Code of Vermont Rules › Agency 13 - AGENCY OF HUMAN SERVICES › Sub-Agency 010 - DIVISION OF RATE SETTING › Chapter 001 - METHODS, STANDARDS AND PRINCIPLES FOR ESTABLISHING MEDICAID PAYMENT RATES FOR LONG-TERM CARE FACILITIES › Section 13 010 001 - METHODS, STANDARDS AND PRINCIPLES FOR ESTABLISHING MEDICAID PAYMENT RATES FOR LONG-TERM CARE FACILITIES

Current through June, 2024
Part 1 GENERAL
				PROVISIONS
Section 1.1 Purpose
The purpose of these rules is to implement state and federal
				  reimbursement policy with respect to nursing facilities providing services to
				  Medicaid eligible persons. The methods, standards, and principles of rate
				  setting established herein reflect the objectives set out in
				  33 V.S.A. §
												901 and balance the competing policy
				  objectives of access, quality, cost containment and administrative feasibility.
				  Rates set under this payment system are consistent with the efficiency,
				  economy, and quality of care necessary to provide services in conformity with
				  state and federal laws, regulations, quality and safety standards, and meet the
				  requirements of
				  42 U.S.C.
				  §1396 a (a)(13)(A).
Section 1.2 Scope
These rules apply to all privately owned nursing facilities
				  and state nursing facilities providing services to Medicaid residents.
				  Long-term care services in swing-bed hospitals, and Intermediate Care
				  Facilities for the Mentally Retarded are reimbursed under different methods and
				  standards. Swing-bed hospitals are reimbursed pursuant to
				  42
				  U.S.C. §13961(b)(1).
				  Intermediate Care Facilities for the Mentally Retarded are reimbursed pursuant
				  to the Regulations Governing the Operation of Intermediate Care Facilities for
				  the Mentally Retarded adopted by the Agency and are subject to the Division's
				  Accounting Requirements ( Section
				  2
				  ) and Financial Reporting ( Section
				  3
				  ).
Section 1.3 Authority
These rules are promulgated pursuant to
				  33 V.S.A. §§
												904(a) and
				  908(c)
				  to meet the requirements of 33 V.S.A. Chapter 9,
				  42 U.S.C.
				  §§1396 a(a)(13)(A) and §
				  1396a(a)(30).
Section 1.4
				General Description of the Rate Setting System
A prospective case-mix payment system for nursing facilities
				  is established by these rules in which the payment rate for services is set in
				  advance of the actual provision of those services. A per diem rate is set for
				  each facility based on the historic allowable costs of that facility. The costs
				  are divided into certain designated cost categories, some of which are subject
				  to limits. The basis for reimbursement within the Nursing Care cost category is
				  a resident classification system that groups residents into classes according
				  to their assessed conditions and the resources required to care for them. The
				  costs in some categories are adjusted to reflect economic trends and
				  conditions, and the payment rate for each facility is based on the per diem
				  costs for each category.
Section
				1.5 Requirements for Participation in Medicaid Program
(a) Nursing facilities must satisfy all of
				the following prerequisites in order to participate in the Medicaid program:
(1) be licensed by the Agency, pursuant to
				33 V.S.A. §
													7103(b),
(2) be certified by the Secretary of Health
				and Human Services pursuant to 42 C.F.R. Part 442, Subpart C, and
(3) have executed a Provider Agreement with
				the Agency, as required by 42 C.F.R. Part 442, Subpart B.
(b) To the extent economically and
				operationally feasible, providers are encouraged, but not required, to be
				certified for participation in the Medicare program, pursuant to
				42
				C.F.R. §488.3.
(c) Medicaid payments shall not be made to
				any facility that fails to meet all the requirements of Subsection
				1.5(a).
Section 1.6
				Responsibilities of Owners
The owner of a nursing facility shall prudently manage and
				  operate a residential health care program of adequate quality to meet its
				  residents' needs. Neither the issuance of a per diem rate, nor final orders
				  made by the Director or a duly authorized representative shall in any way
				  relieve the owner of a nursing facility from full responsibility for compliance
				  with the requirements and standards of the Agency of Human Services.
Section 1.7 Duties of the Owner
The owner of a nursing facility, or a duly authorized
				  representative shall:
(a) Comply with
				the provisions of Sub sections 1.5 and 1.6 setting forth the requirements for
				participation in the Medicaid Program.
(b) Submit cost reports in accordance with
				the provisions of sub sections 3.2 and 3.3 of these rules.
(c) Maintain adequate financial and
				statistical records and make them available at reasonable times for inspection
				by an authorized representative of the Division, the state, or the federal
				government.
(d) Assure that an
				annual audit is performed in conformance with Generally Accepted Auditing
				Standards (GAAS).
(e) Assure that
				the construction of buildings and the maintenance and operation of premises and
				programs comply with all applicable health and safety standards.
(f) Notwithstanding any other provision of
				these rules, any provider that fails to make a complete cost report filing
				within the time prescribed in subsection 3.3(a) or fails to file any other
				materials requested by the Division within the time prescribed shall receive no
				increase to its Medicaid rate until the first day of the calendar quarter after
				a complete cost report or the requested materials are filed, unless within an
				extension of time previously approved by the Division.
Section 1.8 Powers and Duties of the Division
				and the Director
(a) The Division shall
				establish and certify to the Department of Vermont Health Access per diem rates
				for payment to providers of nursing facility services on behalf of residents
				eligible for assistance under Title XIX of the Social Security Act.
(b) The Division may request any nursing
				facility or related party or organization to file such relevant and appropriate
				data, statistics, schedules or information as the Division finds necessary to
				enable it to carry out its function.
(c) The Division may examine books and
				accounts of any nursing facility and related parties or organizations, subpoena
				witnesses and documents, administer oaths to witnesses and examine them on all
				matters over which the Division has jurisdiction.
(d) From time to time, the Director may issue
				notices of practices and procedures employed by the Division in carrying out
				its functions under these rules.
(e) The Director shall prescribe the forms
				required by these rules and instructions for their completion.
(f) Copies of each notice of practice and
				procedure, form, or set of instructions shall be sent to each nursing facility
				participating in the Medicaid program at the time it is issued. A compilation
				of all such documents currently in force shall be maintained at the Division,
				pursuant to
				3 V.S.A. §
												835, and shall be available to the
				public.
(g) Neither the issuance of
				final per diem rates nor Final Orders of the Division which fail, in any one or
				more instances, to enforce the performance of any of the terms or conditions of
				these rules shall be construed as a waiver of the Division's future performance
				of the right. The obligations of the provider with respect to performance shall
				continue, and the Division shall not be estopped from requiring such future
				performance.
Section 1.9
				Powers and Duties of the Department of Disabilities, Aging and Independent
				Living's Division of Licensing and Protection as Regards Reimbursement
(a) The Division of Licensing and Protection
				of the Department of Disabilities, Aging and Independent Living shall receive
				from providers resident assessments on forms it specifies. The Department of
				Disabilities, Aging and Independent Living shall process this information and
				shall periodically, but no less frequently than quarterly, provide the Division
				of Rate Setting with the average case-mix scores of each facility based upon
				the federal RUG IV classification system (48 group version). This score will be
				used in the quarterly determination of the Nursing Care portion of the
				rate.
(b) The management of the
				resident assessment process used in the determination of case-mix scores shall
				be the duty of the Division of Licensing and Protection of the Department of
				Disabilities, Aging and Independent Living. Any disagreements between the
				facility's assessment of a resident and the assessment of that same resident by
				the audit staff of Licensing and Protection shall be resolved with the Division
				of Licensing and Protection and shall not involve the Division of Rate Setting.
				As the final rates are prospective and adjusted on a quarterly basis to reflect
				the most current data, the Division of Rate Setting will not make retroactive
				rate adjustments as a result of audits or successfully appealed individual
				case-mix scores.
Section
				1.10 Computation of and Enlargement of Time; Filing and Service of
				Documents
(a) In computing any period of time
				prescribed or allowed by these rules, the day of the act or event from which
				the designated period of time begins to run shall not be included. The last day
				of the period so computed shall be included, unless it is a Saturday, a Sunday,
				or a state or federal legal holiday, in which event the period runs until the
				end of the next day which is not a Saturday, a Sunday, or a state or federal
				legal holiday.
(b) For the purposes
				of any provision of these rules in which time is computed from the receipt of a
				notice or other document issued by the Division or other relevant
				administrative officer, the addressee of the notice shall be rebuttably
				presumed to have received the notice or other document three days after the
				date on the document.
(c) When by
				these rules or by a notice given thereunder, an act is required or allowed to
				be done at or within a specified time, the relevant administrative officer, for
				just cause shown, may at any time in her or his discretion, with or without
				motion or notice, order the period enlarged. This subsection shall not apply to
				the time limits for appeals to the Vermont Supreme Court or Superior Court from
				Final Orders of the Division or Final Determinations of the Secretary, which
				are governed by the Vermont Rules of Appellate Procedure and the Vermont Rules
				of Civil Procedure respectively.
(d) Filing shall be deemed to have occurred
				when a document is received and date-stamped as received at the office of the
				Division or in the case of a document directed to be filed under this rule
				other than at the office of the Division, when it is received and stamped as
				received at the appropriate office. Filings with the Division may be made by
				telefacsimile (FAX), but the sender bears the risk of a communications failure
				from any cause. Filings with the Division may also be made electronically, but
				the sender bears the risk of a communications failure from any cause,
				including, but not limited to, filings blocked due to size.
(e) Service of any document required to be
				served by this rule shall be made by delivering a copy of the document to the
				person or entity required to be served or to his or her representative or by
				sending a copy by prepaid first class mail to the official service address.
				Service by mail is complete upon mailing.
Section 1.11 Representation in All Matters
				before the Division
(a) A facility may be
				represented in any matter under this rule by the owner (in the case of a
				corporation, partnership, trust, or other entity created by law, through a duly
				authorized agent), the nursing facility administrator, or by a licensed
				attorney or an independent public accountant.
(b) The provider shall file written
				notification of the name and address of its representative for each matter
				before the Division. Thereafter, on that matter, all correspondence from the
				Division will be addressed to that representative. The representative of a
				provider failing to so file shall not be entitled to notice or service of any
				document in connection with such matter, whether required to be made by the
				Division or any other person, but instead service shall be made directly on the
				provider.
Section 1.12
				Severability
If any part of these rules or their application is held
				  invalid, the invalidity does not affect other provisions or applications which
				  can be given effect without the invalid provision or application, and to this
				  end the provisions of these rules are severable.
Section 1.13 Effective Date
(a) These rules are effective from January
				29, 1992, (as amended June 18, 1993, July 1, 1994, January 4, 1995, January 1,
				1996, January 1, 1997, July 1, 1998, May 1, 1999, July 1, 1999, August 1, 1999,
				July 1, 2001, November 1, 2002, May 1, 2004, July 1, 2004, July 1, 2005,
				October 29, 2007, August 25, 2008, April 1, 2011, September 17, 2012, September
				9, 2013, and March 6, 2015).
(b)
				Application of Rule: Amended provisions of this rule shall apply to:
(1) all cost reports draft findings issued on
				or after the effective date of the most recent amendment, and
(2) all rates set on or after the effective
				date of the most recent amendment.
(c) With respect to any administrative
				proceeding pending on the effective date of the most recent amendment the
				Director or the Secretary may apply any provision of such prior rules where the
				failure to do so would work an injustice or substantial
				inconvenience.