Mont. Admin. r. 37.40.307 - NURSING FACILITY REIMBURSEMENT
(1)
For nursing facility services provided by nursing facilities located within the
state of Montana, the Montana Medicaid program will pay a provider, for each
Medicaid patient day, a per-diem rate determined in accordance with this rule,
minus the amount of the Medicaid recipient's patient contribution.
(2) Effective July 1, 2020, and in subsequent
rate years, the reimbursement rate for each nursing facility will be determined
using the flat-rate component specified in (2)(a) and the quality component
specified in (2)(b).
(a) The flat-rate
component is the same per-diem rate for each nursing facility and will be
determined each year through a public process. Factors that could be considered
in the establishment of this flat-rate component include the cost of providing
nursing facility services and Medicaid recipient access to nursing facility
services. The flat-rate component for state fiscal year (SFY) 2025 is
$278.75.
(b) The quality component
of each nursing facility's rate is based on the five-star rating system for
nursing facility services, calculated by the Centers for Medicare &
Medicaid Services (CMS). It is set for each facility based on its average
five-star ratings for staffing and for quality. Facilities with an average
rating of three to five stars will receive a quality-component payment. The
funding for the quality-component payment will be divided by the total
estimated Medicaid bed days to determine the quality component per Medicaid bed
day. The quality component per bed day is then adjusted based on each
facility's five-star average of staffing and quality-component scores. A
facility with a five-star average of staffing and quality component scores will
receive 100% of the quality-component payment, a four-star average will receive
75%, a three-star average will receive 50%, and one- and two-star average
facilities will receive 0%. Funds unused by the first allocation round will be
reallocated based on the facility's percentage of unused allocation against the
available funds.
(c) The total
payment rate available for the period July 1, 2024, through June 30, 2025, will
be the rate as computed in (2), plus any additional amount computed in ARM
37.40.311 and
37.40.361. Copies of the
department's current nursing facility Medicaid reimbursement rates per facility
are posted at https://medicaidprovider.mt.gov/26,
or may be obtained from the Department of Public Health and Human Services,
Senior and LongTerm Care Division, P.O. Box 4210, Helena, MT
59604-4210.
(3)
Providers who, as of July 1 of the rate year, have not filed with the
department a cost report covering a period of at least six months'
participation in the Medicaid program in a newly constructed facility will have
a rate set at the flat-rate component as computed on July 1, 2024. Following a
change in provider as defined in ARM
37.40.325, the per diem rate for
the new provider will be set at the previous provider's rate, as if no change
in provider had occurred.
(4) For
nursing facility services provided by nursing facilities located outside the
state of Montana, the Montana Medicaid program will pay a provider only as
provided in ARM
37.40.337.
(5) The Montana Medicaid program will not pay
any provider for items billable to residents under the provisions of ARM
37.40.331.
(6) Reimbursement for Medicare coinsurance
days will be as follows:
(a) for dually
eligible Medicaid and Medicare individuals, reimbursement is limited to the
per-diem rate, as determined under (1) or ARM
37.40.336, or the Medicare
co-insurance rate, whichever is lower, minus the Medicaid recipient's patient
contribution; and
(b) for
individuals whose Medicare buy-in premium is being paid under the qualified
Medicare beneficiary (QMB) program under ARM
37.83.201, but are not otherwise
Medicaid eligible, payment will be made only under the QMB program at the
Medicare coinsurance rate.
(7) The department will not make any nursing
facility per-diem or other reimbursement payments for any patient day for which
a resident is not admitted to a facility bed that is licensed and certified as
provided in ARM
37.40.306 as a nursing facility or
skilled nursing facility bed.
(8)
The department will not reimburse a nursing facility for any patient day for
which another nursing facility is holding a bed under the provisions of ARM
37.40.338(1),
unless the nursing facility seeking such payment has, prior to admission,
notified the facility holding a bed that the resident has been admitted to
another nursing facility. The nursing facility seeking such payment must
maintain written documentation of such notification.
(9) Providers must bill for all services and
supplies in accordance with the provisions of ARM
37.85.406. The department's fiscal
agent will pay a provider the amount determined under these rules upon receipt
of an appropriate billing which reports the number of patient days of nursing
facility services provided to authorized Medicaid recipients during the billing
period.
(10) Payments
provided under this rule are subject to all limitations and cost settlement
provisions specified in applicable laws, regulations, rules, and policies. All
payments or rights to payments under this rule are subject to recovery or
nonpayment, as specifically provided in these rules.
Notes
AUTH: 53-2-201, 53-6-113, MCA; IMP: 53-6-101, 53-6-111, 53-6-113, MCA
State regulations are updated quarterly; we currently have two versions available. Below is a comparison between our most recent version and the prior quarterly release. More comparison features will be added as we have more versions to compare.
No prior version found.