With the exception of hospital-based nursing facilities that
are Medicare-certified and provide only the skilled level of care, herein
referred to as Medicare-certified hospital-based nursing facilities, all
facilities in Iowa wishing to participate in the program shall submit a
Financial and Statistical Report to the department. All Medicare-certified
hospital-based nursing facilities must submit a copy of their Medicare cost
report. These reports shall be based on the following rules.
(1)
Failure to maintain
records. Failure to adequately maintain fiscal records, including
census records, medical charts, ledgers, journals, tax returns, canceled
checks, source documents, invoices, and audit reports by or for a facility, may
result in the penalties specified in subrule 81.14(1).
(2)
Accounting procedures.
Financial information shall be based on that appearing in the audited financial
statements of the facility. If the financial statements have been compiled,
reviewed or audited by an outside firm, a copy of the compilation, review or
audit, including notes, for the reporting period shall be included with the
submission of the financial and statistical report. Adjustments to convert to
the accrual basis of accounting shall be made when the records are maintained
on other accounting bases.
a. Facilities that
are a part of a larger health facility extending short-term, intensive, or
other health care not generally considered nursing care may submit a cost
apportionment schedule prepared in accordance with recognized methods and
procedures. A schedule shall be required when necessary for a fair presentation
of expense attributable to nursing facility patients.
b. Costs for patient care services shall be
divided into the subcategories of "direct patient care costs" and "support care
costs." Costs associated with food and dietary wages shall be included in the
"support care costs" subcategory.
(3)
Submission of reports.
All nursing facilities, except the Iowa Veterans Home, shall submit reports
electronically, in a format approved by the department, to the department not
later than the last day of the fifth calendar month after the close of the
provider's reporting year. The Iowa Veterans Home shall submit the report
electronically, in a format approved by the department, no later than three
months after the close of each six-month period of the facility's established
fiscal year. The annual financial report shall coincide with the fiscal year
used by the provider to report federal income taxes for the operation unless
the provider requests in writing that a different reporting period be used.
Such a request shall be submitted within 60 days after the initial
certification of a provider. The option to change the reporting period may be
exercised only one time by a provider, and the reporting period shall coincide
with the fiscal year end for Medicare cost-reporting purposes. If a reporting
period other than the tax year is established, audit trails between the periods
are required, including reconciliation statements between the provider's
records and the annual financial report.
a.
Nursing facilities that are certified to provide Medicare-covered skilled
nursing facility services are required to submit a copy of their Medicare cost
report that covers their most recently completed historical reporting period as
submitted to the Medicare fiscal intermediary.
b. The submission shall include a working
trial balance that corresponds to all financial data contained on the cost
report. The working trial balance must provide sufficient detail to enable the
department to reconcile accounts reported on the general ledger to those on the
financial and statistical report. For reporting costs that are not directly
assigned to the nursing facility in the working trial balance, an allocation
method must be identified for each line, including the statistics used in the
calculation. Reports submitted without a working trial balance shall be
considered incomplete, and the facility shall be subject to the rate reductions
set forth in paragraph 81.5(3)"e."
c. If the financial statements have been
compiled, reviewed or audited by an outside firm, a copy of the compilation,
review or audit, including notes, for the reporting period shall be included
with the submission of the financial and statistical report as set forth in
subrule 81.5(2).
d. For nursing
facilities, except the Iowa Veterans Home, an extension of the five-month
filing period shall not be granted unless one is granted for the filing of the
Medicare cost report. If the Medicare filing deadline for submitting the
Medicare cost report is delayed by the Medicare fiscal intermediary, the
Medicaid cost report and all required forms shall be submitted on the date
Medicare requires submission of its report. Notice of the extension shall be
presented to the department within ten days of a decision by
Medicare.
e. A complete submission
shall include all of the items identified in this subrule. Failure to submit a
complete report that meets the requirements of this rule within the stated time
shall reduce payment to 75 percent of the current rate.
(1) The reduced rate will be effective the
first day of the sixth month following the provider's fiscal year end and will
remain in effect until the first day of the month after the delinquent report
is received by the department.
(2)
The reduced rate will be paid for no longer than three months, after which time
no further payments will be made until the first day of the month after the
delinquent report is received by the department.
f. When a nursing facility continues to
include in the total costs an item or items that had in a prior period been
removed through an adjustment made by the department or its contractor, the
contractor shall recommend to the department that the per diem be reduced to 75
percent of the current payment rate for the entire quarter beginning the first
day of the fourth month after the facility's fiscal year end. If the adjustment
has been contested and is still in the appeals process, the provider may
include the cost, but must include sufficient detail so that the department can
determine if a similar adjustment is needed in the current period. The
department may, after considering the seriousness of the offense, make the
reduction.
g. Nothing in this
subrule relieves a facility of its obligation to immediately inform the
department that the facility has retained Medicaid funds to which the facility
is not entitled as a result of any cost report process. A facility shall notify
the department when the facility determines that funds have been incorrectly
paid or when an overpayment has been detected.
h. A facility may change its fiscal year one
time in any two-year period. If the facility changes its fiscal year, the
facility shall notify the department 60 days prior to the first date of the
change.
(4)
Payment at new rate.
a.
Except for state-operated nursing facilities and special population nursing
facilities, payment rates will be updated July 1, 2001, and every second year
thereafter with new cost report data, and adjusted quarterly to account for
changes in the Medicaid average case-mix index. For nursing facilities
receiving both an ICF and SNF Medicaid rate effective June 30, 2001, the June
30, 2001, Medicaid rate referenced in subparagraphs (1) and (2) below will be
the patient-day-weighted average of the ICF and SNF Medicaid rates effective
June 30, 2001, excluding the case-mix transition add-on amount.
(1) The Medicaid payment rates for services
rendered from July 1, 2001, through June 30, 2002, will be 66.67 percent of the
facility's Medicaid rate effective June 30, 2001, excluding the case-mix
transition add-on amount, plus an inflation allowance of 6.21 percent, not to
exceed $94, and 33.33 percent of the July 1, 2001, modified price-based rate
pursuant to subrule 81.5(16). In no case will the July 1, 2001, Medicaid rate
be less than the Medicaid rate effective June 30, 2001, excluding the case-mix
transition addon amount, and increased by a 6.21 percent inflation
allowance.
(2) Payment rates for
services rendered from July 1, 2002, through June 30, 2003, shall be 33.33
percent of the facility's Medicaid rate effective June 30, 2001, excluding the
case-mix transition add-on amount, plus an inflation allowance of 6.21 percent,
and an additional inflation factor based on the CMS/SNF Total Market Basket
Index. However, the current system rate to be used effective July 1, 2002,
shall not exceed $94, times an inflation factor pursuant to subrule 81.5(18),
and 66.67 percent of the July 1, 2002, modified price-based rate. In no case
will the July 1, 2002, Medicaid rate be less than the Medicaid rate effective
June 30, 2002, plus an inflation factor pursuant to subrule 81.5(18) projected
for the following 12 months.
(3)
Payment rates for services rendered from July 1, 2003, and thereafter will be
100 percent of the modified price-based rate.
b. The Medicaid payment rate for special
population nursing facilities will be updated annually without a quarterly
adjustment.
c. The Medicaid payment
rate for state-operated nursing facilities will be updated annually without a
quarterly adjustment.
(5)
Accrual basis.
Facilities not using the accrual basis of accounting shall adjust recorded
amounts to the accrual basis. Records of cash receipts and disbursements shall
be adjusted to reflect accruals of income and expense.
(6)
Census of Medicaid
members. Census figures of Medicaid members shall be obtained on the
last day of the month ending the reporting period.
(7)
Patient days. In
determining inpatient days, a patient day is that period of service rendered a
patient between the census-taking hours on two successive days, the day of
discharge being counted only when the patient was admitted that same
day.
(8)
Opinion of
accountant. The department may require that an opinion of a certified
public accountant or public accountant accompany the report when adjustments
made to prior reports indicate disregard of the certification and reporting
instructions.
(9)
Calculating patient days. When calculating patient days,
facilities shall use an accumulation method.
a. Census information shall be based on a
patient's status at midnight at the end of each day.
b. When a recipient is on a reserve bed
status and the department is paying on a per diem basis for the holding of a
bed, or any day a bed is reserved for a public assistance or nonpublic
assistance patient and a per diem rate for the bed is charged to any party, the
reserved days shall be included in the total census figures for inpatient
days.
(10)
Revenues. Revenues shall be reported as recorded in the
general books and records. Expense recoveries credited to expense accounts
shall not be reclassified in order to be reflected as revenues.
a. Routine daily services shall represent the
established charge for daily care. Routine daily services include room, board,
nursing services, therapies, and such services as supervision, feeding,
pharmaceutical consulting, over-the-counter drugs, incontinence, and similar
services, for which the associated costs are in nursing service. Routine daily
services shall not include:
(1) Laboratory or
diagnostic radiology services, unless the service is provided by facility staff
using facility equipment, and
(2)
Prescription (legend) drugs.
b. Revenue from ancillary services provided
to patients shall be applied in reduction of the related expense.
c. Revenue from the sale of medical supplies,
food or services to employees or nonresidents of the facility shall be applied
in reduction of the related expense. Revenue from the sale to private pay
residents of items or services that are included in the medical assistance per
diem will not be offset.
d.
Investment income adjustment is necessary only when interest expense is
incurred, and only to the extent of the interest expense.
e. Laundry revenue shall be applied to
laundry expense.
f. Accounts
receivable charged off or provision for uncollectible accounts shall be
reported as a deduction from gross revenue.
(11)
Limitation of expenses.
Certain expenses that are not normally incurred in providing patient care shall
be eliminated or limited according to the following:
a. Federal and state income taxes are not
allowed as reimbursable costs.
b.
Fees paid directors and nonworking officers' salaries are not allowed as
reimbursable costs.
c. Bad debts
are not an allowable expense.
d.
Charity allowances and courtesy allowances are not an allowable
expense.
e. Personal travel and
entertainment are not allowable as reimbursable costs. Certain expenses such as
rental or depreciation of a vehicle and expenses of travel that include both
business and personal costs shall be prorated. Amounts that appear to be
excessive may be limited after consideration of the specific circumstances.
Records shall be maintained to substantiate the indicated charges.
(1) Commuter travel by the owner(s),
owner-administrator(s), administrator, nursing director or any other employee
is not an allowable cost (from private residence to facility and return to
residence).
(2) The expense of one
car or one van or both designated for use in transporting patients shall be an
allowable cost. All expenses shall be documented by a sales slip, invoice or
other document setting forth the designated vehicle as well as the charges
incurred for the expenses to be allowable.
(3) At the time of annual contract renewal
with the Iowa department of transportation, each facility that supplies
transportation services as defined in Iowa Code section
324A.1 shall provide current
documentation of compliance with or exemption from public transit coordination
requirements as found in Iowa Code section
324A.5 and 761-Chapter 910 of
the Iowa department of transportation's rules. Failure to cooperate in
obtaining or in providing the required documentation of compliance or exemption
after receipt from the Iowa department of transportation shall result in
disallowance of vehicle costs and other costs associated with transporting
residents.
(4) Expenses related to
association business meetings, limited to individual members of the association
who are members of a national affiliate, and expenses associated with
workshops, symposiums, and meetings that provide administrators or department
heads with hourly credits required to comply with continuing education
requirements for licensing, are allowable expenses.
(5) Travel of an emergency nature required
for supplies, repairs of machinery or equipment, or building is an allowable
expense.
(6) Travel for which a
patient must pay is not an allowable expense.
(7) Allowable expenses in subparagraphs (2)
through (5) above are limited to 6 percent of total administrative
expense.
f.
Entertainment provided by the facility for participation of all residents who
are physically and mentally able to participate is an allowable expense except
that entertainment for which the patient is required to pay is not an allowable
expense.
g. Loan acquisition fees
and standby fees are not considered part of the current expense of patient
care, but should be amortized over the life of the related loan.
h. A reasonable allowance of compensation for
services of owners or immediate relatives is an allowable cost, provided the
services are actually performed in a necessary function. For this purpose, the
following persons are considered immediate relatives: husband and wife; natural
parent, child and sibling; adopted child and adoptive parent; stepparent,
stepchild, stepbrother, and stepsister; father-in-law, mother-in-law,
son-in-law, daughter-in-law, brother-in-law, and sister-in-law; grandparent and
grandchild. Adequate time records shall be maintained. Adjustments may be
necessary to provide compensation as an expense for nonsalaried working
proprietors and partners. Members of religious orders serving under an
agreement with their administrative office are allowed salaries paid persons
performing comparable services. When maintenance is provided these persons by
the facility, consideration shall be given to the value of these benefits and
this amount shall be deducted from the amount otherwise allowed for a person
not receiving maintenance.
(1) Compensation
means the total benefit received by the owner or immediate relative for
services rendered. Compensation includes all remuneration, paid currently or
accrued, for managerial, administrative, professional and other services
rendered during the period. Compensation includes all items that should be
reflected on IRS Form W-2, Wage and Tax Statement, including but not limited to
salaries, wages, and fringe benefits; the cost of assets and services received;
and deferred compensation. Fringe benefits shall include but are not limited to
costs of leave, employee insurance, pensions and unemployment plans. If the
facility's fiscal year end does not correlate to the period of the W-2, a
reconciliation between the latest issued W-2 and current compensation shall be
required to be disclosed to the department. Employer portions of payroll taxes
associated with amounts of compensation that exceed the maximum allowed
compensation shall be considered unallowable for reimbursement. All
compensation paid to related parties, including payroll taxes, shall be
required to be reported to the department with the submission of the financial
and statistical report. If it is determined that there have been undisclosed
related-party salaries, the cost report will be determined to have been
submitted incomplete and the facility shall be subject to the penalties set
forth in paragraph 81.5(3)"e."
(2) Reasonableness requires that the
compensation allowance be the same amount as would ordinarily be paid for
comparable services by comparable institutions, and depends upon the facts and
circumstances of each case.
(3)
Necessary requires that the function be such that had the owner or immediate
relative not rendered the services, the facility would have had to employ
another person to perform the service, and be pertinent to the operation and
sound conduct of the institution.
(4) The base maximum allowed compensation for
an administrator who is involved in ownership of the facility or who is an
immediate relative of an owner of the facility is $3,296 per month plus $35.16
per month per licensed bed capacity for each bed over 60, not to exceed $4,884
per month. An administrator is considered to be involved in ownership of a
facility when the administrator has ownership interest of 5 percent or more.
On an annual basis, the maximum allowed compensation amounts
for these administrators shall be increased or decreased by an annual inflation
factor as specified by subrule 81.5(18).
(5) The maximum allowed compensation for an
assistant administrator who is involved in ownership of the facility or who is
an immediate relative of an owner of the facility in facilities having a
licensed capacity of 151 or more beds is 60 percent of the amount allowed for
the administrator. An assistant administrator is considered to be involved in
ownership of a facility when the assistant administrator has ownership interest
of 5 percent or more.
(6) The
maximum allowed compensation for a director of nursing or any employee who is
involved in ownership of the facility or who is an immediate relative of an
owner of the facility is 60 percent of the amount allowed for the
administrator. Persons involved in ownership or relatives providing
professional services shall be limited to rates prevailing in the community not
to exceed 60 percent of the allowable rate for the administrator on a
semiannual basis. Records shall be maintained in the same manner for an
employee involved in ownership or a relative as are maintained for any other
employee of the facility. Ownership is defined as an interest of 5 percent or
more.
(7) The maximum allowed
compensation for anyone working for another entity (e.g., home office) that
allocates cost to the nursing facility and is involved in ownership of the
facility or allocating entity or who is an immediate relative of an owner of
the facility or allocating entity is 60 percent of the amount allowed for the
administrator. An employee working for another entity that allocates cost to
the nursing facility is considered to be involved in ownership of a facility
when that individual has ownership interest of 5 percent or more of the home
office or the nursing facility.
(8)
The maximum allowed compensation for employees as set forth in subparagraphs
81.5(11)"h"(4) through 81.5(11)"h"(7) shall
be adjusted by the percentage of the average work week that the employee
devoted to business activity at the nursing facility for the fiscal year of the
financial and statistical report. The time devoted to the business shall be
disclosed on the financial and statistical report and shall correspond to any
amounts reported to the Medicare fiscal intermediary. In the case that an
owner's or immediate relative's time is allocated to the facility from another
entity (e.g., home office), the compensation limit shall be adjusted by the
percentage of total costs of the entity allocated to the nursing facility. In
no case shall the amount of salary for one employee allocated to multiple
nursing facilities be more than the maximum allowed compensation for that
employee had the salary been allocated to only one facility.
i. Management fees paid to a
related party shall be limited on the same basis as the owner administrator's
salary, but shall have the amount paid the resident administrator deducted.
When the parent company can separately identify accounting costs, the costs are
allowed.
j. For financial and
statistical reports received after March 18, 2020, the depreciation, as limited
in this rule, may be included as an allowable patient cost.
(1) Limitation on calculation. Depreciation
shall be calculated based on the tax cost using only the straight-line method
of computation and recognizing the estimated useful life of the asset as
defined in the most recent edition of the American Hospital Association's
Estimated Useful Lives of Depreciable Hospital Assets (2023 edition).
(2) Limitation-full depreciation. Once an
asset is fully depreciated, no further depreciation shall be claimed on that
asset.
(3) Change of ownership.
Depreciation is further limited by the limitations in subrule
81.5(12).
k. Necessary
and proper interest on both current and capital indebtedness is an allowable
cost.
(1) Interest is the cost incurred for
the use of borrowed funds. Interest on current indebtedness is the cost
incurred for funds borrowed for a relatively short term. Interest on capital
indebtedness is the cost incurred for funds borrowed for capital
purposes.
(2) Necessary requires
that the interest be incurred on a loan made to satisfy a financial need of the
provider, be incurred on a loan made for a purpose reasonably related to
patient care, and be reduced by investment income except where the income is
from gifts and grants whether restricted or unrestricted, and that are held
separate and not commingled with other funds.
(3) Proper requires that interest be incurred
at a rate not in excess of what a prudent borrower would have had to pay in the
money market on the date the loan was made, and be paid to a lender not related
through control or ownership to the borrowing organization.
(4) Interest on loans is allowable as cost at
a rate not in excess of the amount an investor could receive on funds invested
in the locality on the date the loan was made.
(5) Interest is an allowable cost when the
general fund of a provider borrows from a donor-restricted fund, a funded
depreciation account of the provider, or the provider's qualified pension fund,
and pays interest to the fund, or when a provider operated by members of a
religious order borrows from the order.
(6) When funded depreciation is used for
purposes other than improvement, replacement or expansion of facilities or
equipment related to patient care, allowable interest expense is reduced to
adjust for offsets not made in prior years for earnings on funded depreciation.
A similar treatment will be accorded deposits in the provider's qualified
pension fund where the deposits are used for other than the purpose for which
the fund was established.
l. Costs applicable to supplies furnished by
a related party or organization are a reimbursable cost when included at the
cost to the related party or organization. The cost shall not exceed the price
of comparable supplies that could be purchased elsewhere.
(1) Related means that the facility, to a
significant extent, is associated with or has control of or is controlled by
the organization furnishing the services, facilities, or supplies.
(2) Common ownership exists when an
individual or individuals possess significant ownership or equity in the
facility and the institution or organization serving the provider.
(3) Control exists where an individual or an
organization has power, directly or indirectly, to significantly influence or
direct the actions or policies of an organization or institution.
(4) When the facility demonstrates by
convincing evidence that the supplying organization is a bona fide separate
organization; that a substantial part of its business activity of the type
carried on with the facility is transacted with others and there is an open
competitive market for the type of services, facilities, or supplies furnished
by the organization; that the services, facilities, or supplies are those that
commonly are obtained by similar institutions from other organizations and are
not a basic element of patient care ordinarily furnished directly to patients
by the institutions; and that the charge to the facility is in line with the
charge for the services, facilities, or supplies in the open market and no more
than the charge made under comparable circumstances to others by the
organization for the services, facilities, or supplies, the charges by the
supplier shall be allowable costs.
m. For financial and statistical reports
received after March 18, 2020, the following definitions, calculations, and
limitations shall be used to determine allowable rent expense on a cost report.
(1) Landlord's other expenses. Landlord's
other expenses are limited to amortization, mortgage interest, property taxes
unless claimed as a lessee expense, utilities paid by the landlord unless
claimed as a lessee expense, property insurance, and building maintenance and
repairs.
(2) Reasonable rate of
return. Reasonable rate of return means the historical cost of the facility in
the hands of the owner when the facility first entered the Medicaid program
multiplied by the 30-year Treasury bond rate as reported by the Federal Reserve
Board at the date of lease inception.
(3) Nonrelated party leases. When the
operator of a participating facility rents from a party that is not a related
party, as defined in paragraph 81.5(11)
"l," the allowable cost
report rental expense shall be the lesser of:
1. Lessor's annual depreciation as identified
in paragraph 81.5(11)"j" plus the landlord's other expenses,
plus a reasonable rate of return; or
2. Actual rent payments.
(4) Related party leases. When the operator
of a participating facility rents from a related party, as defined in paragraph
81.5(11)
"l," the allowable cost report rental expense shall be
the lesser of:
1. Lessor's annual depreciation
as identified in paragraph 81.5(11)"j" plus the landlord's
other expenses; or
2. Actual rent
payments.
n.
Reasonable legal, accounting, consulting and other professional fees, including
association dues, are allowable costs if the fees are directly related to
patient care. Legal, accounting, consulting and other professional fees,
including association dues, described by the following are not considered to be
patient-related and therefore are unallowable:
(1) Any fees or portion of fees used or
designated for lobbying.
(2)
Nonrefundable and unused retainers.
(3) Fees paid by the facility for the benefit
of employees.
(4) Legal fees,
expenses related to expert witnesses, accounting fees and other consulting fees
incurred in an administrative or judicial proceeding. However, facilities may
report the reasonable costs incurred in an administrative or judicial
proceeding if all of the conditions below are met. Recognition of any costs
will be in the fiscal period when a final determination in the administrative
or judicial proceeding is made.
1. The costs
have actually been incurred and paid,
2. The costs are reasonable expenditures for
the services obtained,
3. The
facility has made a good-faith effort to settle the disputed issue before the
completion of the administrative or judicial proceeding, and
4. The facility prevails on the disputed
issue.
o. The
nursing facility quality assurance assessment paid pursuant to 441-Chapter 36
shall not be an allowable cost for cost reporting and audit purposes but shall
be reimbursed pursuant to paragraph 81.5(21)"a."
p. Prescription (legend) drug costs are
excluded from services covered as part of the nursing facility per diem rate as
set forth in paragraph 81.10(5)"d." The department will
provide direct payment for drugs covered pursuant to 441-subrule 78.1(2) to
relieve the facility of payment responsibility. As Medicaid reimburses pharmacy
providers only for the cost and dispensation of legend drugs included on the
Medicaid preferred drug list, no drug costs will be recognized for other payor
sources.
q. Inpatient therapy
services provided by nursing facilities are included in the established rate as
a direct care cost and subject to the normalization process and quarterly
case-mix index adjustments.
(1) Under no
circumstances shall therapies for Medicaid members residing in a nursing
facility be billed to Medicaid through any provider other than the nursing
facility. Therapy services for nursing facility residents that are reimbursed
by other payment sources shall not be reimbursed by Medicaid.
(2) For purposes of determining allowable
therapy costs, the department will adjust each provider's reported cost of
therapy services, including any employee benefits prorated based on total
salaries and wages, to account for nonfacility patients including patients with
costs paid by Medicare. Such adjustments will be applied to each cost report in
order to remove reported costs attributable to outpatient therapy services
reimbursed for non-inpatient services. When the costs of the services are not
determinable, an adjustment shall be calculated based on an allocation of
reported therapy revenues and shall be subject to field audit
verification.
r.
Penalties or fines imposed by federal, state or local agencies are not
allowable expenses.
s. Penalties,
fines or fees imposed for insufficient funds or delinquent payments are not
allowable expenses.
t. Laboratory
costs are excluded from services covered as part of the nursing facility per
diem rate unless the service is provided by facility staff using facility
equipment.
u. Diagnostic radiology
costs are excluded from services covered as part of the nursing facility per
diem rate unless the service is provided by facility staff using facility
equipment.
(12)
Termination or change of owner.
a. A participating facility contemplating
termination of participation or negotiating a change of ownership shall provide
the department with at least 60 days' prior notice. A transfer of ownership or
operation terminates the participation agreement. A new owner or operator shall
establish that the facility meets the conditions for participation and enter
into a new agreement. The person responsible for transfer of ownership or for
termination is responsible for submission of a final financial and statistical
report through the date of the transfer. The new owner shall be responsible for
all Medicaid debts incurred by the previous owner, including those incurred due
to changes in rates, fines, penalties and quality assurance fees, from the
first day of the quarter until the date the change occurs. No payment to the
new owner will be made until formal notification is received. The following
situations are defined as a transfer of ownership:
(1) In the case of a partnership that is a
party to an agreement to participate in the medical assistance program, the
removal, addition, or substitution of an individual for a partner in the
association in the absence of an express statement to the contrary, dissolves
the old partnership and creates a new partnership that is not a party to the
previously executed agreement and a transfer of ownership has
occurred.
(2) When a participating
nursing facility is a sole proprietorship, a transfer of title and property to
another party constitutes a change of ownership.
(3) When the facility is a corporation,
neither a transfer of corporate stock nor a merger of one or more corporations
with the participating corporation surviving is a transfer of ownership. A
consolidation of two or more corporations resulting in the creation of a new
corporate entity constitutes a change of ownership.
(4) When a participating facility is leased,
a transfer of ownership is considered to have taken place. When the entire
facility is leased, the total agreement with the lessor terminates. When only
part of the facility is leased, the agreement remains in effect with respect to
the unleased portion, but terminates with respect to the leased
portion.
b. No increase
in the value of property is allowed in determining the Medicaid rate for the
new owner with any change of ownership (including lease agreements). When
filing the first cost report, the new owner shall either continue the schedule
of depreciation and interest established by the previous owner, or the new
owner may choose to claim the actual rate of interest expense. The results of
the actual rate of interest expense shall not be higher than would be allowed
under the Medicare principles of reimbursement and shall be applied to the
allowed depreciable value established by the previous owner, less any down
payment made by the new owner.
c.
Other acquisition costs of the new owner such as legal fees, accounting and
administrative costs, travel costs and the costs of feasibility studies
attributable to the negotiation or settlement of the sale or purchase of the
property shall not be allowed.
d.
In general, the provisions of Section 1861(v)(1)(0) of the Social Security Act
(as amended to August 1, 2024) regarding payment allowed under Medicare
principles of reimbursement at the time of a change of ownership shall be
followed, except that no return on equity or recapture of depreciation
provisions shall be employed.
e. A
new owner or lessee wishing to claim a new rate of interest expense must submit
documentation that verifies the amount of down payment made, the actual rate of
interest, and the number of years required for repayment with the next annual
cost report. In the absence of the necessary supportive documentation, interest
and other property costs for all facilities that have changed or will change
ownership shall continue at the rate allowed the previous owner.
(13)
Amended
reports. The department, in its sole discretion, may reopen a review
of a financial and statistical report at any time. No other entity or person
has the right to request that the department or its contractor reopen a review
of a financial and statistical report, or submit an amended financial and
statistical report for review by the department, after the facility is notified
of its per diem summary and adjustments following a review of a financial and
statistical report. Nothing in this subrule relieves a facility of its
obligation to immediately inform the department that the facility has retained
Medicaid funds to which the facility is not entitled as a result of any cost
report process. A facility shall notify the department when the facility
determines that funds have been incorrectly paid or when an overpayment has
been detected.
(14)
Payment
to new facility. The payment to a new facility will be the sum of the
patient-day-weighted median cost for the direct care and non-direct care
components pursuant to paragraph 81.5(16)"c." After the first
full calendar quarter of operation, the patient-day-weighted median cost for
the direct care component will be adjusted by the facility's average Medicaid
case-mix index pursuant to subrule 81.5(19). A financial and statistical report
shall be submitted from the beginning day of operation to the end of the fiscal
year. Following the completion of the new facility's first fiscal year, rates
will be established in accordance with subrule 81.5(16). Subsequent financial
and statistical reports shall be submitted annually for a 12-month period
ending with the facility's fiscal year.
(15)
Payment to new owner.
An existing facility with a new owner will continue to be reimbursed using the
previous owner's per diem rate adjusted quarterly for changes in the Medicaid
average case-mix index. The facility shall submit a financial and statistical
report for the period from beginning of actual operation under new ownership to
the end of the facility's fiscal year. Subsequent financial and statistical
reports shall be submitted annually for a 12-month period ending with the
facility's fiscal year. The facility shall notify the department of the date
the facility's fiscal year will end.
(16)
Establishment of the direct care
and non-direct care patient-day-weighted medians and modified price-based
reimbursement rate. This subrule provides for the establishment of the
modified price-based reimbursement rate.
a.
Calculation of per diem cost. For purposes of calculating the non-state
government owned nursing facility Medicaid reimbursement rate and the
Medicare-certified hospital-based nursing facility Medicaid reimbursement rate,
the costs will be divided into two components, the direct care component and
nondirect care component as defined in rule
441-81.1 (249A). Each nursing
facility's per diem allowable direct care and non-direct care cost shall be
established. Effective July 1, 2001, and every second year thereafter, the per
diem allowable cost will be determined by dividing total reported allowable
costs by total inpatient days during the reporting period. On July 1, 2001;
July 1, 2003; July 1, 2004; July 1, 2005; and every second year thereafter,
total reported allowable costs will be adjusted using the inflation factor
specified in subrule 81.5(18) from the midpoint of the cost report period to
the beginning of the state fiscal year rate period.
(1) Non-state government owned nursing
facilities. Effective December 1, 2009, patient days for purposes of the
computation of administrative, environmental, and property expenses for
non-state government owned nursing facilities will be inpatient days as
determined in subrule 81.5(7) or 85 percent of the licensed capacity of the
facility, whichever is greater. For the reimbursement period beginning July 1,
2023, and ending June 30, 2025, patient days for purposes of the computation of
administrative, environmental, and property expenses for non-state government
owned nursing facilities will be inpatient days as determined in subrule
81.5(7)) or 70 percent of the licensed capacity of the facility, whichever is
greater. Patient days for purposes of the computation of all other expenses
will be inpatient days as determined in subrule 81.5(7).
(2) Medicare-certified hospital-based nursing
facilities. Patient days for purposes of the computation of all expenses shall
be inpatient days as determined by subrule 81.5(7).
b. Cost normalization. The per diem allowable
direct care costs are normalized by dividing a facility's per diem direct care
costs by the facility's cost report period case-mix index as defined in rule
441-81.1 (249A) and subrule
81.5(19).
c. Calculation of
patient-day-weighted medians. For each of the rate components, a
patient-day-weighted median will be established for both the non-state
government owned nursing facilities and the Medicare-certified hospital-based
nursing facilities, hereinafter referred to as the non-state government owned
nursing facility patient-day-weighted medians and the Medicare-certified
hospital-based nursing facility patient-day-weighted medians.
The per diem normalized direct care cost for each facility is
arrayed from low to high to determine the direct care component
patient-day-weighted median cost based on the number of patient days provided
by facilities. The per diem non-direct care cost for each facility is also
arrayed from low to high to determine the non-direct care component
patient-day-weighted median cost based on the number of patient days provided
by facilities. An array and patient-day-weighted median for each cost component
is determined separately for both non-state government owned nursing facilities
and the Medicare-certified hospitalbased nursing facilities.
(1) For the fiscal period beginning July 1,
2001, and ending June 30, 2003, the non-state government owned nursing facility
direct care and non-direct care patient-day-weighted medians and the
Medicare-certified hospital-based nursing facility direct care and non-direct
care patient-day-weighted medians will be calculated using the latest financial
and statistical report with a fiscal year end of December 31, 2000, or earlier,
inflated from the midpoint of the cost report period to July 1, 2001, using the
inflation factor specified in subrule 81.5(18).
(2) Effective July 1, 2003, and each second
year thereafter, the patient-day-weighted medians used in rate setting will be
recalculated. The non-state government owned nursing facility direct care and
nondirect care patient-day-weighted medians and the Medicare-certified
hospital-based nursing facility direct care and non-direct care
patient-day-weighted medians will be calculated using the latest completed cost
report with a fiscal year end of the preceding December 31 or earlier. When
patient-day-weighted medians are recalculated, inflation is applied from the
midpoint of the cost report period to the first day of the state fiscal year
rate period using the inflation factor specified in subrule 81.5(18).
(3) For the fiscal period beginning July 1,
2004, and ending June 30, 2005, the non-state-owned and Medicare-certified
hospital-based nursing facility direct care and the non-direct care
patient-day-weighted medians calculated July 1, 2003, will be inflated to July
1, 2004, using the inflation factor specified in subrule 81.5(18).
d. Excess payment allowance.
(1) For non-state government owned nursing
facilities not located in a Metropolitan Statistical Area as defined by CMS,
not including Medicare-certified hospital-based nursing facilities, the excess
payment allowance is calculated as follows:
1.
For the direct care component, subject to the limit provided below, the excess
payment allowance is equal to the percentage specified in 441-subrule 79.1(2)
times the difference (if greater than zero) of the following: the direct care
non-state government owned nursing facility patient-day-weighted median times
the percentage specified in 441-subrule 79.1(2) times the Medicaid average
case-mix index pursuant to subrule 81.5(19), minus a provider's allowable
normalized per patient day direct care costs pursuant to
81.5(16)"b" times the Medicaid average case-mix index pursuant
to subrule 81.5(19). In no case will the excess payment allowance exceed the
percentage specified in 441-subrule 79.1(2) times the direct care non-state
government owned nursing facility patient-day-weighted median.
2. For the non-direct care component, subject
to the limit provided below, the excess payment allowance is equal to the
percentage specified in 441-subrule 79.1(2) times the difference (if greater
than zero) of the following: the non-direct care non-state government owned
nursing facility patient-day-weighted median times the percentage specified in
441-subrule 79.1(2), minus a provider's allowable per patient day non-direct
care cost pursuant to paragraph 81.5(16)"a." In no case will
the excess payment allowance exceed the percentage specified in 441-subrule
79.1(2) times the non-direct care non-state government owned nursing facility
patient-day-weighted median.
(2) For non-state government owned nursing
facilities located in a Metropolitan Statistical Area as defined by CMS (not
including Medicare-certified hospital-based nursing facilities), the excess
payment allowance is calculated as follows:
1.
For the direct care component, subject to the limit provided below, the excess
payment allowance is equal to the percentage specified in 441-subrule 79.1(2)
times the difference (if greater than zero) of the following: the direct care
non-state government owned nursing facility patient-day-weighted median times
the percentage specified in 441-subrule 79.1(2) times the wage index factor
specified below times the Medicaid average case-mix index pursuant to subrule
81.5(19), minus a provider's allowable normalized per patient day direct care
costs pursuant to paragraph 81.5(16)
"b" times the Medicaid
average case-mix index pursuant to subrule 81.5(19). In no case will the excess
payment allowance exceed the percentage specified in 441-subrule 79.1(2) times
the direct care non-state government owned nursing facility
patient-day-weighted median.
The wage index factor will be determined annually by
calculating the average difference between the Iowa hospital-based rural wage
index and all Iowa hospital-based Metropolitan Statistical Area wage indices as
published by CMS each July. The geographic wage index adjustment will not
exceed $8 per patient day.
A nursing facility may request an exception to application of
the geographic wage index based upon a reasonable demonstration of wages,
locations, and total cost. The nursing facility shall request the exception
within 30 days of receipt of notification to the nursing facility of the new
reimbursement rate using the department's procedures for requesting exceptions
at rule 441-1.8 (17A,217).
2. For the non-direct care
component, subject to the limit provided below, the excess payment allowance is
equal to the percentage specified in 441-subrule 79.1(2) times the difference
(if greater than zero) of the following: the non-direct care non-state
government owned nursing facility patient-day-weighted median times the
percentage specified in 441-subrule 79.1(2), minus a provider's allowable per
patient day non-direct care cost pursuant to paragraph
81.5(16)"a." In no case will the excess payment allowance
exceed the percentage specified in 441-subrule 79.1(2) times the non-direct
care non-state government owned nursing facility patient-day-weighted
median.
(3) For
Medicare-certified hospital-based nursing facilities, the excess payment
allowance is calculated as follows:
1. For
the direct care component, subject to the limit provided below, the excess
payment allowance is equal to the percentage specified in 441-subrule 79.1(2)
times the difference (if greater than zero) of the following: the direct care
Medicare-certified hospital-based nursing facility patient-day-weighted median
times the percentage specified in 441-subrule 79.1(2) times the Medicaid
average case-mix index pursuant to subrule 81.5(19), minus a provider's
normalized allowable per patient day direct care costs pursuant to paragraph
81.5(16)"b" times the Medicaid average case-mix index pursuant
to subrule 81.5(19). In no case will the excess payment allowance exceed the
percentage specified in 441-subrule 79.1(2) times the direct care
Medicare-certified hospital-based nursing facility patient-day-weighted
median.
2. For the non-direct care
component, subject to the limit provided below, the excess payment allowance is
equal to the percentage specified in 441-subrule 79.1(2) times the difference
(if greater than zero) of the following: the non-direct care Medicare-certified
hospital-based nursing facility patient-day-weighted median times the
percentage specified in 441-subrule 79.1(2), minus a provider's allowable per
patient day non-direct care cost pursuant to paragraph
81.5(16)"a." In no case will the excess payment allowance
exceed the percentage specified in 441-subrule 79.1(2) times the non-direct
care Medicare-certified hospital-based nursing facility patient-day-weighted
median.
e.
Reimbursement rate. The Medicaid reimbursement rate is based on allowable
costs, updated July 1, 2001, and every second year thereafter, as specified in
subparagraphs (1) and (2) below, plus a potential excess payment allowance
determined by the methodology in paragraph
"d," not to exceed
the rate component limits determined by the methodology in paragraph
"f."
(1) For non-state
government owned nursing facilities and Medicare-certified hospital-based
nursing facilities, direct care and non-direct care rate components are
calculated as follows:
1. The direct care
component is equal to the provider's normalized allowable per patient day costs
times the Medicaid average case-mix index pursuant to subrule 81.5(19), plus
the allowed excess payment allowance as determined by the methodology in
paragraph "d."
2.
The non-direct care component is equal to the provider's allowable per patient
day costs, plus the allowed excess payment allowance as determined by the
methodology in paragraph "d" and the allowable capital cost
per diem instant relief add-on as determined by the methodology in paragraph
"h."
(2) The reimbursement rate for state-operated
nursing facilities and special population nursing facilities will be the
facility's average allowable per diem costs, adjusted for inflation pursuant to
subrule 81.5(18), based on the most current financial and statistical
report.
f.
Notwithstanding paragraphs
"d" and
"e," in no
instance will a rate component exceed the rate component limit defined as
follows:
(1) For non-state government owned
nursing facilities not located in a Metropolitan Statistical Area (not
including Medicare-certified hospital-based nursing facilities), the direct
care and non-direct care rate component limits are calculated as follows:
1. The direct care rate component limit is
the direct care non-state government owned nursing facility
patient-day-weighted median times the percentage of the median specified in
441-subrule 79.1(2) times the Medicaid average case-mix index pursuant to
subrule 81.5(19).
2. The non-direct
care rate component limit is the non-direct care non-state government owned
nursing facility patient-day-weighted median multiplied by the percentage of
the median specified in 441-subrule 79.1(2) or is 120 percent of the median if
the facility qualifies for the enhanced non-direct care rate component limit
pursuant to paragraph "h."
(2) For non-state government owned nursing
facilities located in a Metropolitan Statistical Area (not including
Medicare-certified hospital-based nursing facilities), the direct care and
non-direct care rate component limits are calculated as follows:
1. The direct care rate component limit is
the direct care non-state government owned nursing facility
patient-day-weighted median times the percentage of the median specified in
441-subrule 79.1(2) times the wage factor specified in paragraph
"d" times the Medicaid average case-mix index pursuant to
subrule 81.5(19).
2. The non-direct
care rate component limit is the non-direct care non-state government owned
nursing facility patient-day-weighted median multiplied by the percentage of
the median specified in 441-subrule 79.1(2) or is 120 percent of the median if
the facility qualifies for the enhanced non-direct care rate component limit
pursuant to paragraph "h."
(3) For Medicare-certified hospital-based
nursing facilities, the direct care and non-direct care rate component limits
are calculated as follows:
1. The direct care
rate component limit is the direct care Medicare-certified hospital-based
nursing facility patient-day-weighted median times the percentage of the median
specified in 441-subrule 79.1(2) times the Medicaid average case-mix index
pursuant to subrule 81.5(19).
2.
The non-direct care rate component limit is the non-direct care
Medicare-certified hospital-based nursing facility patient-day-weighted median
multiplied by the percentage of the median specified in 441-subrule 79.1(2) or
is 120 percent of the median if the facility qualifies for the enhanced
non-direct care rate component limit pursuant to paragraph
"h."
(4) For special population nursing facilities
enrolled on or after June 1, 1993, the upper limit on their rate is equal to
the sum of the following:
1. The direct care
Medicare-certified hospital-based nursing facility patient-day-weighted median
times the percentage of the median specified in 441-subrule 79.1(2).
2. The non-direct care Medicare-certified
hospital-based nursing facility patient-day-weighted median multiplied by the
percentage of the median specified in 441-subrule 79.1(2) or 120 percent of the
median if the facility qualifies for the enhanced non-direct care rate
component limit pursuant to paragraph "h."
g. Pay-for-performance
program. Additional reimbursement based on the nursing facility
pay-for-performance program is available for non-state government owned nursing
facilities as provided in this paragraph in state fiscal years for which
funding is appropriated by the legislature. The pay-for-performance program
provides additional reimbursement based upon a nursing facility's achievement
of multiple favorable outcomes as determined by established benchmarks. The
reimbursement is issued as an add-on payment after the end of any state fiscal
year (which is referred to in this paragraph as the "payment period") for which
there is funding appropriated by the legislature.
(1) Scope. Additional reimbursement for the
nursing facility pay-for-performance program is not available to
Medicare-certified hospital-based nursing facilities, state-operated nursing
facilities, or special population nursing facilities. Therefore, data from
these facility types will not be used when determining eligibility for or the
amount of additional reimbursement based on the nursing facility
pay-for-performance program.
(2)
Benchmarks. The pay-for-performance benchmarks include characteristics in four
domains: quality of life, quality of care, access, and efficiency. These
characteristics are objective and measurable and when considered in combination
with each other are deemed to have a correlation to a resident's quality of
life and care. While any single measure does not ensure the delivery of quality
care, a nursing facility's achievement of multiple measures suggests that
quality is an essential element in the facility's delivery of resident
care.
(3) Definition of direct
care. For the purposes of the nursing facility pay-for-performance program,
"direct care staff" is defined to include registered nurses (RNs), licensed
practical nurses (LPNs), certified nurse assistants (CNAs), rehabilitation
nursing, and other contracted nursing services. "Direct care staff" does not
include the director of nursing (DON) or minimum data set (MDS)
coordinator.
(4) Qualifying for
additional reimbursement. The department will annually award points based on
the measures achieved in each of the four domains, as described in
subparagraphs (5) through (8). The maximum available points are 100. To qualify
for additional Medicaid reimbursement under the nursing facility
pay-for-performance program, a facility must achieve a minimum score of 51
points. The relationship of the score achieved to additional payments is
described in subparagraph (10). Payments are subject to reduction or forfeiture
as described in subparagraphs (12) and (13).
(5) Domain 1: Quality of life.
|
Standard
|
Measurement Period
|
Value
|
Source
|
|
Subcategory: Person-Directed Care
|
|
Enhanced Dining A:
The facility makes available menu options and
alternative selections for all meals.
|
Payment period
|
1 point
|
Self-certification
|
|
Enhanced Dining B:
The facility provides residents with access to food
and beverages 24 hours per day and 7 days per week and empowers staff to honor
resident choices.
|
Payment period
|
1 point
|
Self-certification
|
|
Enhanced Dining C:
The facility offers at least one meal per day for an
extended period to give residents the choice of what time to
eat.
|
Payment period
|
2 points
|
Self-certification
|
|
Resident Activities A:
The facility employs a certified activity coordinator
for at least 38 minutes per week per licensed bed.
|
Payment period
|
1 point
|
Self-certification
|
|
Resident Activities B:
The facility either has activity staff that exceed
the required minimum set by law or has direct care staff who are trained to
plan and conduct activities and carry out both planned and spontaneous
activities on a daily basis.
|
Payment period
|
1 point
|
Self-certification
|
|
Resident Activities C:
The facility's residents report that activities meet
their social, emotional and spiritual needs.
|
July through March of payment period
|
2 points
|
Self-certification
|
|
Resident Choice A:
The facility allows residents to set their own
schedules, including what time to get up and what time to go to
bed.
|
Payment period
|
1 point
|
Self-certification
|
|
Resident Choice B:
The facility allows residents to have a choice of
whether to take a bath or shower and on which days and at what time the bath or
shower will be taken.
|
Payment period
|
1 point
|
Self-certification
|
|
Consistent Staffing:
The facility has all direct care staff members caring
for the same residents at least 70% of their shifts.
|
Payment period
|
3 points
|
Self-certification
|
|
National Accreditation:
The facility has CARF or another nationally
recognized accreditation for the provision of person-directed
care.
|
Payment period
|
13 points Note: A facility that receives points for
this measure does not receive points for any other measures in this
subcategory.
|
Self-certification
|
|
Subcategory: Resident Satisfaction
|
|
Resident/Family Satisfaction Survey: The facility
administers an anonymous resident/family satisfaction survey annually. The
survey tool must be developed, recognized, and standardized by an entity
external to the facility. Results must be tabulated by an entity external to
the facility.
To qualify for the measure, the facility must have a
response rate of at least 35%. A summary report of the aggregate results and
point scale must be made publicly available and be posted prominently along
with the facility's state survey results until the next satisfaction survey is
completed.
|
Survey completed between October 1 and March 31 of
the payment period
|
5 points
|
Nursing Facility Opinion Survey Transmittal,
submitted by independent entity that compiled results
|
|
Long-Term Care Ombudsman:
The facility has resolved 70% or more of complaints
received and investigated by the local or state ombudsman.
|
Calendar year ending December 31 of the payment
period
|
5 points if resolution 70% to 74%
7 points if resolution 75% or greater
|
LTC ombudsman's list of facilities meeting the
standard
|
(6)
Domain 2: Quality of care.
|
Standard
|
Measurement Period
|
Value
|
Source
|
|
Subcategory: Survey
|
|
Deficiency-Free Survey:
The facility is deficiency-free on the latest annual
state and federal licensing and certification survey and any subsequent
surveys, complaint investigations, or revisit investigations.
If a facility's only scope and severity deficiencies
are an A level pursuant to 42 CFR Part 483, Subparts B and C, as amended to
August 1, 2024, the facility is deemed to have a deficiency-free survey for
purposes of this measure. Surveys are considered complete when all appeal
rights have been exhausted.
|
Calendar year ending December 31 of the payment
period, including any subsequent surveys, revisit, or complaint
investigations
|
10 points
|
DIAL list of facilities meeting the
standard
|
|
Regulatory Compliance with Survey:
No on-site revisit to the facility is required for
recertification surveys or for any substantiated complaint investigations
during the measurement period.
|
Calendar year ending December 31 of the payment
period, including any subsequent surveys, revisits, or complaint
investigations
|
5 points. A facility that receives points for a
deficiency-free survey does not receive points for this
measure.
|
DIAL list of facilities meeting the
standard
|
|
Subcategory: Staffing
|
|
Nursing Hours Provided:
The facility's per-resident-day nursing hours are at
or above one-half standard deviation above the mean of per-resident-day nursing
hours for all facilities.
Nursing hours include those of RNs, LPNs, CNAs,
rehabilitation nurses, and other contracted nursing services. Nursing hours
will be normalized to remove variations in staff hours associated with
different levels of resident case mix.
|
Facility fiscal year ending on or before December 31
of the payment period
|
5 points if case-mix adjusted nursing hours are above
mean plus one-half standard deviation
10 points if casemix adjusted nursing hours are
greater than mean plus one standard deviation
|
Financial and Statistical Report, as analyzed by the
department. The facility cost report period casemix index shall be used to
normalize nursing hours.
|
|
Employee Turnover:
The facility has overall employee turnover of 50% or
less and CNA turnover of 55% or less.
|
Facility fiscal year ending on or before December 31
of the payment period
|
5 points if overall turnover is between 40% and 50%
and CNA turnover is between 45% and 55%
10 points if overall turnover is less than or equal
to 40% and CNA turnover is less than or equal to 45%
|
Financial and Statistical Report, as analyzed by the
department
|
|
Staff Education, Training and Development:
The facility provides staff education, training, and
development at 25% above the basic requirements for each position that requires
continuing education. The number of hours for these programs must apply to at
least 75% of all staff of the facility, based upon administrator or officer
certification.
|
Calendar year ending December 31 of the payment
period
|
5 points
|
Self-certification
|
|
Staff Satisfaction Survey:
The facility annually administers an anonymous staff
satisfaction survey. The survey tool must be developed, recognized, and
standardized by an entity external to the facility and must identify worker job
classification. Results must be tabulated by an entity external to the
facility.
To qualify for this measure, the facility must have a
response rate of at least 35%. A summary report of the aggregate results and
point scale must be made publicly available and be posted prominently along
with the facility's state survey results until the next satisfaction survey is
completed.
|
Survey completed between October 1 and March 31 of
the payment period
|
5 points
|
Nursing Facility Opinion Survey Transmittal,
submitted by independent entity that compiled results
|
|
Subcategory: Nationally Reported Quality
Measures
|
|
High-Risk Pressure Ulcer:
The facility has occurrences of high-risk pressure
ulcers at rates one-half standard deviation or more below the mean percentage
of occurrences for all facilities, based on MDS data as applied to the
nationally reported quality measures.
|
12-month period ending September
30 of the payment period
|
3 points if one-half to one standard deviation below
the mean percentage of occurrences
5 points if one standard deviation or more below the
mean percentage of occurrences
|
Department report based on MDS data as reported by
CMS
|
|
Physical Restraints:
The facility has a physical restraint rate of 0%
based on MDS data as applied to the nationally reported quality
measures.
|
12-month period ending September 30 of the payment
period
|
5 points
|
Department report based on MDS data as reported by
CMS
|
|
Chronic Care Pain:
The facility has occurrences of chronic care pain at
rates one-half standard deviation or more below the mean rate of occurrences
for all facilities based on MDS data as applied to the nationally reported
quality measures.
|
12-month period ending September
30 of the payment period
|
3 points if one-half to one standard deviation below
the mean rate of occurrences
5 points if one standard deviation or more below the
mean rate of occurrences
|
Department report based on MDS data as reported by
CMS
|
|
High Achievement of Nationally Reported Quality
Measures:
The facility received at least 9 points from a
combination of the measures listed in this subcategory.
|
12-month period ending September 30 of the payment
period
|
2 points if the facility receives 9 to 12 points in
the subcategory of nationally reported quality measures
4 points if the facility receives 13 to 15 points in
this subcategory
|
Department report based on MDS data as reported by
CMS
|
(7)
Domain 3: Access.
|
Standard
|
Measurement Period
|
Value
|
Source
|
|
Special Licensure Classification:
The facility has a unit licensed for the care of
residents with chronic confusion or a dementing illness (CCDI
unit).
|
Status on December 31 of the payment
period
|
4 points
|
DIAL list of facilities meeting the
standard
|
|
High Medicaid Utilization:
The facility has Medicaid utilization at or above the
statewide median plus 10%. Medicaid utilization is determined by dividing total
nursing facility Medicaid days by total nursing facility patient
days.
|
Facility fiscal year ending on or before December 31
of the payment period
|
3 points if Medicaid utilization is more than the
median plus 10%
4 points if Medicaid utilization is more than the
median plus 20%
|
Financial and Statistical Report, as analyzed by the
department
|
(8)
Domain 4: Efficiency.
|
Standard
|
Measurement Period
|
Value
|
Source
|
|
High Occupancy Rate:
The facility has an occupancy rate at or above 95%.
"Occupancy rate" is defined as the percentage derived when dividing total
patient days based on census logs by total bed days available based on the
number of authorized licensed beds within the facility.
|
Facility fiscal year ending on or before December 31
of the payment period
|
4 points
|
Financial and Statistical Report, as analyzed by the
department
|
|
Low Administrative Costs:
The facility's percentage of administrative costs to
total allowable costs is one-half standard deviation or more below the mean
percentage of administrative costs for all Iowa facilities.
|
Facility fiscal year ending on or before December 31
of the payment period
|
3 points if administrative costs percentage is less
than the mean less one-half standard deviation
4 points if administrative costs percentage is less
than the mean less one standard deviation
|
Financial and Statistical Report, as analyzed by the
department
|
(9)
Source of measurements. Source reports are due to the department by May 1 of
each year. For those measures whose source is self-certification, the data will
be drawn from a report submitted by the facility to the department. The
independent party that collects and compiles the results of the resident/
family survey shall communicate the results to the department on the Nursing
Facility Opinion Survey Transmittal. The department will request required
source reports from the long-term care ombudsman and the department of
inspections, appeals, and licensing.
(10) Calculation of potential add-on payment.
The number of points awarded will be determined annually, for each state fiscal
year for which funding is appropriated by the legislature. A determination is
made on whether a facility qualifies for an add-on payment at the end of the
payment period. Based upon the number of points awarded, a retroactive add-on
payment is made effective beginning the first day of the payment period as
follows, contingent upon legislative funding for the state fiscal year, and
subject to subparagraph (11):
|
Score
|
Amount of Add-on
Payment
|
|
0-50 points
|
No additional reimbursement
|
|
51-60 points
|
1 percent of the direct care plus nondirect care cost
component patient-day-weighted medians, subject to reduction as provided in
subparagraph (13)
|
|
61-70 points
|
2 percent of the direct care plus nondirect care cost
component patient-day-weighted medians, subject to reduction as provided in
subparagraph (13)
|
|
71-80 points
|
3 percent of the direct care plus nondirect care cost
component patient-day-weighted medians, subject to reduction as provided in
subparagraph (13)
|
|
81-90 points
|
4 percent of the direct care plus nondirect care cost
component patient-day-weighted medians, subject to reduction as provided in
subparagraph (13)
|
|
91-100 points
|
5 percent of the direct care plus nondirect care cost
component patient-day-weighted medians, subject to reduction as provided in
subparagraph (13)
|
(11)
Monitoring for reduction or forfeiture of reimbursement. The department will
request the department of inspections, appeals, and licensing to furnish by
September 1, December 1, March 1, and August 1 of each year a list of nursing
facilities subject to a reduction or forfeiture of the additional reimbursement
pursuant to the criteria in subparagraph (12) or (13).
(12) Forfeiture of additional reimbursement.
A nursing facility shall not be eligible for any additional reimbursement under
this program if during the payment period the nursing facility is cited for a
deficiency resulting in actual harm or immediate jeopardy pursuant to the
federal certification guidelines at a scope and severity level of H or higher,
regardless of the amount of fines assessed.
(13) Reduction of additional reimbursement.
The additional reimbursement for the nursing facility pay-for-performance
program calculated according to subparagraph (10) shall be subject to reduction
based on survey compliance as follows:
1. The
add-on payment shall be suspended for any month in which the nursing facility
has received denial of payment for new admission status that was enforced by
CMS.
2. A facility's add-on payment
shall be reduced by 25 percent for each citation received during the year for a
deficiency resulting in actual harm at a scope and severity level of G pursuant
to the federal certification guidelines.
3. If the facility fails to cure a cited
level G deficiency within the time allowed by the department of inspections,
appeals, and licensing, the add-on payment shall be forfeited, and the facility
shall not receive any nursing facility pay-for-performance program payment for
the payment period.
(14)
Application of additional payments. The additional reimbursement for the
nursing facility pay-for-performance program will be paid to qualifying
facilities at the end of the state fiscal year. At the end of each state fiscal
year, the department will:
1. Retroactively
adjust each qualifying facility's quarterly rates from the first day of the
state fiscal year to include the amount of additional reimbursement for the
nursing facility pay-for-performance program calculated according to paragraph
81.5(16)"g"; and
2. Reprice all facility claims with dates of
service during the period in which an additional reimbursement for the nursing
facility pay-for-performance program is effective to reflect the adjusted
reimbursement rate.
(15)
Use of additional payments. As a condition of eligibility for such payments,
any additional payments received by a nursing facility for the
pay-for-performance program must be:
1. Used
to support direct care staff through increased wages, enhanced benefits, and
expanded training opportunities; and
2. Used in a manner that improves and
enhances quality of care for residents.
(16) Monitoring facility compliance on the
use of payments. Each nursing facility shall complete the Nursing Facility
Medicaid Enhanced Payment Report to report the use of any additional payments
received for the nursing facility pay-for-performance program. The report is
due to the department each year by May 1. Failure to submit the report by the
due date shall result in disqualification for add-on payment for the next
pay-for-performance payment period.
(17) Reporting results of the program. The
department will publish the results of the nursing facility pay-for-performance
program annually.
h.
Capital cost per diem instant relief add-on and enhanced non-direct care rate
component limit. Contingent upon approval from the CMS and to the extent that
funding is appropriated by the Iowa general assembly, additional reimbursement
is available for nursing facilities that have completed a complete replacement,
new construction, or major renovations. Additional reimbursement under this
paragraph is available for services rendered beginning on October 1, 2007, or
beginning on the effective date of CMS approval if CMS approval is effective on
a later date.
(1) Types of additional
reimbursement. Two types of additional reimbursement are available:
1. The capital cost per diem instant relief
add-on is an amount per patient day to be added to the nondirect care component
of the reimbursement rate and is subject to the non-direct care rate component
limit as determined in paragraph "f."
2. The enhanced non-direct care rate
component limit provides an increase in the percentage of the median that is
applied when calculating the non-direct care rate component limit as defined in
paragraph "f." The percentage of the median is increased to
120 percent when the enhanced non-direct care rate component limit is
granted.
(2) Eligible
projects. To qualify for either the capital cost per diem instant relief add-on
or the enhanced non-direct care rate component limit, a facility must have
undertaken a complete replacement, new construction, or major renovations for
the purpose of:
1. Rectification of a
violation of Life Safety Code requirements; or
2. Development of home- and community-based
waiver program services; or
3.
Improving infection control by replacing or enhancing an HVAC system, as
defined in Iowa Code section
105.2.
(3) Additional requirements for all requests.
To qualify for additional reimbursement, a facility with an eligible project
must also meet the following requirements:
1.
The facility has Medicaid utilization at or above 40 percent. Medicaid patient
day utilization for this purpose is calculated as total nursing facility
Medicaid patient days divided by total patient days as reported on the
facility's most current financial and statistical report. Medicaid hospice
patient days will be counted toward the total nursing facility Medicaid patient
days.
2. The facility meets the
accountability measure criteria set forth in paragraph "g,"
subparagraph (1), deficiency-free survey, or subparagraph (2), regulatory
compliance with survey, based on the most current information available when
the request for additional reimbursement is submitted.
3. The facility has documented active
participation in a quality of care program.
4. The facility has documented plans to
facilitate person-directed care, dementia units, or specialty post-acute
services.
(4) Additional
requirements for waiver services. To qualify for additional reimbursement for
the development of home- and community-based waiver services, the facility
shall also meet the following requirements:
1. Services shall be provided in an
underserved area, which may include a rural area.
2. Services shall be provided on the direct
site of the facility but not as a nursing facility service.
3. Services shall meet all federal and state
requirements for Medicaid reimbursement.
4. Services shall include one or more of the
following: adult day care as defined by 441-subrule 78.37(1), consumer-directed
attendant care as defined by 441-subrule 78.37(15) provided in an assisted
living setting, day habilitation as defined by 441-subrule 78.41(14),
home-delivered meals as defined by 441-subrule 78.37(8), emergency response
system as defined by 441-subrule 78.37(2), and respite care as defined by
441-subrule 78.37(6).
(5) Submission of request. A facility shall
submit a written request for the capital cost per diem instant relief add-on,
the enhanced non-direct care rate component limit, or a preliminary evaluation
of whether a project may qualify for additional reimbursement to the
department. A qualifying facility may request one or both types of additional
reimbursement.
1. A request for the capital
cost per diem instant relief add-on may be submitted no earlier than 30 days
before the complete replacement, new construction, or major renovations are
placed in service.
2. A request for
the enhanced non-direct care rate component limit may be submitted with a
request for a capital cost per diem instant relief add-on or within 60 days
after the release of a rate determination letter reflecting a change in the
non-direct care rate component limit.
3. A request for a preliminary evaluation may
be submitted when a facility is preparing a feasibility projection for a
construction or renovation project. A preliminary evaluation does not guarantee
approval of the capital cost per diem instant relief add-on or enhanced
non-direct care rate component limit upon submission of a formal
request.
(6) Content of
request for add-on. A facility's request for the capital cost per diem instant
relief addon shall include:
1. A description
of the project for which the add-on is requested, including a list of goals for
the project and a time line of the project that spans the life of the
project.
2. Documentation that the
facility meets the qualifications in subparagraphs (2) and (3) and, if
applicable, in subparagraph (4).
3.
The period during which the add-on is requested (no more than two
years).
4. Whether the facility is
also requesting the enhanced non-direct care rate component limit. (See
subparagraph (7) for requirements.)
5. A copy of the facility's most current
depreciation schedule that clearly identifies the cost of the project for which
the add-on is requested if assets placed in service by that project are
included on the schedule. Any removal of assets shall be clearly identifiable
either on the depreciation schedule or on a separate detailed schedule, and
that schedule shall include the amount of depreciation expense for removed
assets that is included in the current reimbursement rate.
6. If the cost of the project is not reported
on the submitted depreciation schedule, a detailed schedule of the assets to be
placed in service by the project, including:
* The estimated date the assets will be placed into
service;
* The total estimated depreciable value of the assets;
* The estimated useful life of the assets based upon existing
Medicaid and Medicare provisions; and
* The estimated annual depreciation expense of the assets
using the straight-line method in accordance with generally accepted accounting
principles.
7. The
facility's estimated annual licensed bed capacity and estimated annual total
patient days. If this information is not provided, estimated annual total
patient days will be determined using the most current submitted financial and
statistical report.
8. If interest
expense has been or will be incurred and is related to the project for which
the add-on is requested, a copy of the general terms of the debt service and
the estimated annual amount of interest expense shall be submitted.
9. If any debt service has been retired, a
copy of the general terms of the debt service and the amount of interest
expense for debt service retired that is included in the current reimbursement
rate.
(7) Content of
request for enhanced limit. A facility's request for the enhanced non-direct
care rate component limit shall include:
1. A
description of the project for which the enhanced non-direct care rate
component limit is requested, including a list of goals for the project and a
time line of the project that spans the life of the project.
2. Documentation that the facility meets the
qualifications in subparagraphs (2) and (3) and, if applicable, in subparagraph
(4).
3. Identification of any
period in which the capital cost per diem instant relief add-on was previously
granted and the number of times the capital cost per diem instant relief add-on
and the enhanced non-direct care rate component limit have previously been
granted.
(8) Content of
request for preliminary evaluation. A facility's request for a preliminary
evaluation of a proposed project shall include:
1. The estimated completion date of the
project.
2. The estimated date when
a formal request for an add-on or enhanced limit will be submitted.
3. For a preliminary evaluation for a capital
cost per diem instant relief add-on, all information required in subparagraph
(6).
4. For a preliminary
evaluation for the enhanced non-direct care rate component limit, all
information required in subparagraph (7).
(9) Calculation of capital cost per diem
instant relief add-on. The capital cost per diem instant relief add-on is
calculated by dividing the annual estimated property costs for the complete
replacement, new construction, or major renovation project for which the add-on
is granted by the facility's estimated annual total patient days.
1. Effective December 1, 2009, total patient
days will be determined using the most current submitted financial and
statistical report or using the estimated total patient days as reported in the
request for the add-on. For purposes of calculating the add-on, total patient
days will be the greater of the estimated annual total patient days or 85
percent of the facility's estimated licensed capacity. For the period beginning
July 1, 2023, and ending June 30, 2025, patient days for purposes of the
computation of administrative, environmental, and property expenses for
non-state government-owned facilities will be inpatient days or the minimum
occupancy of 70 percent of the licensed capacity of the facility, whichever is
greater.
2. The annual estimated
property costs for the project are calculated as the estimated annual
depreciation expense for the cost of the project, plus estimated annual
interest expense for the cost of the project, less the amount of depreciation
expense for assets removed that is included in the current reimbursement rate
and the amount of interest expense for debt service retired that is included in
the current reimbursement rate.
3.
Estimated amounts and actual amounts will be reconciled as described in
subparagraph (12).
(10)
Effective date of capital cost per diem instant relief add-on. Subject to
available funding and previously approved requests for capital cost per diem
instant relief add-ons and enhanced non-direct care rate component limits, a
capital cost per diem instant relief add-on will be effective the first day of
the calendar quarter following the placement in service of the assets
associated with the add-on and receipt of all required information. The capital
cost per diem instant relief add-on will be added to the non-direct care
component of the reimbursement rate, not to exceed the non-direct care rate
component limit as determined in paragraph "f."
(11) Term of capital cost per diem instant
relief add-on. The period for which a facility may be granted the capital cost
per diem instant relief add-on shall not exceed two years. The capital cost per
diem instant relief add-on shall terminate at the time of the subsequent
biennial rebasing. If the facility's submitted annual financial and statistical
report used in the subsequent biennial rebasing does not include 12 months of
property costs for the assets with which the capital cost per diem instant
relief add-on is associated, including interest expense, if applicable, the
facility may submit a new request for the capital cost per diem instant relief
add-on.
(12) Reconciliation of
capital cost per diem instant relief add-on. During the period in which the
capital cost per diem instant relief add-on is granted, the department will
recalculate the amount of the add-on based on actual allowable costs and
patient days reported on the facility's submitted annual financial and
statistical report. A separate reconciliation will be performed for each cost
report period in which the capital cost per diem instant relief add-on was
paid. The facility shall submit with the annual financial and statistical
report a separate schedule reporting total patient days per calendar quarter
and a current depreciation schedule identifying the assets related to the
add-on.
1. For purposes of recalculating the
capital cost per diem instant relief add-on, total patient days will be based
on the greater of the number of actual patient days during the period in which
the add-on was paid or 85 percent of the facility's actual licensed bed
capacity during the period in which the add-on was paid. For the period
beginning July 1, 2023, and ending June 30, 2025, patient days for purposes of
the computation of administrative, environmental, and property expenses for
non-state government owned nursing facilities will be inpatient days or the
minimum occupancy of 70 percent of the licensed capacity of the facility,
whichever is greater.
2. The
recalculated capital cost per diem instant relief add-on will be added to the
non-direct care component of the reimbursement rate for the relevant period,
not to exceed the non-direct care rate component limit as determined in
paragraph "f." The facility's quarterly rates for the relevant
period will be retroactively adjusted to reflect the recalculated non-direct
care component of the reimbursement rate. All claims with dates of service
during the period the capital cost per diem instant relief add-on is paid will
be repriced to reflect the recalculated capital cost per diem instant relief
add-on.
(13) Effective
date of enhanced non-direct care rate component limit. Subject to available
funding and previously approved requests for capital cost per diem instant
relief add-ons and enhanced non-direct care rate component limits, an enhanced
non-direct care rate component limit will be effective:
1. With a capital cost per diem instant
relief add-on (if requested at the same time); or
2. Retroactive to the first day of the
quarter in which the revised non-direct care rate component limit amount is
effective. All claims with dates of service from the effective date will be
repriced.
(14) Term of
enhanced non-direct care rate component limit. The period for which a facility
may be granted an enhanced non-direct care rate component limit without
reapplication shall not exceed two years. The total period for which a facility
may be granted enhanced non-direct care rate component limits shall not exceed
ten years. If the amount of the non-direct care rate component limit is revised
during the period for which a facility is granted the enhanced limit, the
approval will be terminated effective the first day of the quarter in which the
revised non-direct care rate component limit is effective. The facility may
submit a new request for the enhanced non-direct care rate component
limit.
(15) Ongoing conditions. Any
capital cost per diem instant relief add-on or enhanced non-direct care rate
component limit granted by the department is temporary. Additional
reimbursement shall be immediately terminated if:
1. The facility does not continue to meet all
of the initial qualifications for additional reimbursement; or
2. The facility does not make reasonable
progress on any plans required for initial qualification; or
3. The facility's medical assistance program
or Medicare certification is revoked. A facility whose certification is revoked
is not eligible to submit a subsequent request for a capital cost per diem
instant relief add-on or the enhanced non-direct care rate component
limit.
(16) Change of
ownership. Following a change in nursing facility ownership, any capital cost
per diem instant relief add-on or enhanced non-direct care rate component limit
that was granted before the change in ownership will continue under the new
owner. Future reimbursement rates will be determined pursuant to subrules
81.5(15) and 81.5(16).
i. Quality incentive payment program (QIPP).
The QIPP add-on rate will be made to a qualified nonstate government-owned
nursing facility (NSGO nursing facility) to promote, maintain, and improve
resident quality of care and health outcomes.
(1) An NSGO nursing facility qualifies for
participation in the QIPP if all the following conditions are met:
1. The NSGO nursing facility has executed a
participation agreement with the department.
2. The NSGO nursing facility has provided
proof that the entity holds the NSGO nursing facility's license and has
complete operational responsibility for the NSGO nursing facility.
3. The NSGO nursing facility has filed a
certification of eligibility application for the QIPP add-on rate program with
the department and has received approval from the department for participation
in the program.
4. The NSGO nursing
facility is in compliance with all care criteria requirements.
5. The non-state government entity (NSGE) has
executed a nursing facility provider contract with an NSGO nursing
facility.
6. The NSGE has provided
and identified the source of state share dollars for the intergovernmental
transfer (IGT).
7. The NSGO nursing
facility has provided proof of ownership, if applicable, as the licensed
operator of the NSGO nursing facility.
8. The NSGO nursing facility has provided to
the department an executed management agreement between the NSGE and the NSGO
nursing facility manager if applicable.
(2) If at any time a provider is determined
not eligible due to not meeting survey standards, the provider will be
disqualified for the remainder of the year.
(3) An NSGO nursing facility will qualify for
participation in the QIPP if all the following quality measures are met:
|
Quality Measures
|
Metrics
|
Tracking/Scoring
|
Data Resource
|
|
Staffing
|
Metric 1: Nursing facility maintains an
additional four or more hours of registered nurse (RN) coverage per day beyond
the CMS minimum standard (8 hrs/day). Does not include managerial hours.
Metric 2: Nursing facility's
per-resident day certified nursing assistants (CNAs), rehabilitation aid, and
other contracted aid services are at or above one-half standard deviation above
the statewide mean of per-resident-day CNA hours. CNA hours include those of
CNAs, rehabilitation aid, and other contracted aide services. CNA hours will be
normalized to remove variations in staff hours associated with different levels
of resident case mix.
Metric 3: Nursing facility's
per-resident day total nursing hours are at or above one-half standard
deviation above the statewide mean of per-resident-day total nursing hours.
Nursing hours include those of RNs and licensed practical nurses (LPNs)
including restorative nurses. Nursing hours will be normalized to remove
variations in staff hours associated with different levels of resident case
mix.
|
Staffing metrics 1, 2, and 3 must be met for facility
to be eligible for per diem rate addon payment.
|
Payroll-based journal (PBJ) or cost
reports
|
|
Infection Control
|
Metric 1: Nursing facility has an
infection control program that includes antibiotic stewardship. The program
incorporates policies and training as well as monitoring, documenting, and
providing staff with feedback.
Metric 2: Percentage of residents with
urinary tract infections (UTIs) at rates one-half standard deviation or more
below the mean percentage of occurrences for all facilities, based on minimum
data set (MDS) data as applied to the nationally reported quality
measures.
Metric 3: Percentage of residents with
up-to-date pneumonia vaccine measured against a fixed benchmark that is set as
the most recently published national average for the related MDS quality
metric.
|
Infection control metrics 1, 2, and 3 must be met for
facility to be eligible for per diem rate add-on payment.
|
Nursing facility will be required to provide its
infection control policy and procedure. In addition, facilities will need to
provide information regarding training, monitoring, documentation and
monitoring of required elements to meet this metric on a periodic basis CASPER
Report MDS Assessment Care Compare
|
|
Quality Measures
|
Metric 1: Percentage of high-risk
residents with pressure ulcers (for longer-term stay residents) are at rates
one-half standard deviation or more below the mean percentage of occurrences
for all facilities, based on MDS data as applied to the nationally reported
quality measures.
Metric 2: Percentage of residents who
had a fall with major injury (for longer-term stay residents) are at rates
one-half standard deviation or more below the mean percentage of occurrences
for all facilities, based on MDS data as applied to the nationally reported
quality measures.
Metric 3: Percentage of residents who
received antipsychotic medications are at rates one-half standard deviation or
more below the mean percentage of occurrences for all facilities, based on MDS
data as applied to the nationally reported quality measures.
Metric 4: Percentage of residents who
required increased activities of daily living (ADL) assistance (for longer-term
stay residents) are at rates one-half standard deviation or more below the mean
percentage of occurrences for all facilities, based on MDS data as applied to
the nationally reported quality measures.
|
Quality measures metrics 1, 2, 3, and 4 must be met
for the facility to be eligible for per diem rate add-on
payment.
|
CASPER Report MDS Assessment Care Compare
|
|
State Survey Results
|
Number of deficiencies is at or below the state of
Iowa average number of nursing facility deficiencies
AND the facility has no deficiencies with a scope of
F, H, I, J, K, or L.
|
State survey results must be met for the facility to
be eligible for per diem rate addon payment.
|
Department of inspections, appeals, and licensing
(DIAL) surveys
|
|
Quality Assurance Performance Improvement
(QAPI) Report
|
Nursing facility must submit QAPI reports on
quarterly basis.
|
QAPI results must be submitted for the facility to be
eligible for per diem rate add-on payment.
|
QAPI reports
|
(4)
A provider must submit the Intent to Participate Agreement on or before
September 30 each year and include all necessary documentation related to the
quality measures.
1. Upon receipt of the
participation agreement, the department will complete a determination of
eligibility based on the care criteria defined above.
2. Providers will be notified of their
eligibility annually within 60 days of the agreement due date.
(5) The nursing facility QIPP
add-on rate provided to a participating NSGO nursing facility under the QIPP
will not exceed Medicare payment principles pursuant to
42 CFR
447.272 (as amended to August 1, 2024) and
will be calculated pursuant to
42 CFR
438.6 (as amended to August 1, 2024). The
QIPP add-on rate will be calculated and paid as follows:
1. The methodology utilized to calculate the
upper payment limit will be based on the data available during the calculation
period.
2. The eligible amount used
in determining the QIPP add-on rate will be the difference between the state
Medicaid payment and the Medicare upper payment limit as determined, on an
annual basis, using all Medicaid claims, including fee-for-service (FFS) and
Medicaid managed care claims.
3.
The difference calculated under numbered paragraph "2" will be divided by total
patient days pursuant to subrule 81.5(7).
4. The QIPP add-on rate will be paid
prospectively.
(6) A
participating NSGO nursing facility shall notify the department of any change
of ownership that may affect the participating NSGO nursing facility's
continued eligibility for the QIPP a minimum of 30 days prior to such change.
1. If a participating NSGO nursing facility
changes ownership to a privately owned entity, on or after the first day of the
QIPP add-on rate calculation period, the privately owned provider is no longer
eligible for the QIPP add-on rate.
2. A participating facility must meet the CMS
and department requirements to be classified as an NSGO nursing facility. All
changes of ownership must be a fair market value transaction.
3. If it is determined that a provider is not
a qualified NSGO nursing facility per CMS and the department, the provider
shall repay all QIPP add-on payments to the department.
(7) Providers that do not meet eligibility
requirements above will be notified of the metrics that were not met.
(8) A participating NSGO nursing facility
shall secure allowable intergovernmental transfer funds from a participating
NSGE to provide the state share amount. The process for the intergovernmental
transfer shall comply with the following:
1.
The department, or the department's designee, will notify the participating
NSGO nursing facility of the state share amount to be transferred in the form
of an intergovernmental transfer for purposes of seeking federal financial
participation for the QIPP add-on rate, within 15 business days after the end
of each month. The participating NSGO shall have until the end of the month to
remit payment of the state share amount in the form of an intergovernmental
transfer to the department or the department's designee.
2. If there is any outstanding
intergovernmental transfer amount at the end of the payment period, the
provider will not be able to participate in the QIPP the following
year.
(17)
Cost report
documentation. All nursing facilities, except the Iowa Veterans Home,
shall submit an annual cost report based on the closing date of the facility's
fiscal year that incorporates documentation as set forth below. The Iowa
Veterans Home shall submit semiannual cost reports based on the closing date of
the facility's fiscal year and the midpoint of the facility's fiscal year that
incorporate documentation as set forth below. The documentation incorporated in
all cost reports shall include all of the following information:
a. Information on staffing costs, including
the number of hours of the following provided per resident per day by all the
following: nursing services provided by registered nurses, licensed practical
nurses, certified nurse aides, restorative aides, certified medication aides,
and contracted nursing services; other care services; administrative functions;
housekeeping and maintenance; and dietary services.
b. The starting and average hourly wage for
each class of employees for the period of the report.
c. An itemization of expenses attributable to
the home or principal office or headquarters of the nursing facility included
in the administrative cost line item.
(18)
Inflation factor. The
department will consider an inflation factor in determining the reimbursement
rate. The inflation factor will be based on the CMS Total Skilled Nursing
Facility (CMS/ SNF) Market Basket Index published by Data Resources, Inc. The
CMS/SNF index listed in the latest available quarterly publication prior to the
July 1 rate setting will be used to determine the inflation factor.
(19)
Case-mix index
calculation.
a. The RUG-III Version
5.12b, 34 group, index maximizer model will be used as the resident
classification system to determine all case-mix indices, using data from the
minimum data set (MDS) submitted by each facility pursuant to subrule 81.12(9).
Standard Version 5.12b case-mix indices developed by CMS will be the basis for
calculating the average case-mix index and will be used to adjust the direct
care costs in the determination of the direct care patient-day-weighted median
and the reimbursement rate pursuant to subrule 81.5(16).
b. Each resident in the facility on the last
day of each calendar quarter with a completed and submitted assessment will be
assigned a RUG-III 34 group calculated on the resident's most current
assessment available on the last day of each calendar quarter. This RUG-III
group will be translated to the appropriate case-mix index referenced in
paragraph
"a." From the individual resident case-mix indices,
two average case-mix indices for each Medicaid nursing facility will be
determined four times per year based on the last day of each calendar quarter.
The facilitywide average case-mix index is the simple
average, carried to four decimal places, of all resident case-mix indices. The
Medicaid average case-mix index is the simple average, carried to four decimal
places, of all indices for residents where Medicaid is known to be the per diem
payor source on the last day of the calendar quarter. Assessments that cannot
be classified to a RUG-III group due to errors will be excluded from both
average case-mix index calculations.
(20)
Medicare crossover claims for
nursing facility services.
a.
Definitions. For purposes of this subrule:
"Crossover claim" means a claim for Medicaid
payment for Medicare-covered nursing facility services rendered to a Medicare
beneficiary who is also eligible for Medicaid. Crossover claims include claims
for services rendered to beneficiaries who are eligible for Medicaid in any
category, including but not limited to qualified Medicare beneficiaries and
beneficiaries who are eligible for full Medicaid coverage.
"Medicaid-allowed amount" means the Medicaid
reimbursement rate for the services rendered (including any portion to be paid
by the Medicaid beneficiary as client participation) multiplied by the number
of Medicaid units of service included in a crossover claim, as determined under
state and federal law and policies.
"Medicaid reimbursement" includes any amount
to be paid by the Medicaid beneficiary as Medicaid client participation and any
amount to be paid by the department after application of any applicable
Medicaid client participation.
"Medicare payment amount" means the Medicare
reimbursement rate for the services rendered multiplied by the number of
Medicare units of service included in a crossover claim, excluding any Medicare
coinsurance or deductible amounts to be paid by the Medicare
beneficiary.
b.
Crossover claims. Crossover claims for services covered under
Medicare Part A and under Medicaid are reimbursed as set out in this paragraph.
(1) If the Medicare payment amount for a
crossover claim exceeds or equals the Medicaid-allowed amount for that claim,
Medicaid reimbursement for the crossover claim will be zero.
(2) If the Medicaid-allowed amount for a
crossover claim exceeds the Medicare payment amount for that claim, Medicaid
reimbursement for the crossover claim is the lesser of:
1. The Medicaid-allowed amount minus the
Medicare payment amount; or
2. The
Medicare coinsurance and deductible amounts applicable to the claim.
(21)
Nursing facility quality assurance payments.
a.
Quality assurance assessment
pass-through. Effective with the implementation of the quality
assurance assessment paid pursuant to 441-Chapter 36, a quality assurance
assessment pass-through will be added to the Medicaid per diem reimbursement
rate as otherwise calculated pursuant to this rule. The quality assurance
assessment pass-through will equal the per-patient-day assessment determined
pursuant to 441-subrule 36.6(2).
b.
Quality assurance assessment rate add-on. Effective with the
implementation of the quality assurance assessment paid pursuant to 441-Chapter
36, a quality assurance add-on of $37 per patient day will be added to the
Medicaid per diem reimbursement rate as otherwise calculated pursuant to this
rule.
c.
Use of the
pass-through and add-on. As a condition for receipt of the
pass-through and add-on, each nursing facility shall submit information to the
department on the Nursing Facility Medicaid Enhanced Payment Report
demonstrating compliance by the nursing facility with the requirements for use
of the pass-through and add-on. If the sum of the quality assurance assessment
pass-through and the quality assurance assessment rate add-on is greater than
the total cost incurred by a nursing facility in payment of the quality
assurance assessment:
(1) No less than 35
percent of the difference will be used to increase compensation and costs of
employment for direct care workers determined pursuant to Iowa Code section
249L.4.
(2) No less than 60 percent of the difference
will be used to increase compensation and costs of employment for all nursing
facility staff, with increases in compensation and costs of employment
determined pursuant to Iowa Code section
249L.4.
d.
Effective date. Until
federal financial participation to match money collected from the quality
assurance assessment pursuant to 441-Chapter 36 has been approved by CMS, none
of the nursing facility rate-setting methodologies of this subrule will become
effective.
e.
End
date. If CMS determines that federal financial participation to match
money collected from the quality assurance assessment pursuant to 441-Chapter
36 is unavailable for any period, or if the department no longer has the
authority to collect the assessment, then beginning on the effective date that
such federal financial participation is not available or authority to collect
the assessment is rescinded, none of the nursing facility rate-setting
methodologies of this subrule will be effective. If the period for which
federal match money is unavailable or the authority to collect the assessment
is rescinded includes a retroactive period, the department will:
(1) Recalculate Medicaid rates in effect
during that period without the rate-setting methodologies of this
subrule;
(2) Recompute Medicaid
payments due based on the recalculated Medicaid rates;
(3) Recoup any previous overpayments;
and
(4) Determine for each nursing
facility the amount of quality assurance assessment collected during that
period and refund that amount to the facility.
This rule is intended to implement Iowa Code sections
249A.4 and
249A.16 and chapters 249K and
249L.
