101 CMR, § 129.06 - Administrative Adjustment to Inpatient Per Diem Rate

(1) Timing. An ICF may apply for a discretionary administrative adjustment to its Inpatient Per Diem Rate based upon the grounds set forth in 101 CMR 129.06(1)(a) and (b). Adjustments shall be effective on the later of:

(a) the beginning of the quarter (July 1^st, October 1^st, January 1^st, April 1^st) in which a complete application is received; or

(b) the date the costs shall be incurred.

(2) Limitations. The following are grounds for an administrative adjustment.

(a) Mechanical Error. There has been a mechanical error in calculating the Inpatient Per Diem Rate approved under 101 CMR 129.00.

(b) Governmental Requirements. Statutory or regulatory requirements of a governmental unit or the federal government have generated a substantial change in allowable costs as adjusted pursuant to 101 CMR 129.05. Documentation shall include written certification or a copy of an official notice from the governmental unit detailing the new requirements imposed on the ICF and the verification of the costs.

(c) Disaster Losses. The ICF has incurred disaster losses in excess of insurance or extraordinary costs related to disaster losses not covered by outside sources. Documentation shall include verification of loss or extraordinary cost and the insurance or outside source payment. If, however, the loss or extraordinary cost is caused by a facility being inadequately insured according to the standards of the ICF industry, or through negligence on the part of facility management, such losses or costs shall not be approved.

(d) Determination of Need (DON) Operating Costs. An ICF has incurred or expects to incur an increase in operating costs associated with a major capital expenditure or substantial change in services that is subject to and has received a DON pursuant to M.G.L. c. 111, §§ 25B through 25G. In its application, the ICF must segregate the increased costs from other allowed operating costs and must demonstrate that the increased costs requested are reasonable. If an approved DON results in increased patient days, those increased patient days shall be added to the Total Patient Days used in the Inpatient Rate.

(e) Substantial Change from Base Year Costs. An ICF may request an adjustment to its Initial Per Diem Rate if the ICF has determined that there shall be a substantial variance between base year costs and rate year costs. The ICF may request that EOHHS set the Initial Per Diem Rate without the cost adjustment factor determined pursuant to 101 CMR 129.05(3). The ICF may also request that EOHHS review more recent cost and utilization data to determine a revised Initial Per Diem Rate.

(3) Submission for Administrative Adjustment.

(a) An application for administrative adjustment shall be made to the Medicaid Director of EOHHS in writing and shall contain the following:

1. the name and address of the ICF;

2. the approved Inpatient Rate and change to be reviewed and the rate or change sought by administrative adjustment;

3. a clear, concise statement of the reasons for the application for administrative adjustment;

4. a detailed statement of financial, statistical and related information in support of the application;

5. all information and documentation required under 101 CMR 129.03;

6. a citation to any statutory, regulatory or contractual requirement in support of the application.

7. such other books, records and information as may be required by EOHHS; and

8. a certification by the chief executive officer or financial officer of the ICF that the application and all information, reports, schedules, budgets, books, and records submitted are true, correct, and accurate.

(b) Requests for an administrative adjustment shall be accompanied by full and complete documentation of the request. EOHHS may deny any request for an administrative adjustment for which documentation is not submitted.

(4) Administrative Adjustment Decision. Within 60 days from receipt of a complete and satisfactory application for administrative adjustment, EOHHS shall render a decision. A written statement of reasons for the decision shall be provided upon request.

Notes

101 CMR, § 129.06