Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 90 - METHODS AND STANDARDS FOR ESTABLISHING PAYMENT RATES FOR LONG-TERM CARE › Part II - Nursing Home Payment System › Subpart II - Rate Determination Procedures › Article 4 - Operating Cost Component › Section 12VAC30-90-41 - Nursing facility reimbursement formula

Current through Register Vol. 40, No. 24, July 15, 2024
A. Effective on and after July 1, 2002, all
						NFs subject to the prospective payment system shall be reimbursed under "The
						Resource Utilization Group-III (RUG-III) System as defined in Appendix IV
						(12VAC30-90-305 through
						12VAC30-90-307 )." RUG-III is a
						resident classification system that groups NF residents according to resource
						utilization. Case-mix indices (CMIs) are assigned to RUG-III groups and are
						used to adjust the NF's per diem rates to reflect the intensity of services
						required by a NF's resident mix. See
						12VAC30-90-305 through
						12VAC30-90-307 for details on the
						Resource Utilization Groups.
1. Any NF
						receiving Medicaid payments on or after October 1, 1990, shall satisfy all the
						requirements of § 1919(b) through (d) of the Social Security Act as they
						relate to provision of services, residents' rights and administration and other
						matters.
2. Direct and indirect
						group ceilings and rates.
a. Direct patient
						care operating cost peer groups shall be established for the Virginia portion
						of the Washington DC-MD-VA MSA, the Richmond-Petersburg MSA, and the rest of
						the state. Direct patient care operating costs shall be as defined in
						12VAC30-90-271.
b. Indirect patient care operating cost peer
						groups shall be established for the Virginia portion of the Washington DC-MD-VA
						MSA, for the rest of the state for facilities with less than 61 licensed beds,
						and for the rest of the state for facilities with more than 60 licensed
						beds.
3. Each facility's
						average case-mix index shall be calculated based upon data reported by that
						nursing facility to the Centers for Medicare and Medicaid Services (CMS)
						Minimum Data Set (MDS) System. See
						12VAC30-90-306 for the case-mix
						index calculations.
4. The
						normalized facility average Medicaid CMI shall be used to calculate the direct
						patient care operating cost prospective ceilings and direct patient care
						operating cost prospective rates for each semiannual period of a NFs subsequent
						fiscal year. See
						12VAC30-90-306 D 2 for the
						calculation of the normalized facility average Medicaid CMI.
a. A NF's direct patient care operating cost
						prospective ceiling shall be the product of the NF's peer group direct patient
						care ceiling and the NF's normalized facility average Medicaid CMI. A NF's
						direct patient care operating cost prospective ceiling will be calculated
						semiannually.
b. A CMI rate
						adjustment for each semiannual period of a nursing facility's prospective
						fiscal year shall be applied by multiplying the nursing facility's normalized
						facility average Medicaid CMI applicable to each prospective semiannual period
						by the nursing facility's case-mix neutralized direct patient care operating
						cost base rate for the preceding cost reporting period (see
						12VAC30-90-307 ).
c. See
						12VAC30-90-307 for the
						applicability of case-mix indices.
5. Direct and indirect ceiling calculations.
a. Effective for services on and after July
						1, 2006, the direct patient care operating ceiling shall be set at 117% of the
						respective peer group day-weighted median of the facilities' case-mix
						neutralized direct care operating costs per day. The calculation of the medians
						shall be based on cost reports from freestanding nursing homes for provider
						fiscal years ending in the most recent base year. The medians used to set the
						peer group direct patient care operating ceilings shall be revised and case-mix
						neutralized every two years using the most recent reliable calendar year cost
						settled cost reports for freestanding nursing facilities that have been
						completed as of September 1.
b. The
						indirect patient care operating ceiling shall be set at 107% of the respective
						peer group day-weighted median of the facility's specific indirect operating
						cost per day. The calculation of the peer group medians shall be based on cost
						reports from freestanding nursing homes for provider fiscal years ending in the
						most recent base year. The medians used to set the peer group indirect
						operating ceilings shall be revised every two years using the most recent
						reliable calendar year cost settled cost reports for freestanding nursing
						facilities that have been completed as of September 1.
6. Reimbursement for use of specialized
						treatment beds. Effective for services on and after July 1, 2005, nursing
						facilities shall be reimbursed an additional $10 per day for those recipients
						who require a specialized treatment bed due to their having at least one Stage
						IV pressure ulcer. Recipients must meet criteria as outlined in
						12VAC30-60-350, and the additional
						reimbursement must be preauthorized as provided in
						12VAC30-60-40. Nursing facilities
						shall not be eligible to receive this reimbursement for individuals whose
						services are reimbursed under the specialized care methodology. Beginning July
						1, 2005, this additional reimbursement shall be subject to adjustment for
						inflation in accordance with
						12VAC30-90-41 B, except that the
						adjustment shall be made at the beginning of each state fiscal year, using the
						inflation factor that applies to provider years beginning at that time. This
						additional payment shall not be subject to direct or indirect ceilings and
						shall not be adjusted at year-end settlement.