Current through July 10, 2024
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 1 - MEDICAID PROVIDERS AND SERVICES › Rule 4 - Rate-Setting Criteria for State-Owned Intermediate Care Facilities for the Mentally Retarded › Section 4-28 - Nursing facilities; separate reimbursement for ventilator units in nursing homes (Repealed)

Current through July 10, 2024
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 1 - MEDICAID PROVIDERS AND SERVICES › Rule 4 - Rate-Setting Criteria for State-Owned Intermediate Care Facilities for the Mentally Retarded › Section 4-29 - Skilled nursing facilities; separate reimbursement for brain and high spinal cord trauma and major progressive neuromuscular disorders (Repealed)

Current through July 10, 2024
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 1 - MEDICAID PROVIDERS AND SERVICES › Rule 4 - Rate-Setting Criteria for State-Owned Intermediate Care Facilities for the Mentally Retarded › Section 4-30 - Skilled nursing facilities; separate reimbursement for "chronically medically dependent" people infected by the human immunodeficiency virus (HIV) (Repealed)

Current through July 10, 2024
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 1 - MEDICAID PROVIDERS AND SERVICES › Rule 4 - Rate-Setting Criteria for State-Owned Intermediate Care Facilities for the Mentally Retarded › Section 4-31 - Skilled nursing facilities; separate reimbursement for "chronically medically dependent" people infected by the human immunodeficiency virus (HIV) (Repealed)

Current through July 10, 2024
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 1 - MEDICAID PROVIDERS AND SERVICES › Rule 4.2 - Home Health Services › Section 4.2-1 - Policy; scope

Current through July 10, 2024
Authority: IC
				  12-15-21-1; IC
				  12-15-21-3
Affected: IC
				  12-15-13-2
Sec. 1.
(a) This rule
				provides general information regarding the criteria for providing home health
				services to Medicaid members and sets forth the criteria for reimbursement for
				services rendered to Medicaid members by home health agencies. The information
				and procedures contained in this rule apply to home health agencies. Continued
				participation in Medicaid and payment for services are contingent upon
				maintenance of state licensure and compliance with the Medicaid provider
				agreement.
(b) In accordance with
				federal law, reimbursement for home health services will be consistent with
				efficiency, economy, and quality of care and sufficient to enlist enough
				providers so that care and services are available to Medicaid members at least
				to the extent that such care and services are available to the general
				population in the geographic area.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 1 - MEDICAID PROVIDERS AND SERVICES › Rule 4.2 - Home Health Services › Section 4.2-2 - Definitions

Current through July 10, 2024
Authority: IC
				  12-15-5-11; IC
				  12-15-21
Affected: IC
				  12-15-13-2; IC
				  12-15-34-1
Sec. 2.
The following definitions in this section apply throughout
				  this rule:
(1) "HHA" means a home
				health agency as defined in IC
				12-15-34-1 that is licensed by
				ISDH to provide home health services and is enrolled as a provider.
(2) "Home health care" means health care
				provided to Medicaid members in the member's place of residence as follows:
(A) A place of residence for home health
				services does not include a hospital, nursing facility, or intermediate care
				facility for individuals with intellectual disabilities.
(B) Nothing in this subdivision should be
				read to prohibit a member from receiving home health services in any setting in
				which normal life activities take place, other than a hospital, nursing
				facility, intermediate care facility for individuals with intellectual
				disabilities, or any setting in which payment is or could be made under
				Medicaid for inpatient services that include room and board. Home health
				services cannot be limited to services furnished to members who are
				homebound.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 1 - MEDICAID PROVIDERS AND SERVICES › Rule 4.2 - Home Health Services › Section 4.2-3 - Home health care services; general information

Current through July 10, 2024
Authority: IC 12-15-5-11; IC 12-15-21
Affected: IC 12-15-13-2
Sec. 3.
(a) Medicaid
				will reimburse HHAs for the following home health services:
(1) Skilled nursing performed by a registered
				nurse or licensed practical nurse.
(2) Home health aide services.
(3) Physical and occupational
				therapies.
(4) Speech pathology
				services.
(5) Renal
				dialysis.
(6) Telehealth services.
The services in this subsection must be provided within the
				  limitations set forth in
				  405 IAC 5-16.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 1 - MEDICAID PROVIDERS AND SERVICES › Rule 4.2 - Home Health Services › Section 4.2-4 - Home health care services; reimbursement methodology

Current through July 10, 2024
Authority: IC 12-15
Affected: IC 12-15-13-2; IC 12-15-22-1
Sec. 4.
(a) HHAs will
				be reimbursed for covered services provided to Medicaid members through
				standard, statewide rates as:
(1) one (1)
				overhead rate per HHA visit, per member, per day; plus
(2) the staffing rate multiplied by the
				number of billing units spent in the performance of billable patient care
				activities; to equal the total reimbursement per visit.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 1 - MEDICAID PROVIDERS AND SERVICES › Rule 4.2 - Home Health Services › Section 4.2-5 - Home health care services reimbursement rates

Current through July 10, 2024
Authority: IC
				  12-15-21-1; IC
				  12-15-21-2; IC
				  12-15-21-3
Affected: IC
				  12-15-13-2; IC
				  12-15-22-1; IC
				  12-15-34-14.5
Sec. 5.
(a) The
				staffing and overhead billing units for HHA services are as follows:
Home Health Service
Billing Unit
Overhead
One unit per provider per member per day
Registered Nurse (RN)
Hourly
Licensed Practical Nurse (LPN)
Hourly
Home Health Aide
Hourly
Physical Therapist
15-minute increments
Occupational Therapist
15-minute increments
Speech Pathologist
15-minute increments
(b)
				For dates of service on or after July 1, 2018, Medicaid reimbursement shall be
				at the rates effective July 1, 2018.
(c) All fee schedules are available through
				the agency's website at
www.indianamedicaid.com
. Except as
				otherwise noted, state-developed fee schedule rates are the same for both
				governmental and private providers of home health care.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 1 - MEDICAID PROVIDERS AND SERVICES › Rule 4.2 - Home Health Services › Section 4.2-6 - Telehealth services

Current through July 10, 2024
Authority: IC
				  12-15-5-11; IC
				  12-15-21
Affected: IC
				  12-15-13-2; IC
				  12-15-22-1
Sec. 6.
(a) Approved
				telehealth services are reimbursed separately from other home health services.
				The unit of reimbursement for telehealth services provided by an HHA is one (1)
				calendar day.
(b) Reimbursement is
				available for telehealth services as follows:
(1) One-time amount per client of fourteen
				dollars and forty-five cents ($14.45) related to an initial face-to-face visit
				necessary to train the member to appropriately operate the telehealth
				equipment.
(2) One (1) payment of
				nine dollars and eighty-four cents ($9.84) for each day the telehealth
				equipment is used by a registered nurse (RN) to monitor and manage the client's
				care in accordance with the written order from a physician.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 1 - MEDICAID PROVIDERS AND SERVICES › Rule 4.3 - Additional Rate-Setting Criteria for Nursing Facilities, Community Residential Facilities for the Developmentally Disabled, and Intermediate Care Facilities for the Mentally Retarded › Section 4.3-1 - Limitations or qualifications to Medicaid reimbursement; litigation expenses

Current through July 10, 2024
Authority: IC
				  12-15-21-1; IC
				  12-15-21-3
Affected: IC
				  12-15-14-2
Sec. 1.
(a)
				Notwithstanding any other sections of this article, the criteria in this
				section apply to litigation expenses for nursing facilities, ICFs/IID, and
				CRFs/DD.
(b) Legal fees, expenses
				related to expert witnesses, accounting fees, and other consulting fees shall
				not be reimbursed by the office as reasonably related medical expenses under
				Medicaid if the expenses are incurred as the result of an administrative or
				judicial action or proceeding against any agency of the state or the federal
				government.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 1 - MEDICAID PROVIDERS AND SERVICES › Rule 8 - Hospital and Ambulatory Surgical Center Reimbursement for Outpatient Services › Section 8-2 - Policy; scope

Current through July 10, 2024
Authority: IC 12-15-21-2; IC 12-15-21-3
Affected: IC 12-15-15-1
Sec. 2.
(a)
				Reimbursement for outpatient hospital services as defined by
				42 CFR
				440.20(a) and to ambulatory
				surgical centers is available to providers enrolled by the office as providers
				who are in good standing. Continued participation in Medicaid and payment for
				outpatient hospital services and ambulatory surgical centers are contingent
				upon maintenance of state licensure and conformance with the office's provider
				agreement.
(b) The methodology for
				the reimbursement described in subsection (a) shall be based on set fee
				schedule allowances for each procedure or occurrence as established by the
				office.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 1 - MEDICAID PROVIDERS AND SERVICES › Rule 8 - Hospital and Ambulatory Surgical Center Reimbursement for Outpatient Services › Section 8-3 - Reimbursement methodology

Current through July 10, 2024
Authority: IC 12-15-21-2; IC 12-15-21-3
Affected: IC 12-15-15-1
Sec. 3.
(a) The
				reimbursement methodology for all covered outpatient hospital and ambulatory
				surgical center services shall be subject to the lower of the submitted charges
				for the procedure or the established fee schedule allowance for the procedure
				as provided in this section. Services shall be billed in accordance with
				provider manuals and update bulletins.
(b) Surgical procedures shall be:
(1) classified into a group corresponding to
				the Medicare ambulatory surgical center (ASC) methodology; and
(2) paid a rate established for each ASC
				payment group.
Outpatient surgeries that are not classified into the nine
				  (9) groups designated by Medicare will be classified by the office into one (1)
				  of those nine (9) groups or additional payment groups. Reimbursement will be
				  based on the Indiana Medicaid statewide allowed amount for that service in
				  effect during state fiscal year 2003.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 1 - MEDICAID PROVIDERS AND SERVICES › Rule 8 - Hospital and Ambulatory Surgical Center Reimbursement for Outpatient Services › Section 8-4 - Client copayment

Current through July 10, 2024
Authority: IC
				  12-15-21-2; IC
				  12-15-21-3
Affected: IC
				  12-15-6-3; IC
				  12-15-6-4
Sec. 4.
(a) Except
				for those categories of individuals and services specifically exempted in
				subsection (e), Medicaid members shall be responsible for paying directly to
				providers a set portion of the payment for nonemergency services provided in an
				emergency room setting. Services defined as nonemergency shall be determined by
				the office.
(b) The amount of
				copayment to be charged shall be three dollars ($3) for nonemergency services
				provided in emergency room settings.
(c) The provider shall be responsible for
				collecting the appropriate copayment amount from the member.
(d) Participating providers may not deny
				services to any eligible individual on account of the individual's inability to
				pay the copayment amount. This services guarantee does not apply to an
				individual who is able to pay, nor does an individual's inability to pay
				eliminate the individual's liability for the copayment.
(e) The following categories of members and
				services are exempt from the copayment requirements:
(1) Services provided to children under
				eighteen (18) years of age.
(2)
				Services provided to pregnant women.
(3) Family planning services.
(4) Services provided by a health maintenance
				organization (HMO) to members enrolled in an HMO.
(5) Medicaid members residing in
				participating long term care facilities.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 1 - MEDICAID PROVIDERS AND SERVICES › Rule 8 - Hospital and Ambulatory Surgical Center Reimbursement for Outpatient Services › Section 8-5 - Outpatient hospital assessment fee

Current through July 10, 2024
Authority: IC 12-15-21-2; IC 12-15-21-3; IC
				  16-21-10-16
Affected: IC 4-21.5-3; IC 12-15-15-1; IC 12-15-21-3; IC
				  12-25; IC 16-18-2-179; IC 16-21-2; IC 16-21-10
Sec. 5.
(a) Effective
				through June 30, 2019, the office shall collect an outpatient hospital
				assessment fee (HAF) from each outpatient hospital that:
(1) meets the definition set forth in IC
				16-18-2-179(b); and
(2) is licensed
				under either:
(A) IC 16-21-2 as an acute care
				hospital; or
(B) IC 12-25 as a
				private psychiatric hospital.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 1 - MEDICAID PROVIDERS AND SERVICES › Rule 10.5 - Reimbursement for Inpatient Hospital Services › Section 10.5-1 - Policy; scope

Current through July 10, 2024
Authority: IC 12-15-21-2; IC 12-15-21-3
Affected: IC 12-15-15-1
Sec. 1.
Reimbursement for inpatient hospital services, as defined by
				  42 CFR
				  440.10, is available to providers enrolled by
				  the office as Medicaid providers and who are in good standing. Continued
				  participation in the Medicaid program and payment of inpatient hospital
				  services are contingent upon maintenance of state licensure and conformance
				  with the office's provider agreement.
				  405 IAC 5-17 and
				  405 IAC 5-28 establish criteria
				  for providing inpatient hospital services to Medicaid members and set forth the
				  types of services for which Medicaid reimbursement may be
				  available.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 1 - MEDICAID PROVIDERS AND SERVICES › Rule 10.5 - Reimbursement for Inpatient Hospital Services › Section 10.5-2 - Definitions

Current through July 10, 2024
Authority: IC 12-15-21-2; IC 12-15-21-3
Affected: IC 12-15-15-1; IC 12-24-1-3; IC 12-25; IC
				  16-21
Sec. 2.
(a) The
				definitions in this section apply throughout this rule.
(b) "All patient refined diagnosis-related
				group (DRG) grouper" refers to a classification system used to assign inpatient
				stays to DRGs.
(c) "Base amount"
				means the rate per Medicaid stay that is multiplied by the relative weight to
				determine the DRG rate.
(d) "Base
				period" means the fiscal years used for calculation of the prospective payment
				rates including base amounts and relative weights.
(e) "Capital costs" are costs associated with
				the capital costs of the facility. The term includes, but is not limited to,
				the following:
(1) Depreciation.
(2) Interest.
(3) Property taxes.
(4) Property insurance.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 1 - MEDICAID PROVIDERS AND SERVICES › Rule 10.5 - Reimbursement for Inpatient Hospital Services › Section 10.5-4 - Reimbursement for new providers and out-of-state providers

Current through July 10, 2024
Authority: IC 12-15-21-2; IC 12-15-21-3
Affected: IC 12-15-15-1
Sec. 4.
(a) The
				purpose of this section is to establish payment rates for inpatient hospital
				facilities that commenced participation in the state Medicaid program after
				fiscal year 1990 and for out-of-state hospital providers participating in the
				Indiana Medicaid program.
(b)
				Payment for inpatient stays reimbursed according to the DRG methodology shall
				be equal to the sum of the DRG rate, the capital rate calculated using the
				statewide median capital rate, the medical education rate, and, if applicable,
				the outlier payment calculated using the statewide median cost-to-charge
				ratio.
(c) Payment for inpatient
				stays reimbursed as level-of-care cases shall be equal to the sum of the per
				diem rate for each Medicaid day, the capital rate calculated using the
				statewide median capital rate, and the medical education rate.
(d) Outlier payments for inpatient stays
				reimbursed under subsection (b) shall be determined according to the
				methodology described in section 3 of this rule. Each out-of-state hospital
				that submits a Medicaid hospital cost report will receive a cost-to-charge
				ratio. All other out-of-state facilities must use the statewide median
				cost-to-charge ratio to determine applicable cost outlier payments.
(e) To be eligible for a facility-specific
				per diem medical education rate, out-of-state providers must be located in an
				area designated in-state pursuant to
				405 IAC 5-5 or have a minimum of
				sixty (60) Medicaid inpatient days. Providers must submit annually a Medicaid
				hospital cost report to be eligible for this reimbursement. The
				facility-specific per diem medical education rate for an out-of-state provider
				shall not exceed the highest in-state medical education per diem
				rate.
(f) To be considered for a
				separate base amount for children's hospitals, out-of-state children's
				hospitals must be located in an area designated in-state pursuant to
				405 IAC 5-5 or have a minimum of
				sixty (60) Medicaid inpatient days. Providers must submit annually a Medicaid
				hospital cost report to be eligible for a separate base amount.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 1 - MEDICAID PROVIDERS AND SERVICES › Rule 10.5 - Reimbursement for Inpatient Hospital Services › Section 10.5-5 - Health care-acquired conditions and other provider-preventable conditions

Current through July 10, 2024
Authority: IC 12-15
Affected: IC 12-15-15-1
Sec. 5.
(a) This
				section applies to the following:
(1) Payment
				for inpatient stays reimbursed according to the DRG and level-of-care
				methodologies.
(2) All inpatient
				hospital facility reimbursement provisions, including the following:
(A) Medicaid supplemental payments.
(B) Medicaid enhanced payments.
(C) Medicaid disproportionate share hospital
				payments.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 1 - MEDICAID PROVIDERS AND SERVICES › Rule 10.5 - Reimbursement for Inpatient Hospital Services › Section 10.5-6 - Rate reduction

Current through July 10, 2024
Authority: IC
				  12-15-21-2; IC
				  12-15-21-3
Affected: IC
				  12-15-15-1
Sec. 6.
Notwithstanding all other provisions of this rule,
				  reimbursement rates shall be reduced, through June 30, 2021, by three percent
				  (3%) for inpatient hospital services that have been calculated under this
				  rule.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 1 - MEDICAID PROVIDERS AND SERVICES › Rule 10.5 - Reimbursement for Inpatient Hospital Services › Section 10.5-7 - Inpatient hospital assessment fee

Current through July 10, 2024
Authority: IC 12-15-21-2; IC 12-15-21-3; IC
				  16-21-10-16
Affected: IC 4-21.5-3; IC 12-15-15-1; IC 12-15-15-11; IC
				  12-15-21-3; IC 12-25; IC 16-18-2-179; IC 16-21-2; IC 16-21-10
Sec. 7.
(a) Effective
				through June 30, 2019, the office shall collect an inpatient hospital
				assessment fee (HAF) from each inpatient hospital that:
(1) meets the definition set forth in IC
				16-18-2-179(b); and
(2) is licensed
				under either:
(A) IC 16-21-2 as an acute care
				hospital; or
(B) IC 12-25 as a
				private psychiatric hospital.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 1 - MEDICAID PROVIDERS AND SERVICES › Rule 11.5 - Reimbursement for Services Performed by Physicians, Limited License Practitioners, and Nonphysician Practitioners › Section 11.5-1 - Policy; scope

Current through July 10, 2024
Authority: IC 12-15-21-2; IC 12-15-21-3
Affected: IC 12-15-13-2
Sec. 1.
(a)
				Reimbursement for physician services, limited license practitioner services,
				and nonphysician practitioner services as defined by
				42 CFR
				440.50 and
				42 CFR 440.60(a) is available to
				providers licensed by the professional licensing agency and enrolled by the
				office as providers who are in good standing. Continued participation in
				Medicaid and payment for services is contingent upon maintenance of state
				licensure and conformance with the office's provider agreement.
(b) As used in this rule, "physician and
				limited license practitioner" or "LLP" means any of the following:
(1) A doctor of medicine.
(2) A doctor of osteopathy.
(3) A physician group practice.
(4) A primary care group practice.
(5) An optometrist.
(6) A podiatrist.
(7) A dentist who is an oral
				surgeon.
(8) A
				chiropractor.
(9) A health service
				provider in psychology.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 1 - MEDICAID PROVIDERS AND SERVICES › Rule 11.5 - Reimbursement for Services Performed by Physicians, Limited License Practitioners, and Nonphysician Practitioners › Section 11.5-2 - Reimbursement methodology

Current through July 10, 2024
Authority: IC 12-15-21-2; IC 12-15-21-3
Affected: IC 12-15-13-2
Sec. 2.
(a) The
				office shall establish fee schedules with maximum allowable payment amounts for
				services and procedures:
(1) covered under
				Medicaid; and
(2) provided by
				eligible physicians, LLPs, and other NPPs.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 1 - MEDICAID PROVIDERS AND SERVICES › Rule 11.5 - Reimbursement for Services Performed by Physicians, Limited License Practitioners, and Nonphysician Practitioners › Section 11.5-3 - Additional provisions

Current through July 10, 2024
Authority: IC
				  12-15-21-2; IC
				  12-15-21-3
Affected: IC
				  4-21.5-3; IC
				  12-15-13-2
Sec. 3.
(a) Physician
				reimbursement is subject to all other Medicaid rules not otherwise specifically
				covered by this section. As an example, the provider of service may not develop
				or bill Medicaid for charges that are in excess of the usual and customary
				charges billed for similar services to non-Medicaid payers.
(b) In the event that the provider is
				dissatisfied with rates issued in accordance with this section and has
				exhausted all interim review procedures provided in this article, it may seek
				an administrative appeal under IC
				4-21.5-3.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 1 - MEDICAID PROVIDERS AND SERVICES › Rule 12 - Rate-Setting Criteria for Nonstate-Owned Intermediate Care Facilities for the Mentally Retarded and Community Residential Facilities for the Developmentally Disabled › Section 12-1 - Policy; scope

Current through July 10, 2024
Authority: IC
				  12-15-1-10; IC
				  12-15-21-2
Affected: IC
				  6-8.1-10-1; IC
				  12-13-7-3; IC
				  12-15-13-4
Sec. 1.
(a) This rule
				sets forth procedures for payment for services rendered to Medicaid members by
				duly certified nonstate-operated ICFs/IID, nonstate-operated CRMNFs, and
				nonstate-operated CRFs/DD. 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 12 - Rate-Setting Criteria for Nonstate-Owned Intermediate Care Facilities for the Mentally Retarded and Community Residential Facilities for the Developmentally Disabled › Section 12-2 - 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) "All-inclusive rate" means a per diem
				rate that, at a minimum, reimburses for all nursing or resident:
(1) care;
(2) room and board;
(3) supplies; and
(4) ancillary 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 12 - Rate-Setting Criteria for Nonstate-Owned Intermediate Care Facilities for the Mentally Retarded and Community Residential Facilities for the Developmentally Disabled › Section 12-3 - Accounting records; retention schedule; audit trail; accrual 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 GAAP. All cost and charges reported on the provider's cost report must
				also be recorded on the provider's financial statements. Costs must be reported
				in the cost report in accordance with the following authorities, in the
				hierarchical order listed:
(1) Costs must be
				reported in accordance with the specific provisions as set forth in this rule,
				any financial report instructions, provider bulletins, and any other policy
				communications.
(2) Costs must be
				reported in conformance with cost finding principles published in the Medicare
				Provider Reimbursement Manual, CMS 15-1.
(3) Costs must be reported in conformance
				with GAAP.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 1 - MEDICAID PROVIDERS AND SERVICES › Rule 12 - Rate-Setting Criteria for Nonstate-Owned Intermediate Care Facilities for the Mentally Retarded and Community Residential Facilities for the Developmentally Disabled › Section 12-4 - Financial report to office; annual schedule; prescribed form; extensions; penalty for untimely filing

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. 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 enrollment 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 or resident 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 or resident related interest bearing
				debt.
(6) Complete balance sheet
				data.
(7) Schedule of Medicaid and
				private pay charges in effect on the last day of the reporting period and on
				the rate effective date as defined by this rule. Private pay charges shall be
				the lowest usual and customary charge.
(8) Certification statement signed by the
				provider that:
(A) the data are true,
				accurate, related to patient or resident care; and
(B) expenses not related to patient or
				resident care have been clearly identified.
(9) Certification statement signed 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 12 - Rate-Setting Criteria for Nonstate-Owned Intermediate Care Facilities for the Mentally Retarded and Community Residential Facilities for the Developmentally Disabled › Section 12-5 - New provider; initial financial report to office; criteria for establishing initial interim rates; supplemental report; base rate setting; penalty for untimely filing of Checklist of Management Representations

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) Rate
				requests to establish initial interim rates for a new operation, a new type of
				certified service, a new type of licensure for an existing group home, or a
				change of provider status shall be filed by submitting an initial rate request
				to the office on or before thirty (30) days after notification of the
				enrollment date or establishment of a new service or type of licensure. Initial
				interim rates will be set at the greater of:
(1) the prior provider's then current rate,
				including any changes due to a field audit, if applicable; or
(2) the fiftieth percentile rates as computed
				in this subsection.
Initial interim rates shall be effective upon the later of
				  the enrollment date, the effective date of a licensure change, or the date that
				  a service is established. The fiftieth percentile rates shall be computed on a
				  statewide basis for like levels of care, except as provided in subsection (b),
				  using current rates of all CRF/DD and ICF/IID providers. The fiftieth
				  percentile rates shall be maintained by the office, and a revision shall be
				  made to these rates four (4) times per year effective on April 1, July 1,
				  October 1, and January 1.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 1 - MEDICAID PROVIDERS AND SERVICES › Rule 12 - Rate-Setting Criteria for Nonstate-Owned Intermediate Care Facilities for the Mentally Retarded and Community Residential Facilities for the Developmentally Disabled › Section 12-6 - Active providers; rate review; annual request

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. 6.
(a) The rate
				effective date of the annual rate review established during rebasing years and
				nonrebasing years shall be the first day of the fourth 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.
(b) The annual rate review
				that shall become effective during a rebasing year shall be established using
				the annual financial report as the basis of the review.
(c) The annual rate review that shall become
				effective during a nonrebasing year shall be established by applying an
				inflation adjustment to the previous year's annual or base Medicaid rate that
				excludes the rate reduction amount specified in section 24(d) of this rule. The
				inflation adjustment prescribed by this subsection shall be applied by using
				the CMS Nursing Home without Capital
Market Basket index as published by DRI/WEFA. The inflation
				  adjustment shall apply from the midpoint of the previous year's annual or base
				  Medicaid rate period to the midpoint of the current year annual Medicaid rate
				  period prescribed as follows:
Rate Effective Date
Midpoint Quarter
January 1, Year 1
July 1, Year 1
April 1, Year 1
October 1, Year 1
July 1, Year 1
January 1, Year 2
October 1, Year 1
April 1, Year 2
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 1 - MEDICAID PROVIDERS AND SERVICES › Rule 12 - Rate-Setting Criteria for Nonstate-Owned Intermediate Care Facilities for the Mentally Retarded and Community Residential Facilities for the Developmentally Disabled › Section 12-7 - Request for rate review; effect of inflation; occupancy level assumptions

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. 7.
(a) Rate
				setting during rebasing years shall be based on the provider's annual or
				historical financial report for the most recent completed year. In determining
				prospective allowable costs during rebasing years, each provider's costs from
				the most recent completed year will be adjusted for inflation by the office
				using the following methodology. All allowable costs of the provider, except
				for:
(1) mortgage interest on facilities and
				equipment;
(2) depreciation on
				facilities and equipment;
(3) rent
				or lease costs for facilities and equipment; and
(4) working capital interest;
shall be increased for inflation using the CMS Nursing Home
				  without Capital Market Basket index as published by IHS. The inflation
				  adjustment shall apply from the midpoint of the annual or historical financial
				  report period to the midpoint of the expected rate period.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 1 - MEDICAID PROVIDERS AND SERVICES › Rule 12 - Rate-Setting Criteria for Nonstate-Owned Intermediate Care Facilities for the Mentally Retarded and Community Residential Facilities for the Developmentally Disabled › Section 12-8 - Limitations or qualifications to Medicaid reimbursement; advertising; vehicle basis

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. 8.
(a)
				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 or fundraising or to
				encourage patient or resident utilization.
(b) Each facility and distinct home office
				location shall be allowed:
(1) one (1)
				patient or resident care-related automobile; and
(2) one (1) vehicle that can be utilized for
				facility maintenance or patient or resident support or for both uses;
to be included in the vehicle basis for purposes of cost
				  reimbursement under this rule. Vehicle basis means the purchase price of the
				  vehicle used for facility or home office operations. If a portion of the use of
				  the vehicle is for personal purposes or for purposes other than operation of
				  the facility or home office, then such portion of the cost must not be included
				  in the vehicle basis. The facility and home office location(s) are responsible
				  for maintaining records to substantiate operational and personal use for all
				  allowable vehicles. This limitation does not apply to vehicles with a gross
				  vehicle weight of more than six thousand (6,000) pounds.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 1 - MEDICAID PROVIDERS AND SERVICES › Rule 12 - Rate-Setting Criteria for Nonstate-Owned Intermediate Care Facilities for the Mentally Retarded and Community Residential Facilities for the Developmentally Disabled › Section 12-9 - Criteria limiting rate adjustment granted by office

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. 9.
During rebasing years and for base rate reviews, the
				  Medicaid reimbursement system is based on recognition of the provider's
				  allowable costs plus a potential profit add-on payment. The payment rate
				  established during rebasing years and for base rate reviews is subject to the
				  following limitations:
(1) In no
				instance shall the approved Medicaid rate be higher than the rate paid to that
				provider by the general public for the same type of services. For purposes of
				this rule, the rates paid by the general public shall not include rates paid by
				the DDRS.
(2) Should the rate
				calculations produce a rate higher than the reimbursement rate requested by the
				provider, the approved rate shall be the rate requested by the
				provider.
(3) Inflated allowable
				per patient or per resident day costs plus the allowed profit add-on payment as
				determined by the methodology in Table I.
(4) In no instance shall the approved
				Medicaid rate exceed the overall rate limit percent (Column A) in Table II,
				times the average inflated allowable cost of the median patient or resident
				day.
TABLE I
Profit Add-On
The profit add-on is equal to the percent (Column A) of the
				  difference (if greater than zero (0)) between a provider's inflated allowable
				  per patient or resident day cost, and the ceiling (Column B) times the average
				  inflated allowable per patient or resident day cost of the median patient or
				  resident day. Under no circumstances shall a provider's per patient or resident
				  day profit add-on exceed the cap (Column C) times the average inflated
				  allowable per patient or resident day cost of the median patient or resident
				  day.
Level of Care
(A) Percent
(B) Ceiling
(C) Cap
Sheltered living
Intensive training
Child rearing
Nonstate-operated ICF/IID
40%
40%
40%
40%
105%
120%
130%
125%
10%
10%
12%
12%
Developmental training
Child rearing with a specialized program
Small behavior management residences for
								children
Basic developmental
Small extensive medical needs residences for
								adults
Extensive support needs residences for adults
40%
40%
40%
40%
40%
40%
110%
120%
120%
110%
110%
110%
10%
12%
12%
10%
10%
10%
TABLE II
Overall Rate Limit
Level of Care
(A) Percent
Sheltered living
Intensive training
Child rearing
115%
120%
130%
Developmental training
Child rearing with a specialized program
Small behavior management residences for
								children
Basic developmental
120%
120%
120%
120%
Small extensive medical needs residences for
								adults
Extensive support needs residences for
								adults
Nonstate-operated ICF/IID
120%
120%
107%
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 1 - MEDICAID PROVIDERS AND SERVICES › Rule 12 - Rate-Setting Criteria for Nonstate-Owned Intermediate Care Facilities for the Mentally Retarded and Community Residential Facilities for the Developmentally Disabled › Section 12-10 - 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 per
				diem rate shall be an all-inclusive rate. The office shall not set a rate for
				more than one (1) level of care for each CRF/DD provider.
(b) Costs and revenues shall be reported as
				required on the financial report forms. Patient or resident care costs shall be
				clearly identified.
(c) The
				provider shall report as patient or resident care costs only costs that have
				been incurred in the providing of patient or resident care services. The
				provider shall certify on all financial reports that costs not related to
				patient or resident 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 throughout the state. The
				office may request satisfactory documentation from providers whose costs do not
				appear to be accurate and allowable.
(e) Indiana state taxes, including local
				taxes, shall be considered an allowable cost. Federal income taxes are not
				considered allowable costs.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 1 - MEDICAID PROVIDERS AND SERVICES › Rule 12 - Rate-Setting Criteria for Nonstate-Owned Intermediate Care Facilities for the Mentally Retarded and Community Residential Facilities for the Developmentally Disabled › Section 12-11 - Allowable costs; services provided by parties related to provider

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. 11.
(a) Costs
				applicable to services, facilities, and supplies furnished to the provider by
				organizations related to the provider by common ownership or control must be
				included in the allowable cost in the unit of service of the provider at the
				cost to the related organization. However, such cost must not exceed the price
				of comparable services, facilities, or supplies that could be purchased as an
				arm's-length transaction in an open competitive market.
(b) Common ownership exists when an
				individual, individuals, or any legal entity possesses ownership or equity of
				at least five percent (5%) in the provider as well as the institution or
				organization serving the provider. An individual is considered to own the
				interest of immediate family for the determination of percentage of ownership.
				The following persons are considered immediate family:
(1) Husband and wife.
(2) Natural parent, child, and
				sibling.
(3) Adopted child and
				adoptive parent.
(4) Stepparent,
				stepchild, stepsister, and stepbrother.
(5) Father-in-law, mother-in-law,
				sister-in-law, brother-in-law, son-in-law, daughter-in-law, stepson-in-law, and
				stepdaughter-in-law.
(6)
				Grandparent and grandchild.