Missouri Code of State Regulations › Title 13 - DEPARTMENT OF SOCIAL SERVICES › Division 70 - MO HealthNet Division › Chapter 10 - Nursing Home Program › Section 13 CSR 70-10.015 - Scope and Definitions

Current through Register Vol. 49, No. 14, July 15, 2024
PURPOSE: This amendment removes or replaces obsolete
				  processes, language, and terms; clarifies regulation language; revises the
				  definition of audits; allows an extension for cost report filings for good
				  cause shown; amends when cost reports are required for terminating providers or
				  changes in providers; amends when payments will be withheld for late cost
				  report submissions and terminating providers; establishes a required prior
				  authorization process for any out-of-state nursing facility to be reimbursed
				  for nursing facility services; and revises the methodology for determining
				  prospective rates.
PURPOSE: This rule establishes a reimbursement plan
				  for nursing facility services required by the Code of Federal Regulations. The
				  plan describes principles to be followed by Title XIX nursing facility
				  providers in making financial reports and presents the necessary procedures for
				  setting rates, making adjustments, and auditing the cost
				  reports.
PUBLISHER'S NOTE: The secretary of state has
				  determined that the publication of the entire text of the material which is
				  incorporated by reference as a portion of this rule would be unduly cumbersome
				  or expensive. This material as incorporated by reference in this rule shall be
				  maintained by the agency at its headquarters and shall be made available to the
				  public for inspection and copying at no more than the actual cost of
				  reproduction. This note applies only to the reference material. The entire text
				  of the rule is printed here.
(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. 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 January 1, 1995.
(C) The effective date of this regulation
				shall be January 1, 1995.
(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) and (M)
				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.
				1396 r ), 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.
				1396 r ). 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 division. Facilities previously certified shall retain the same provider
				number regardless of any change in ownership.
(I) Regardless of changes in control or
				ownership for any facility certified for participation in the Medicaid Program,
				the division shall issue payments to the facility identified in the current
				Medicaid participation agreement. Regardless of changes in control or ownership
				for any facility certified for participation in Medicaid, the division shall
				recover from that entity liabilities, sanctions, and penalties pertaining to
				the Medicaid Program, regardless of when the services were rendered.
(J) Changes in ownership, management,
				control, operation, leasehold interest by whatever form for any facility
				previously certified for participation in the Medicaid Program at any time that
				results in increased capital 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 regulation, 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 facility's
				fiscal year or the end of the cost report period, if different. 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)
				Rebasing.
1. The division based on its
				discretion shall pick at least one (1) cost report year from cost reports with
				fiscal years ending in 2001 or later to compare the allowable costs from the
				selected desk audited and/or field audited cost report year to the
				reimbursement rate in effect at the time of the comparison. The rebased rates
				shall be determined in accordance with section(s) (20)-(21), as
				applicable.
2. The asset value will
				be adjusted annually based on the R. S. Means Construction Index. The asset
				value as adjusted will be used only for determining reimbursement in section
				(11) for the year(s) selected above for rebasing and as determined in
				paragraphs (13)(B)6. and (13)(B)7.
(T) Effective for dates of service beginning
				April 1, 2010, 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.