reglab/statecodes huggingface dataset:
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 XI - Provider Notification › Section 12VAC30-90-210 - Provider notification

Current through Register Vol. 40, No. 24, July 15, 2024
DMAS shall notify providers of State Plan changes
						affecting reimbursement 30 days prior to the enactment of such
						changes.
Statutory Authority
§ 32.1-325 of the Code of Virginia.
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 XII - Start-Up Costs and Organizational Costs › Section 12VAC30-90-220 - Start-up costs

Current through Register Vol. 40, No. 24, July 15, 2024
A. In the period
					 of developing a provider's ability to furnish patient care services, certain
					 costs are incurred. The costs incurred during this time of preparation are
					 referred to as start-up costs. Since these costs are related to patient care
					 services rendered after the time of preparation, they shall be capitalized as
					 deferred charges and amortized over a 60-month time frame.
B. Start-up costs may include, but are not
					 limited to, administrative and nursing salaries; heat, gas, and electricity;
					 taxes, insurance; employee training costs; repairs and maintenance;
					 housekeeping; and any other allowable costs incident to the start-up period.
					 However, any costs that are properly identifiable as operating costs must be
					 appropriately classified as such and excluded from start-up costs.
C. Start-up costs that are incurred
					 immediately before a provider enters the Program and that are determined by the
					 provider, subject to the DMAS approval, to be immaterial need not be
					 capitalized but rather may be charged to operations in the first cost reporting
					 period.
D. Where a provider incurs
					 start-up costs while in the Program and these costs are determined by the
					 provider, subject to the DMAS approval, to be immaterial, these costs shall not
					 be capitalized but shall be charged to operations in the periods
					 incurred.
Statutory Authority
§ 32.1-325 of the Code of Virginia.
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 XII - Start-Up Costs and Organizational Costs › Section 12VAC30-90-221 - Time frames

Current through Register Vol. 40, No. 24, July 15, 2024
A. Start-up
					 costs are incurred from the time preparation begins on a newly constructed or
					 purchased building, wing, floor, unit, or expansion thereof to the time the
					 first patient (whether Medicaid or non-Medicaid) is admitted for treatment, or
					 where the start-up costs apply only to nonrevenue producing patient care
					 functions or nonallowable functions, to the time the areas are used for their
					 intended purposes.
B. If a provider
					 intends to prepare all portions of its entire facility at the same time,
					 start-up costs for all portions of the facility shall be accumulated in a
					 single deferred charge account and shall be amortized when the first patient is
					 admitted for treatment.
C. If a
					 provider intends to prepare portions of its facility on a piecemeal basis
					 (i.e., preparation of a floor or wing of a provider's facility is delayed),
					 start-up costs shall be capitalized and amortized separately for the portion or
					 portions of the provider's facility prepared during different time
					 periods.
D. Moreover, if a provider
					 expands its NF by constructing or purchasing additional buildings or wings,
					 start-up costs shall be capitalized and amortized separately for these
					 areas.
E. Depreciation time frames.
1. Costs of the provider's facility and
					 building equipment shall be depreciated using the straight line method over the
					 lives of these assets starting with the month the first patient is admitted for
					 treatment.
2. Where portions of the
					 provider's NF are prepared for patient care services after the initial start-up
					 period, those asset costs applicable to each portion shall be depreciated over
					 the remaining lives of the applicable assets. If the portion of the NF is a
					 nonrevenue-producing patient care area or nonallowable area, depreciation shall
					 begin when the area is opened for its intended purpose. Costs of major movable
					 equipment, however, shall be depreciated over the useful life of each item
					 starting with the month the item is placed into operation.
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 XII - Start-Up Costs and Organizational Costs › Section 12VAC30-90-222 - Organizational costs

Current through Register Vol. 40, No. 24, July 15, 2024
A.
					 Organizational costs are those costs directly incident to the creation of a
					 corporation or other form of business. These costs are an intangible asset in
					 that they represent expenditures for rights and privileges which have a value
					 to the enterprise. The services inherent in organizational costs extend over
					 more than one accounting period and thus affect the costs of future periods of
					 operations.
B. Allowable
					 organizational costs shall include, but not be limited to, legal fees incurred
					 in establishing the corporation or other organization (such as drafting the
					 corporate charter and by-laws, legal agreements, minutes of organizational
					 meeting, terms of original stock certificates), necessary accounting fees,
					 expenses of temporary directors and organizational meetings of directors and
					 stockholders and fees paid to states for incorporation.
C. The following types of costs shall not be
					 considered allowable organizational costs: costs relating to the issuance and
					 sale of shares of capital stock or other securities, such as underwriters fees
					 and commissions, accountant's or lawyer's fees, cost of qualifying the issues
					 with the appropriate state or federal authorities, stamp taxes, etc.
D. Allowable organization costs shall
					 generally be capitalized by the organization. However, if DMAS concludes that
					 these costs are not material when compared to total allowable costs, they may
					 be included in allowable indirect operating costs for the initial cost
					 reporting period. In all other circumstances, allowable organization costs
					 shall be amortized ratably over a period of 60 months starting with the month
					 the first patient is admitted for treatment.
Statutory Authority
§ 32.1-325 of the Code of Virginia.
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 XII - Start-Up Costs and Organizational Costs › Section 12VAC30-90-223 to 12VAC30-90-229 - Reserved

Current through Register Vol. 40, No. 24, July 15, 2024
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 XIII - DMAS Authorization › Section 12VAC30-90-230 - Access to records

Current through Register Vol. 40, No. 24, July 15, 2024
A. DMAS
					 shall be authorized to request and review, either through a desk or field
					 audit, all information related to the provider's cost report that is necessary
					 to ascertain the propriety and allocation of costs (in accordance with Medicare
					 and Medicaid rules, regulations, and limitations) to patient care and
					 nonpatient care activities.
B.
					 Examples of such information shall include, but not be limited to, all
					 accounting records, mortgages, deeds, contracts, meeting minutes, salary
					 schedules, home office services, cost reports, and financial
					 statements.
C. This access also
					 applies to related organizations as defined in
					 12VAC30-90-51 who provide assets
					 and other goods and services to the provider.
Statutory Authority
§ 32.1-325 of the Code of Virginia.
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 XIV - DMAS Authorization › Section 12VAC30-90-240 - Home office operating costs

Current through Register Vol. 40, No. 24, July 15, 2024
A. Home office operating costs shall be
					 allowable to the extent they are reasonable, relate to patient care, and
					 provide cost savings to the provider.
B. Provider purchases from related
					 organizations, whether for services, or supplies, shall be limited to the lower
					 of the related organizations actual cost or the price of comparable purchases
					 made elsewhere.
C. Home office
					 operating costs shall be allocated in accordance with § 2150.3,
					 PRM-15.
D. Home office costs
					 associated with providing management services to nonrelated entities shall not
					 be recognized as allowable reimbursable cost.
E. Allowable and nonallowable home office
					 costs shall be recognized in accordance with § 2150.2, PRM-15.
F. Item 398 D Chapter 723 of 1987 Acts of
					 Assembly (as amended), effective April 8, 1987, eliminated reimbursement of
					 return on equity capital to proprietary providers for periods or portions
					 thereof on or after July 1, 1987.
Statutory Authority
§ 32.1-325 of the Code of Virginia and Item 319
						  (II) of Chapter 1073 of the 2000 Acts of Assembly.
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 XV - Refund of Overpayments › Section 12VAC30-90-250 - Lump sum payment

Current through Register Vol. 40, No. 24, July 15, 2024
When the provider files a cost report indicating that an
						overpayment has occurred, full refund shall be remitted with the cost report.
						In cases where DMAS discovers an overpayment during desk audit, field audit, or
						final settlement, DMAS shall promptly send the first demand letter requesting a
						lump sum refund.
Statutory Authority §
													32.1-325
						  of the Code of Virginia and Item 319 (II) of Chapter 1073 of the 2000 Acts of
						  Assembly.
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 XV - Refund of Overpayments › Section 12VAC30-90-251 - Offset

Current through Register Vol. 40, No. 24, July 15, 2024
If the provider has been overpaid for a particular
						fiscal year and has been underpaid for another fiscal year, the underpayment
						shall be offset against the overpayment. So long as the provider has an
						overpayment balance, any underpayments discovered by subsequent review or audit
						shall be used to reduce the balance of the overpayment.
Statutory Authority
§ 32.1-325 of the Code of Virginia.
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 XV - Refund of Overpayments › Section 12VAC30-90-252 - Payment schedule

Current through Register Vol. 40, No. 24, July 15, 2024
A. If the
					 provider cannot refund the total amount of the overpayment (i) at the time it
					 files a cost report indicating that an overpayment has occurred, the provider
					 shall request in writing an extended repayment schedule at the time of filing,
					 or (ii) within 30 days after receiving the DMAS demand letter, the provider
					 shall promptly request in writing an extended repayment schedule.
B. DMAS may establish a repayment schedule of
					 up to 12 months to recover all or part of an overpayment or, if a provider
					 demonstrates that repayment within a 12-month period would create severe
					 financial hardship, the Director of DMAS may approve a repayment schedule of up
					 to 36 months.
C. A provider shall
					 have no more than one extended repayment schedule in place at one time. If
					 subsequent audits identify additional overpayment, the full amount shall be
					 repaid within 30 days unless the provider submits further documentation
					 supporting a modification to the existing extended repayment schedule to
					 include the additional amounts.
D.
					 If, during the time an extended repayment schedule is in effect, the provider
					 ceases to be a participating provider or fails to file a cost report in a
					 timely manner, the outstanding balance shall become immediately due and
					 payable.
E. When a repayment
					 schedule is used to recover only part of an overpayment, the remaining amount
					 shall be recovered from interim payments to the provider or by lump sum
					 payments.
Statutory Authority
§ 32.1-325 of the Code of Virginia.
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 XV - Refund of Overpayments › Section 12VAC30-90-253 - Extension request documentation

Current through Register Vol. 40, No. 24, July 15, 2024
In the written request for an extended repayment
						schedule, the provider shall document the need for an extended (beyond 30 days)
						repayment and submit a written proposal scheduling the dates and amounts of
						repayments. The provider must make payments in accordance with the proposed
						schedule while the schedule is pending approval. If DMAS approves the schedule,
						DMAS shall send the provider written notification of the approved repayment
						schedule, which shall be effective retroactive to the date the provider
						submitted the proposal.
Statutory Authority
§ 32.1-325 of the Code of Virginia and Item 319
						  (II) of Chapter 1073 of the 2000 Acts of Assembly.
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 XV - Refund of Overpayments › Section 12VAC30-90-254 - Interest charge on extended repayment

Current through Register Vol. 40, No. 24, July 15, 2024
A. Once an initial determination of
					 overpayment has been made, DMAS shall undertake full recovery of such
					 overpayment whether or not the provider disputes, in whole or in part, the
					 initial determination of overpayment. If an appeal follows, interest shall be
					 waived during the period of administrative appeal of an initial determination
					 of overpayment.
B. Interest charges
					 on the unpaid balance of any overpayment shall accrue pursuant to §
					 32.1-313 of the Code of Virginia from the date the director's determination
					 becomes final.
C. The director's
					 determination shall be deemed to be final on (i) the due date of any cost
					 report filed by the provider indicating that an overpayment has occurred, or
					 (ii) the issue date of any notice of overpayment, issued by DMAS, if the
					 provider does not file an appeal, or (iii) the issue date of any administrative
					 decision issued by DMAS after an informal fact finding conference, if the
					 provider does not file an appeal, or (iv) the issue date of any administrative
					 decision signed by the director, regardless of whether a judicial appeal
					 follows. In any event, interest shall be waived if the overpayment is
					 completely liquidated within 30 days of the date of the final determination. In
					 cases in which a determination of overpayment has been judicially reversed, the
					 provider shall be reimbursed that portion of the payment to which it is
					 entitled, plus any applicable interest which the provider paid to
					 DMAS.
Statutory Authority
§ 32.1-325 of the Code of Virginia.
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 XV - Refund of Overpayments › Section 12VAC30-90-255 to 12VAC30-90-256 - Reserved

Current through Register Vol. 40, No. 24, July 15, 2024
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 XV - Refund of Overpayments › Section 12VAC30-90-257 - Credit balance reporting

Current through Register Vol. 40, No. 24, July 15, 2024
A.
					 Definitions. The following words and terms when used in this regulation shall
					 have the following meanings unless the context clearly indicates otherwise:
"Claim" means a bill consistent with
						12VAC30-20-180 submitted by a
						provider to the department for services furnished to a recipient.
"Credit balance" means an excess or overpayment made to
						a provider by Medicaid as a result of patient billings.
B. Credit balances may occur when a
					 provider's reimbursement for services it provides exceeds the allowable amount
					 or when the reimbursement has been for unallowable costs, resulting in an
					 overpayment. Credit balances also may occur when a provider receives payments
					 from Medicaid or another third party payer for the same services.
C. For a credit balance arising on a Medicaid
					 claim within three years of the date paid by the department, the NF shall
					 submit an adjustment claim. For credit balances arising on claims over three
					 years old, the NF shall submit a check for the balance due and a copy of the
					 original DMAS payment.
D. A
					 periodic audit shall be conducted of an NF's claim adjustments of Medicaid
					 credit balance data. NFs shall maintain an audit trail back to the underlying
					 accounts receivable records supporting each claim adjusted for credit
					 balances.
Statutory Authority: § 32.1-325 of the Code of
						  Virginia; 42 USC § 1396 et seq.
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 XV - Refund of Overpayments › Section 12VAC30-90-258 to 12VAC30-90-259 - Reserved

Current through Register Vol. 40, No. 24, July 15, 2024
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 XVI - Revaluation of Assets [Repealed] › Section 12VAC30-90-260

Current through Register Vol. 40, No. 24, July 15, 2024
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 XVII - Specialized Care Services › Section 12VAC30-90-266 - Traumatic Brain Injury (TBI) payment

Current through Register Vol. 40, No. 24, July 15, 2024
DMAS shall provide a fixed per day payment for nursing
						facility residents with TBI served in the program in accordance with resident
						and provider criteria, in addition to the reimbursement otherwise payable under
						the provisions of the Nursing Home Payment System. Effective for dates of
						service on and after August 19, 1998, a per day rate add-on shall be paid for
						recipients who meet the eligibility criteria for these TBI payments and who are
						residents in a designated nursing facility TBI unit of 20 beds or more that
						meets the provider eligibility criteria. The rate add-on for any qualifying
						provider's fiscal year shall be reviewed annually to determine the
						appropriateness of the amount, not to exceed $50 per patient day, and any
						changes will be published and distributed to the providers. (Refer to
						12VAC30-90-330, Traumatic brain
						injury diagnoses, for related resident and provider
						requirements.)
Statutory Authority
§ 32.1-325 of the Code of Virginia and Item 319
						  (II) of Chapter 1073 of the 2000 Acts of Assembly.
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 XVII - Specialized Care Services › Section 12VAC30-90-267 - Private room differential

Current through Register Vol. 40, No. 24, July 15, 2024
A.
					 Payment shall be made for a private room or other accommodations more expensive
					 than semi-private (two or more bed accommodations) only when such
					 accommodations are medically necessary. Private rooms will be considered
					 necessary when the resident's condition requires the resident to be isolated
					 for his own health or that of others.
B. Physician certification justifying the
					 private room must be on file prior to the resident's discharge from the
					 semi-private room. The term "isolation" applies when treating a number of
					 physical and mental conditions. These conditions include communicable diseases
					 that require isolation of the resident for certain periods. Private room
					 accommodations may also be necessary for residents whose symptoms or treatments
					 are likely to alarm or disturb others in the same room.
C. Reimbursement for private rooms will only
					 be made when authorized by the Virginia Department of Medical Assistance
					 Services.
D. The Medicaid private
					 room differential shall be calculated by applying the percentage difference
					 between the facility's private and semi-private room charges to the total
					 case-mix neutral Medicaid rate for the facility.
Statutory Authority: § 32.1-325 of the Code of
						  Virginia; 42 USC § 1396 et seq.
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 III - Nursing Home Payment System Appendices › Appendix I - Uniform Expense Classification › Section 12VAC30-90-270 - Uniform Expense Classification

Current through Register Vol. 40, No. 24, July 15, 2024
This appendix describes the classification of expenses
						applicable to the Nursing Facility Payment System.
Allowable expenses shall meet all of the following
						requirements: necessity, reasonableness, nonduplication, related to patient
						care, not exceeding the limits and/or ceilings established in the Payment
						System and meet applicable Medicare principles of reimbursement. All of the
						references to
						12VAC30-90-270 occurring in
						previous Part II shall be understood to include
						12VAC30-90-270 through
						12VAC30-90-276.
Statutory Authority
§ 32.1-325 of the Code of Virginia and Item 319
						  (II) of Chapter 1073 of the 2000 Acts of Assembly.
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 III - Nursing Home Payment System Appendices › Appendix I - Uniform Expense Classification › Section 12VAC30-90-271 - Direct patient care operating

Current through Register Vol. 40, No. 24, July 15, 2024
A. Nursing service expenses.
1. Salary -- nursing administration. Gross
					 salary (includes sick pay, holiday pay, vacation pay, staff development pay and
					 overtime pay) of all licensed nurses in supervisory positions defined as
					 follows (Director of Nursing, Assistant Director of Nursing, nursing unit
					 supervisors, patient care coordinators and MDS coordinators).
2. Salaries -- RNs. Gross salary of
					 registered nurses.
3. Salaries --
					 LPNs. Gross salary of licensed practical nurses.
4. Salaries -- Nurse aides. Gross salary of
					 certified nurse aides.
5. Salaries
					 -- Quality assurance nurses. Gross salary of licensed nurses who function as
					 quality assurance coordinators and are responsible for quality assurance
					 activities and programs. Quality assurance activities and programs are
					 concerned with resident care and not with the administrative support that is
					 needed to document the care. If a quality assurance coordinator is employed by
					 the home office and spends a percentage of time at nursing facilities, report
					 directly allocated costs to the nursing facility in this category rather than
					 under the home office operating costs.
6. Nursing employee benefits. Benefits
					 related to registered nurses, licensed practical nurses, certified nurse aides,
					 quality assurance nurses, and nursing administration personnel as defined in
					 subdivision 1 of this subsection. See
					 12VAC30-90-272 B for description
					 of employee benefits.
7. Contract
					 nursing services. Cost of registered nurses, licensed practical nurses,
					 certified nurse aides, and quality assurance nurses on a contract
					 basis.
8. Supplies. Cost of
					 supplies, including nursing and charting forms, medication and treatment
					 records, physician order forms.
9.
					 Professional fees. Medical director and pharmacy consultant fees.
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 III - Nursing Home Payment System Appendices › Appendix I - Uniform Expense Classification › Section 12VAC30-90-273 - Plant costs

Current through Register Vol. 40, No. 24, July 15, 2024
A. Interest.
1. Building interest. Interest paid or
					 accrued on notes, mortgages and other loans, the proceeds of which were used to
					 purchase the nursing facility's real property. (See
					 12VAC30-90-30 for
					 Limitations.)
2. Equipment
					 interest. Interest paid or accrued on notes, chattel mortgages and other loans,
					 the proceeds of which were used to purchase the nursing facility's equipment.
					 (See 12VAC30-90-30 for
					 Limitations.)
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 III - Nursing Home Payment System Appendices › Appendix I - Uniform Expense Classification › Section 12VAC30-90-274 - Nonallowable expenses

Current through Register Vol. 40, No. 24, July 15, 2024
Nonallowable expenses include but are not limited to the
						following:
A. Barber and beautician.
					 Direct and indirect operating and capital costs related to the provision of
					 beauty and barber services to patients.
B. Personal items. Cost of personal items,
					 such as cigarettes, toothpaste, and shaving cream sold to patients.
C. Vending machines. Cost of items sold to
					 employees and patients including candy bars and soft drinks.
D. Television/telephones. Cost of television
					 sets and telephones used in patient rooms.
E. Gift shop. Direct and indirect operating
					 and capital cost related to the provision of operating a gift shop.
F. Insurance -- officers. Cost of life
					 insurance on officers, owners and key employees where the provider is a direct
					 or indirect beneficiary.
G. Income
					 taxes. Taxes on net income levied or expected to be levied by any governmental
					 entity.
H. Contributions. Amounts
					 donated to charitable or other organizations which have no direct effect on
					 patient care.
I. Deductions from
					 revenue. Accounts receivable written off as bad debts, charity, courtesy, or
					 from contractual agreements are nonallowable expenses.
J. Advertising. The cost of advertisements in
					 magazines, newspapers, trade publications, radio, and television and certain
					 home office expenses as defined in PRM-15.
K. Cafeteria. Cost of meals to other than
					 patients.
L. Pharmacy. Cost of all
					 prescribed legend and nonlegend drugs.
M. Medical supplies. Cost of medical supplies
					 to other than patients.
N. Plant
					 costs. All plant costs not available for nursing facility patient care-related
					 activities are nonreimbursable plant costs.
Statutory Authority
§ 32.1-325 of the Code of Virginia and Item
						  322(D)(2a) of Chapter 912 of the 1996 Acts of Assembly.
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 III - Nursing Home Payment System Appendices › Appendix I - Uniform Expense Classification › Section 12VAC30-90-275 - Nurse Aide Training and Competency Evaluation Programs (NATCEPs) costs

Current through Register Vol. 40, No. 24, July 15, 2024
A.
					 Facility-based NATCEPs costs.
1. Salary --
					 staff development. Gross salary of personnel conducting the nurse aide training
					 and competency evaluation programs.
2. Employee benefits. Benefits related to
					 personnel conducting the nurse aide training and competency evaluation
					 programs. See
					 12VAC30-90-272 B for description
					 of employee benefits.
3. Contract
					 services. Cost of state qualified nurse aide instructors paid on a contract
					 basis.
4. Supplies. Cost of
					 supplies used in conducting NATCEPs (e.g., pencils, papers, erasers, staples,
					 textbooks and other required course materials).
5. License fees. Cost of nurse aide registry
					 application fees and competency evaluation testing fees paid by the nursing
					 facilities on behalf of the certified nurse aides.
6. Housekeeping expenses. Housekeeping
					 expense as defined in
					 12VAC30-90-272 D, for nursing
					 facilities which dedicate space in the facility to NATCEPs activities 100%.
					 Housekeeping expenses shall be allocated to the NATCEPs operations in
					 accordance with Medicare Principles of Reimbursement.
7. Maintenance and operation of plant.
					 Maintenance and operation of plant as defined in
					 12VAC30-90-272 F, for nursing
					 facilities which dedicate space in the facility to NATCEPs activities 100%.
Maintenance and operation of plant expense shall be
						allocated to the NATCEPs operations in accordance with Medicare Principles of
						Reimbursement.
8. Other
					 direct expenses. Any other direct costs associated with the operation of the
					 NATCEPs. There shall be no allocation of indirect patient care operating costs
					 as defined in
					 12VAC30-90-272, except
					 housekeeping and maintenance and operation of plant expenses.
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 III - Nursing Home Payment System Appendices › Appendix I - Uniform Expense Classification › Section 12VAC30-90-276 - Criminal records background checks

Current through Register Vol. 40, No. 24, July 15, 2024
Included in the Uniform Expense Classifications is the
						cost of obtaining criminal records checks from the Central Criminal Records
						Exchange for all persons hired for compensated employment after July 1,
						1993.
Statutory Authority
§ 32.1-325 of the Code of Virginia and Item
						  322(D)(2a) of Chapter 912 of the 1996 Acts of Assembly.
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 III - Nursing Home Payment System Appendices › Appendix III - Cost Reimbursement Limitations › Section 12VAC30-90-290 - Cost reimbursement limitations

Current through Register Vol. 40, No. 24, July 15, 2024
A. This appendix outlines operating, NATCEPs
					 and plant cost limitations that are not referenced in previous sections of
					 these regulations. All of the operating cost limitations are further subject to
					 the applicable operating ceilings.
B. Directors' fees.
1. Although Medicaid does not require a board
					 of directors (Medicare requires only an annual stockholders' meeting), the
					 Program will recognize reasonable costs for directors' meetings related to
					 patient care.
2. It is not the
					 intent of DMAS to reimburse a facility for the conduct of business related to
					 owner's investments, nor is it the intent of the Program to recognize such
					 costs in a closely held corporation where one person owns all stock, maintains
					 all control, and approves all decisions.
3. To receive reimbursement for directors'
					 meetings, the written minutes must reflect the name of the facility for which
					 the meeting is called, the content and purpose of the meeting, members in
					 attendance, the time the meeting began and ended, and the date. If multiple
					 facilities are discussed during a meeting, total allowable director fees, as
					 limited herein, shall be pro-rated between such facilities.
4. Bona fide directors may be paid an hourly
					 rate of $125 up to a maximum of four hours per month. These fees include
					 reimbursement for time, travel, and services performed.
5. Compensation to owner/administrators who
					 also serve as directors shall include any director's fees paid, subject to the
					 above referenced limit set forth in these regulations.
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 III - Nursing Home Payment System Appendices › Appendix III - Cost Reimbursement Limitations › Section 12VAC30-90-300 to 12VAC30-90-304

Current through Register Vol. 40, No. 24, July 15, 2024
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 III - Nursing Home Payment System Appendices › Appendix IV - Resource Utilization Groups (RUGs) › Section 12VAC30-90-305 - Resource Utilization Groups (RUGs)

Current through Register Vol. 40, No. 24, July 15, 2024
A. The Resource Utilization Groups-III
					 (RUG-III), Version 5.12, 34-group, index maximizing model shall be used as the
					 resident classification system to determine the RUG-III group for each resident
					 assessment. RUG-III classifies resident assessments according to the intensity
					 of each resident's needs. Data from the minimum data set (MDS) submitted by
					 each facility to the Centers for Medicare and Medicaid Services (CMS) shall be
					 used to classify the resident assessments into RUG-III groups.
B. Definitions. The following words and terms
					 when used in this appendix shall have the following meanings unless the context
					 clearly indicates otherwise.
"Base year" means the calendar year for which the most
						recent reliable nursing facility cost settled cost reports are available in the
						DMAS database as of September 1 of the year prior to the year in which the
						rebased rates will be used. (See also definition of rebasing.)
"Case-mix index (CMI)" means a numeric score that
						identifies the relative resources used by similar residents and represents the
						average resource consumption of those residents.
"Case-mix neutralization" means the process of removing
						cost variations for direct patient care costs associated with different levels
						of resident case mix.
"Day-weighted median" means a weighted median where the
						weight is Medicaid days.
"Medicaid average case-mix index" means a simple average,
						carried to four decimal places, of all resident case mix indices where Medicaid
						is known to be the per diem payor source on the last day of the calendar
						quarter.
"Minimum data set (MDS)" means a federally required
						resident assessment instrument. Information from the MDS is used to determine
						the facility's case-mix index.
"Normalization" means the process by which the average
						case mix for the state is set to 1.0.
"Nursing facility" means a facility, not including
						intermediate care facilities for the mentally retarded, licensed by the
						Department of Health and certified as meeting the participation requirements of
						the Medicaid program.
"Rebasing" means the process of updating cost data used
						to calculate peer group ceilings for subsequent base years.
Statutory Authority
§ 32.1-325 of the Code of Virginia.
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 III - Nursing Home Payment System Appendices › Appendix V - Normalized Case Mix Index › Section 12VAC30-90-310 - Normalized Case Mix Index (NCMI)

Current through Register Vol. 40, No. 24, July 15, 2024
A. This appendix illustrates how a
					 specialized care provider's Normalized Case Mix Index (NCMI) is used to adjust
					 the prospective routine operating cost base rate and prospective operating
					 ceiling.
B. Assumptions.
1. The nursing facility's fiscal years are
					 December 31, 1996, and December 31, 1997.
2. The average allowable routine nursing
					 labor and nonlabor base rate for December 31, 1996, is $205.
3. The average allowable indirect patient
					 care operating base rate for December 31, 1996, is $90.
4. The allowance for inflation is 3.0% for
					 the fiscal year end beginning January 1, 1997.
5. The nursing facility's statewide ceiling
					 for the fiscal year end beginning January 1, 1997, is $300.
6. The nursing facility's normalized HCFA
					 nursing wage index is 1.0941 for the fiscal year end beginning January 1,
					 1997.
7. The nursing facility's
					 semiannual normalized NCMIs are as follows:
1996 First semiannual NCMI
1.2000
1996 Second semiannual NCMI
1.2400
1997 First semiannual NCMI
1.2600
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 III - Nursing Home Payment System Appendices › Appendix VI - National RUG-III Categories and Weights › Section 12VAC30-90-320 - National RUG-III categories and weights

Current through Register Vol. 40, No. 24, July 15, 2024
RUG III Group Name
RUG Group Code
Nursing Only Weight
Rehabilitation
RVC
1.79
RVB
1.18
RVA
0.82
RHD
1.93
RHC
1.50
RHB
1.31
RHA
1.06
RMC
2.09
RMB
1.38
RMA
1.25
RLB
1.36
RLA
1.14
Extensive Services
SE3
3.97
SE2
2.65
SE1
1.78
Special Care
SSC
1.61
SSB
1.47
SSA
1.28
Clinically Complex
CD2
1.46
CD1
1.37
CC2
1.19
CC1
1.16
CB2
1.08
CB1
0.94
CA2
0.76
CA1
0.67
Impaired Cognition
IB2
0.88
IB1
0.80
IA2
0.60
IA1
0.49
Behavior Problems
BB2
0.87
BB1
0.78
BA2
0.58
BA1
0.41
Physical Functions
PE2
1.19
PE1
1.13
PD2
1.01
PD1
1.00
PC2
0.86
PC1
0.77
PB2
0.68
PB1
0.66
PA2
0.52
PA1
0.39
Statutory Authority
§ 32.1-325 of the Code of Virginia and Item
						  322(D)(2a) of Chapter 912 of the 1996 Acts of Assembly.
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 IV - Traumatic Brain Injury Payment System › Section 12VAC30-90-330 - Traumatic brain injury diagnoses

Current through Register Vol. 40, No. 24, July 15, 2024
A. Consistent with the Nursing Home Payment
				  System, DMAS shall provide a fixed per day payment for nursing facility
				  residents with traumatic brain injury diagnoses. The residents and facilities
				  must meet the criteria set out in this section.
B. Resident criteria. To meet the criteria
				  for admission and continued stay for the TBI program, there shall be documented
				  evidence in the resident's medical record of all of the following:
1. The resident shall meet the minimum
				  nursing facility criteria, as well as meet the preadmission screening
				  requirements for nursing facility level of care as specified in
				  12VAC30-60-300, Nursing facility
				  criteria;
2. The resident has a
				  physician's diagnosis of TBI which is also recorded on the Patient Intensity
				  Rating System Review (DMAS-80) form by diagnosis code 85000 (trauma to the
				  brain);
3. Abusive, aggressive, or
				  disruptive behavior has been documented within 30 days prior to admission and
				  also recorded on the Patient Intensity Rating System Review (DMAS-80) form by
				  coding of behavior pattern 3 or 4. Behavior coding on the Patient Intensity
				  Rating System Review form must also be supported by documentation in the
				  medical record;
4. The resident is
				  at least 14 years old; and
5. The
				  resident must be appropriate for nursing facility placement and the facility
				  must be able to safeguard him such that the resident will not be a physical or
				  emotional danger to himself or other residents on the unit.
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 IV - Traumatic Brain Injury Payment System › Section - DOCUMENTS INCORPORATED BY REFERENCE (12VAC30-90)

Current through Register Vol. 40, No. 24, July 15, 2024
R.S. Means Building Construction Cost Data, 59th Annual
					 Edition, 2001.
R.S. Means Square Foot Costs, 22nd Annual Edition,
					 2001.
R.S. Means Repair and Remodeling Cost Data, 22nd Annual
					 Edition, 2001.
Estimated Useful Lives of Depreciable Assets, rev. 1993
					 Edition, American Hospital Association.
Federal Reserve Statistical Release (H. 15), updated
					 daily.
Provider Reimbursement Manual, HCFA-Pub. 15 (PRM-15),
					 Health Care Financing Administration.
Virginia Input Price Indexes, Updated Quarterly.
Nursing Facility Reimbursement Report, MMR-240, updated
					 monthly, Department of Medical Assistance Services.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 95 - STANDARDS ESTABLISHED AND METHODS USED FOR FEE-FOR-SERVICE REIMBURSEMENT › Section 12VAC30-95-5 - Applicability; general definitions

Current through Register Vol. 40, No. 24, July 15, 2024
A.
				The requirements of this chapter shall operate in addition to the provider
				requirements set out in other chapters of the Virginia Administrative Code,
				including but not limited to 12VAC30-50 through 12VAC30-90.
B. The following words and terms when used in
				12VAC30 shall have the following meanings unless the context clearly indicates
				otherwise:
"ASAM" means the American Society of Addiction
				  Medicine.
"ICD" means
(i) for
				claims with dates of service on or prior to September 30, 2015, the
				International Classification of Diseases, 9th Revision, Clinical Modification
				(ICD-9-CM) Volumes 1, 2, and 3, OptumInsight, Inc., and
(ii) for claims with dates of service on or
				after October 1, 2015, the International Classification of Diseases, 10th
				Revision, Clinical Modification (ICD-10-CM) and Procedure Coding System
				(ICD-10-PCS) pursuant to 45
				CFR 162.1002, OptumInsight, Inc.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 95 - STANDARDS ESTABLISHED AND METHODS USED FOR FEE-FOR-SERVICE REIMBURSEMENT › Section 12VAC30-95-10 - Timely claims filing

Current through Register Vol. 40, No. 24, July 15, 2024
A.
				Definitions. The following words and terms as used in this section shall have
				the following meanings unless the context clearly indicates otherwise.
"Claim" means the term as defined in
				  42 CFR
				  447.45 and includes a bill or a line item for
				  services, drugs, or devices.
"Submit" or "file" means actual, physical receipt by the
				  Department of Medical Assistance Services (DMAS) that is documented in DMAS
				  records.
B. Consistent with
				42 CFR
				447.45, providers shall submit all claims to
				DMAS no later than 12 months from the date of service for which the provider
				requests reimbursement. In the absence of the two exception conditions set out
				in subsection E of this section, all claims otherwise submitted to DMAS after
				this 12-month time limit shall be denied.
C. In cases where the actual receipt of a
				claim by DMAS is undocumented, the burden of proof shall be on the provider to
				show that the claim was actually, physically received by DMAS. Proof by the
				provider that a claim was mailed, transmitted, or conveyed to DMAS by any
				method shall not constitute proof of receipt. The provider shall confirm actual
				receipt of a claim by DMAS within 12 months from the date of the service
				reflected on a claim.
D. If a claim
				for payment under Medicare has been filed in a timely manner, DMAS may pay a
				Medicaid claim for the same service within six months after the provider
				receives notice of the disposition of the Medicare claim.
E. Exceptions.
1. For cases in which a provider's claim was
				retracted by the third party payer, DMAS shall consider the date of the
				retraction notice by the third party payer as the begin date of the initial
				12-month timely filing period.
2.
				For cases of retroactive Medicaid eligibility, DMAS shall consider the date of
				the notification of delayed eligibility from the local department of social
				services as the begin date of the initial 12-month timely filing
				period.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 100 - STATE PROGRAMS › Part II - State/Local Hospitalization Program › Section 12VAC30-100-80 - Program established

Current through Register Vol. 40, No. 24, July 15, 2024
The State/Local Hospitalization Program is hereby
					 established, within the Department of Medical Assistance Services (DMAS), for
					 indigent persons. The director of the department shall administer this program
					 and expend state and local funds in accordance with the provisions of Chapter
					 12 (§ 32.1-343 et seq.) of Title 32.1 of the Code of
					 Virginia.
Statutory Authority
§§ 32.1-344 and 32.1-346 of the Code of
						Virginia.
Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 100 - STATE PROGRAMS › Part II - State/Local Hospitalization Program › Section 12VAC30-100-90 - Allocation of funds

Current through Register Vol. 40, No. 24, July 15, 2024
From the appropriation made by the General Assembly each
					 state fiscal year, the director shall allocate funds to each locality in
					 accordance with provisions of § 32.1-345 of the Code of Virginia. These
					 allocations will be used for the sole purpose of processing payable claims for
					 that SLH payment year.
Statutory Authority
§§ 32.1-344 and 32.1-346 of the Code of
						Virginia.