Or. Admin. Code § 410-144-0050 - Supplemental Payments Methodology
Supplemental payments are determined using the following methods:
(1) The aggregate available
supplemental payment amount for privately-owned Nursing Facilities (NFs) is
calculated for each aggregate Medicaid supplemental payment limit calculation
period by taking the difference between the aggregate upper payment limit (UPL)
from paragraph (a) of this subsection and the aggregate Medicaid payment from
paragraph (b) of this subsection.
(a) The
aggregate upper payment limit for privately-owned NFs, as presented in the most
recently completed Medicaid NF UPL calculation submitted to CMS, shall be
calculated in accordance with the Medicaid UPL provisions codified at
Title 42 CFR §
447.272 as follows:
(A) Determine aggregate costs under Medicare
cost principles using the most recently filed or settled CMS 2540 skilled
nursing facility cost reports for privately-owned NFs.
(B) Determine the per diem cost by dividing
the aggregate costs from subparagraph (A) of this paragraph by total days of
service associated with the same cost reports.
(C) Extract Medicaid days of service for
privately-owned NFs from the state's Medicaid Management Information System
(MMIS) for the cost reporting periods associated with the cost reports
described in clause (A) of this subparagraph.
(D) Determine aggregate Medicaid costs by
multiplying the per diem Medicaid cost from section (B) of this paragraph by
Medicaid days of service from section 1(a)(C) of this rule.
(b) The aggregate Medicaid payment
is equal to sum of Medicaid payments for privately-owned NFs from the aggregate
Medicaid supplemental payment limit calculation period. Payment data includes
Medicaid regular per diem payments, per diem drug payments, and per diem client
contributions.
(2) The
aggregate available supplemental payment amount is not to exceed the lower of
95 percent of the aggregate available supplemental payment amount for privately
owned NFs from section (1) of this rule and the general fund revenue allocated
to the program plus associated federal matching funds.
(3) The state may further reduce the
aggregate available supplement payment amount from section (2) of this rule if
the aggregate upper payment limit for privately-owned NFs from section (1)(a)
of this rule is projected to decrease between the aggregate Medicaid
supplemental payment limit calculation period and the federal fiscal year
within which the applicable NF-level Medicaid supplemental payment limit
calculation period falls.
(4)
Methodology to calculate NF-specific supplemental payment amounts:
(a) Divide the aggregate available
supplemental payment amount from section (2) of this rule by a minimum of two
(2);
(b) Extract Medicaid days of
service for privately-owned NFs that have qualified for a supplemental payment
from the state's MMIS for the NF-level Medicaid supplemental payment limit
calculation period;
(c) The
allocation percentage for each qualifying NF shall be determined by dividing
the individual NF's total Medicaid days from section (2) of this rule by the
aggregate sum of all qualifying NFs' Medicaid days from the same
section;
(d) The NF-specific
supplemental payment for the NF-level Medicaid supplemental payment limit
calculation period shall equal the aggregate available supplemental payment
amount from subsection (4)(a) of this rule multiplied by the NF's allocation
percentage from subsection (4)(c) of this rule.
(e) The supplemental payment does not exceed
applicable Federal upper payment limit requirements.
(5) Methodology to calculate eligible
behavioral health care provider (BHCP) supplemental payment amounts.
(a) Establish a payment pool of total
available supplemental payment amount for all qualifying BHCP which is equal to
the general fund revenue appropriated plus associated federal matching
funds.
(b) Extract Medicaid
payments for eligible BHCPs determined per Eligibility rule
410-144-0010 section (4)(a-d)
from the state's Medicaid Management Information System (MMIS) for effective
dates of payments.
(c) The
allocation percentage for each eligible BHCP will be determined by dividing the
BHCP's total Medicaid revenue from subsection (4)(b) of this rule by the
aggregate sum of all eligible BHCPs' Medicaid revenue from the same
subsection;
(d) The BHCP-specific
supplemental payment will equal the total available supplemental payment amount
from subsection (4)(a) of this rule multiplied by the allocation percentage
from subsection (4)(c) of this rule.
(e) The supplemental payment does not exceed
applicable Federal upper payment limit requirements.
Notes
Statutory/Other Authority: ORS 410.070 & 413.042
Statutes/Other Implemented: ORS 410.070, 414.033 & OL 2021 ch. 595
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Supplemental payments are determined using the following methods:
(1) The aggregate available supplemental payment amount for privately-owned Nursing Facilities (NFs) is calculated for each aggregate Medicaid supplemental payment limit calculation period by taking the difference between the aggregate upper payment limit (UPL) from paragraph (a) of this subsection and the aggregate Medicaid payment from paragraph (b) of this subsection.
(a) The aggregate upper payment limit for privately-owned NFs, as presented in the most recently completed Medicaid NF UPL calculation submitted to CMS, shall be calculated in accordance with the Medicaid UPL provisions codified at Title 42 CFR § 447.272 as follows:
(A) Determine aggregate costs under Medicare cost principles using the most recently filed or settled CMS 2540 skilled nursing facility cost reports for privately-owned NFs.
(B) Determine the per diem cost by dividing the aggregate costs from subparagraph (A) of this paragraph by total days of service associated with the same cost reports.
(C) Extract Medicaid days of service for privately-owned NFs from the state's Medicaid Management Information System (MMIS) for the cost reporting periods associated with the cost reports described in clause (A) of this subparagraph.
(D) Determine aggregate Medicaid costs by multiplying the per diem Medicaid cost from section (B) of this paragraph by Medicaid days of service from section (C) of this section.
(b) The aggregate Medicaid payment is equal to sum of Medicaid payments for privately-owned NFs from the aggregate Medicaid supplemental payment limit calculation period. Payment data includes Medicaid regular per diem payments, per diem drug payments, and per diem client contributions.
(2) The aggregate available supplemental payment amount is not to exceed the lower of 95 percent of the aggregate available supplemental payment amount for privately owned NFs from section (1) of this rule and the general fund revenue allocated to the program plus associated federal matching funds.
(3) The state may further reduce the aggregate available supplement payment amount from section (2) of this rule if the aggregate upper payment limit for privately-owned NFs from section (1)(a) of this rule is projected to decrease between the aggregate Medicaid supplemental payment limit calculation period and the federal fiscal year within which the applicable NF-level Medicaid supplemental payment limit calculation period falls.
(4) Methodology to calculate NF-specific supplemental payment amounts.
(a) Divide the aggregate available supplemental payment amount from section (2) of this rule by four;
(b) Extract Medicaid days of service for privately-owned NFs that have qualified for a supplemental payment from the state's MMIS for the NF-level Medicaid supplemental payment limit calculation period;
(c) The allocation percentage for each qualifying NF shall be determined by dividing the individual NF's total Medicaid days from section (2) of this rule by the aggregate sum of all qualifying NFs' Medicaid days from the same section;
(d) The NF-specific supplemental payment for the NF-level Medicaid supplemental payment limit calculation period shall equal the aggregate available supplemental payment amount from subsection (4)(a) of this rule multiplied by the NF's allocation percentage from subsection (4)(c) of this rule.
(e) The supplemental payment does not exceed applicable Federal upper payment limit requirements.
Notes
Statutory/Other Authority: ORS 410.070 & 413.042
Statutes/Other Implemented: ORS 410.070, 414.033 & OL 2021 ch. 595