Missouri Code of State Regulations › Title 13 - DEPARTMENT OF SOCIAL SERVICES › Division 70 - MO HealthNet Division › Chapter 10 - Nursing Home Program › Section 13 CSR 70-10.010 - Prospective Reimbursement Plan for Long-Term Care

Current through Register Vol. 49, No. 14, July 15, 2024
PURPOSE: This rule establishes a payment plan for
				  long-term care required by the
Code of Federal Regulations
. The
				  plan describes principles to be followed by Title XIX long-term care providers
				  in making financial reports and presents the necessary procedures for setting
				  rates, making adjustments and auditing the cost reports.
(1) Authority. This rule is established
				pursuant to the authorization granted to the Department of Social Services,
				Division of Medical Services to promulgate rules.
(2) Purpose. This rule establishes a
				methodology for determination of prospective per-diem rates for long-term care
				(LTC) facilities.
(3) General
				Principles.
(A) Provisions of this
				reimbursement plan shall apply only to facilities certified for participation
				in the Missouri Medical Assistance (Medicaid) program.
(B) The per-diem rates determined by this
				rule shall apply only to services provided on and after July 1, 1990.
(C) The effective date of this rule shall be
				July 1, 1990.
(D) The Medicaid
				program shall provide reimbursement for LTC services based solely on the
				individual Medicaid-eligible recipient's covered days of care (within benefit
				limitations) multiplied by the facility's Medicaid per-diem rate. No payments
				may be collected or retained in addition to the Medicaid per-diem rate for
				covered services. Where third-party payment is involved, Medicaid will be the
				payor of last resort with the exception of state programs such as Vocational
				Rehabilitation and the Missouri Crippled Children's Services.
(E) The Medicaid per-diem rate shall be the
				lower of-
1. The Medicare (Title XVIII)
				per-diem rate, if applicable;
2.
				The per-diem rate as determined in accordance with section (11); or
3. The LTC ceiling (LTCC). The LTCC in effect
				on July 1, 1990, shall be a per-diem rate of fifty-four dollars and ninety-five
				cents ($54.95). The LTCC will be increased by the amounts prescribed in
				paragraph (12)(A)1. effective for the dates of services and purposes specified
				in paragraph (12)(A)1.
(F) Medicaid reimbursements shall not be paid
				for services provided to Medicaid-eligible recipients during any time period in
				which the facility failed to have a Medicaid participation agreement in effect.
				A per-diem reimbursement rate may not be established for a facility if a
				Medicaid participation agreement is not in effect.
(G) 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 Division of Medical Services. Facilities previously certified shall retain
				the same provider number regardless of any change in ownership.
(H) Regardless of changes in ownership for
				any facility certified for participation in the Medicaid program, the division
				will issue allowable reimbursements to the facility identified in the current
				Medicaid participation agreement and will recover from that entity liabilities,
				sanctions and penalties pertaining to the Medicaid program.
(I) A facility with certified and
				noncertified beds shall allocate allowable costs related to the provisions of
				LTC services in an equitable manner. The methods for allocation must be
				supported by adequate accounting, statistical data, or both, necessary to
				evaluate the allocation method and its application.
(J) Any facility which is terminated from
				participation in the Medicare program also shall be terminated from
				participation in the state's Medicaid program on the same date as the Medicare
				determination.
(K) No restrictions
				nor limitations shall be placed on a recipient's right to select providers of
				his/her own choice.
(L) The average
				Medicaid rate paid shall not exceed the average private pay rate for the same
				period covered by the facility's Medicaid cost report. Any amount in excess
				will be subject to repayment, recoupment, or both.