Haw. Code R. § 17-1739.2-3 - Reimbursement principles
(a) Except as noted
herein, the Hawaii medical assistance program shall reimburse providers based
on the number of days of care that the provider delivers to the resident, the
acuity level that is medically necessary for each day of care, and the
provider's PPS rate. The provider shall receive payment at the level A rate for
residents who require care at acuity level A, at the level B rate for residents
who require care at acuity level B, at the level C rate for residents who
require care at acuity level C, and at level D rate for residents who require
care at the acuity level D. Any payments made by residents or other third
parties on behalf of residents shall be deducted from the reimbursement paid to
providers.
(b) Except as noted
herein, the Medicaid program shall pay for institutional long-term care
services through the use of a facility-specific prospective per diem
rate.
(c) The basic PPS rate shall
be developed based on each provider's historical costs (as reflected in its
base year cost report) and allocated to three components, which are subject to
component cost ceilings.
(d) A
proprietary provider shall receive the GET and ROE adjustments to its basic PPS
rate to account for gross excise taxes and return on equity.
(e) Rates for acute facilities with federally
designated swing beds shall be established according to
42 C.F.R.
§447.280.
(f) Changes in ownership, management,
control, operation, and leasehold interests which result in increased costs for
the successor owner, management, or leaseholder shall be recognized for
reimbursement purposes only to the following extent: Pursuant to the provisions
of Pub. L. No. 99-272, section 9509 (a)(4)(C), the valuation of capital assets
shall not be increased (as measured from the date of acquisition by the seller
to the date of the change of ownership), solely as a result of a change of
ownership, by more than the lesser of:
(1)
One-half of the percentage increase (as measured over the same period of time,
or, if necessary, as extrapolated retrospectively by the Secretary) in the
Dodge Construction Systems Costs for Nursing Homes, applied in the aggregate
with respect to those facilities which have undergone a change of ownership
during the fiscal year; or
(2)
One-half of the percentage increase (as measured over the same period of time)
in the Consumer Price Index for all urban consumers (United States city
average).
(g) The
department shall pay the providers separately for ancillary services based on a
fee schedule or through an ancillaries payment.
(h) Nursing facilities that have G&A or
capital costs below the median for their peer group are rewarded with an
incentive payment. A formula to determine the G&A incentive adjustment is
defined in section 17-1739.2-1.
(i)
The department may contract with providers to provide acuity level D care to
selected residents.
(j) The
department shall reimburse level A and level C services of a Medicare and
Medicaid certified CAH on a reasonable cost basis following Medicare principles
of reimbursement. Reimbursement for level A and level C routine services
provided in a long term care distinct part by a CAH will be actual costs up to
two hundred per cent of each provider's Medicaid routine cost limit. However,
for CAH providers whose routine costs exceed the routine cost limit,
reimbursement of costs will be limited to two hundred per cent of each
provider's routine cost limit, and only when a routine cost limit exception
request has been filed and only up to the amounts approved by the
State.
(k) Members of the public
may obtain the data and methodology used in establishing payment rates for
providers by following the procedures defined in the Uniform Information
Practices Act, chapter 92F, HRS.
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