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 I - Methods and Standards for Establishing Payment Rates for Long-Term Care › Section 12VAC30-90-10 - Methods and standards for establishing payment rates for long-term care

Current through Register Vol. 40, No. 24, July 15, 2024
The policy and the method to be used in establishing
					 payment rates for nursing facilities listed in § 1905(a) of the Social
					 Security Act and included in this State Plan for Medical Assistance are
					 described in the following paragraphs.
1. Reimbursement and payment criteria will be
				  established which are designed to enlist participation of a sufficient number
				  of providers of services in the Program so that eligible persons can receive
				  the medical care and services included in the Plan to the extent these are
				  available to the general population.
2. Participation in the Program will be
				  limited to providers of services who accept, as payment in full, the amounts so
				  paid.
3. Payment for care of
				  service will not exceed the amounts indicated to be reimbursed in accord with
				  the policy and the methods described in the Plan and payments will not be made
				  in excess of the upper limits described in
				  42 CFR
				  447.253(b)(2).
4. Payments for services to nonstate-owned
				  nursing facilities shall be based on methodologies set out in 12VAC30-90-44 of
				  the Nursing Home Payment System (Part II (12VAC30-90-19 et seq.) of this
				  chapter for nursing facilities and in Subpart XVII (12VAC30-90-264 et seq.) of the
				  Nursing Home Payment System for specialized care facilities.
5. Facilities operated by the Department of
				  Behavioral Health and Developmental Services and facilities operated by the
				  Department of Veterans Services shall be reimbursed retrospectively based on
				  cost.
6. Reimbursement to
				  Intermediate Care Facilities for Individuals with Intellectual Disabilities
				  (ICF/IID) shall be retrospective on the basis of reasonable costs in accordance
				  with Medicare principles of reimbursement. Nonstate facilities shall be limited
				  to a ceiling based on the highest as filed rate paid to an ICF/IID institution
				  in state fiscal year 2012 and annually adjusted thereafter with the application
				  of the NF inflation factor, as set out in
				  12VAC30-90-41 B.
7. Except as specifically modified in this
				  section, Medicare principles of reimbursement, as amended from time to time,
				  shall be used to establish the allowable costs in the rate methodologies.
				  Allowable costs shall be classified in accordance with the DMAS uniform chart
				  of accounts (see
				  12VAC30-90-270 through
				  12VAC30-90-276 ) and shall be
				  identifiable and verifiable by contemporaneous documentation. All matters of
				  reimbursement that are part of the DMAS reimbursement system shall supersede
				  Medicare principles of reimbursement. Wherever the DMAS reimbursement system
				  conflicts with Medicare principles of reimbursement, the DMAS reimbursement
				  system shall take precedence.
8.
				  All nursing facilities and intermediate care facilities shall submit cost
				  reports on the basis of reasonable cost in accordance with the standards and
				  principles set forth in 42
				  CFR 447.252 as follows:
a. A uniform annual cost report which
				  itemizes allowable cost will be required to be filed within 150 days of each
				  provider's fiscal year end.
b. The
				  determination of allowable costs will be in accordance with Medicare principles
				  as established in the Provider Reimbursement Manual (PRM-15) except where
				  otherwise noted in this Plan.
c.
				  Field audits will be conducted on the cost data submitted by the provider to
				  verify the accuracy and reasonableness of such data. Audits will be conducted
				  for each facility on a periodic basis as determined from internal desk audits
				  and more often as required. Audit procedures are in conformance with SSA
				  standards set forth in PRM-13-2. Internal desk audits are conducted annually
				  within six months of receipt of a completed cost report from the
				  provider.
d. Reports of field
				  audits are retained by the state agency for at least three years following
				  submission of the report.
e.
				  Modifications to the Plan for reimbursement will be submitted as Plan
				  amendments.
f. Covered cost will
				  include such items as:
(1) Cost of meeting
				  certification standards.
(2)
				  Routine services, which include items expense providers normally incur in the
				  provision of services.
(3) The cost
				  of such services provided by related organizations except as modified in the
				  payment system at Subpart 2 (12VAC30-90-29 et
				  seq.) of this chapter.
g. Bad debts, charity and courtesy allowances
				  shall be excluded from allowable cost.
h. Payments will be made to facilities no
				  less than monthly based on claims submitted by the facility.
i. Payments shall be adequate to reimburse in
				  full such actual allowable costs that an economically and efficiently operated
				  facility must incur.
j. In
				  accordance with 42 CFR
				  447.205, an opportunity for public comment
				  was permitted before final implementation of rate setting processes.
k. Return on equity capital to proprietary
				  providers shall not be an allowable expense.