The following definitions apply to nursing facility (NF)
provider reimbursement. Additional definitions are contained in Chapter
1200-13-01.
(1) Acceptable Cost
Report- The skilled nursing facility (SNF) cost report (Medicare form 254010),
or hospital health care complex cost report (Medicare form 2552-10), Medicaid
supplemental cost report form, and required additional information. To be
acceptable, the appropriate forms and required additional information must be
filed with the Comptroller by the required due date, and meet the acceptance
criteria on the acceptance check list. The Medicaid supplemental cost report
form and acceptance check list are available on TennCare's main website under
the LTSS subsection.
(2) Active MDS
Assessment- A resident's MDS assessment is considered active when it has been
accepted by CMS. The assessment will remain active until a subsequent MDS
assessment for the same resident is received by CMS, or the assessment becomes
a Delinquent MDS Resident Assessment.
(3) Administrative and Operating Cost
Component - The portion of the Medicaid daily NF rate that is attributable to
the general administration and operation of the NF. These costs include the
allowable and reimbursable SNF/NF costs that are not included in the Direct
Care Case Mix Adjusted, Direct Care Non-Case Mix Adjusted, Capital, Cost-Based,
or Excluded cost components.
(4)
Annualized Medicaid Resident Day-Weighted Median Cost - A numerical value
determined by arraying the per diem costs and total annualized Medicaid
resident days of each NF provider from low to high and identifying the point in
the array at which the cumulative total of all annualized Medicaid resident
days first equals or exceeds half the number of the total annual Medicaid
resident days for all Medicaid participating NF providers. The per diem cost at
this point is the annualized Medicaid resident day-weighted median
cost.
(5) Appraisal Value- The most
current depreciated NF appraised value as determined by the certified appraisal
firm designated by TennCare. TennCare's certified appraisal contractor must be
selected through a formal procurement process for a single statewide
contract.
(6) Capital Cost
Component- The portion of the NF rate that is designed to compensate providers
for their capital costs. These cost centers include the SNF/NF portion of:
1) Capital Related Costs- Building and
Fixtures cost center (and applicable subscripted cost centers);
2) The Capital Related Costs - Moveable
Equipment (and applicable subscripted cost centers); and
3) Other Capital Related Costs (and
applicable subscripted cost centers). If real estate tax cost related to the
SNF/NF is reported in one of these cost centers, then real estate tax cost will
be excluded from the capital cost component, and included in the costbased
component.
(7) Case Mix-
A measure of the intensity of care a resident required, as documented on the
MDS and measured using the RUG-IV 48 Grouper resident classification system.
CMS nursing-only RUG weights will be utilized.
(8) Comptroller- The Tennessee Office of the
Comptroller of the Treasury, or its successor, and the associated work product
of its contractors and agents.
(9)
CMS- The Centers for Medicare and Medicaid Services.
(10) Cost-Based Component- The portion of the
per diem rate attributable to real estate taxes related to NF services, and NF
provider assessment costs.
(11)
Delinquent MDS Resident Assessment- An MDS assessment that is more than 113
days old as of the end date of the MDS assessment collection period for each
semi-annual rate period, as measured from the Assessment Reference Date (ARD)
field on the MDS.
(12) Direct Care
Case Mix Adjusted Cost Component - The portion of the Medicaid daily NF rate
that is attributable to salaries, contract labor, and direct/apportioned
payroll tax and employee benefit expense for registered nurses (RN), licensed
practical/vocational nurses (LPN/LVN), and certified nurse aides (CNA) or
orderlies that are providing direct SNF/NF patient care services. Costs
associated with SNF/NF administrative nursing functions (Director of Nursing
(DON), Assistant Director of Nursing (ADON), Minimum Data Set (MDS)
coordinator, Quality Assurance (QA) coordinator, In-service/training
coordinator) are not included in this cost component. Direct care case mix
adjusted cost also includes a proportionate allocation of pooled payroll taxes
and employee benefits expenses. Pooled payroll taxes and employee benefits will
be apportioned to this cost component using Medicare cost report cost
apportionment mechanics. All cost component costs are subject to the methods of
apportionment in the Medicare cost report. Any portion of cost component
expenses that are allocated to non-reimbursable cost centers or non-nursing
facility (SNF/NF) cost centers, as designated by TennCare, will be excluded
from cost component totals.
(13)
Direct Care Non-Case Mix Adjusted Cost Component - The portion of the Medicaid
daily NF rate that is attributable to salaries, contract labor, and
direct/apportioned payroll tax and employee benefit expense associated with NF
DON and ADON duties, the cost of raw food and special dietary supplements
reported on the Medicaid supplemental cost report (includes those dietary
supplements used for tube feeding or oral feeding, such as elemental high
nitrogen diet, even when prescribed by a physician as defined by CMS
Publication 15-1, The Provider Reimbursement Manual - Part I, section 2203.1),
and staff associated with the provision of social services and recreational
activities to NF residents. Direct care non-case mix adjusted cost also
includes a proportionate allocation of pooled payroll taxes and employee
benefits expenses. Pooled payroll taxes and employee benefits will be
apportioned to this cost component using Medicare cost report cost
apportionment mechanics. All cost component costs are subject to the methods of
apportionment in the Medicare cost report. Any portion of cost component costs
that are allocated to non-reimbursable cost centers or non-nursing facility
(SNF/NF) cost centers, as designated by TennCare, will be excluded from cost
component totals.
(14) Excluded
Cost Component- The portion of NF provider expense that will be excluded from
allowable cost and not included in rate determination:
(a) The Nursing and Allied Health cost center
(and applicable subscripted cost centers).
(b) The Interns and Residents cost centers
(and applicable subscripted cost centers).
(c) The ParaMed Program cost center (and
applicable subscripted cost centers).
(d) The direct costs of all non-overhead
(general services) and non-routine SNF/NF cost centers.
(e) Overhead (general service) cost center
expense allocations to non-SNF/NF routine cost centers, outpatient cost
centers, and non-reimbursable cost centers, as determined by
TennCare.
(f) For hospital-based NF
overhead (general services), cost allocations to cost centers other than the
SNF/NF routine cost centers, are excluded from rate setting allowable
costs.
(15) Fair Rental
Value (FRV)- The methodology used to calculate the capital reimbursement per
diem rate for Medicaid participating NF.
(16) Final Case Mix Index Report (FCIR)- A
semi-annual report reflecting the Medicaid and facility-wide case mix index for
each NF using the time-weighted acuity measurement system, and end of therapy
dates.
(17) Fixed Assets- Buildings
and building equipment, as described by CMS Publication 15-1, The Provider
Reimbursement Manual- Part 1, sections 104.2 and 104.3.
(18) Index Factor- The most recently
published Skilled Nursing Facility without Capital Market Basket Index, as
produced for subscribers by IHS Global Insight (IHS Economics), or a comparable
index, if this index ceases to be produced.
(19) Major Movable Equipment- Capitalized
assets as defined by CMS Publication 15-1, The Provider Reimbursement Manual -
Part 1, section 104.4.
(20)
Medicare Cost Report- CMS Forms 2540-10 and 2552-10, or subsequent versions of
these forms.
(21) Medicaid
Supplemental Cost Report- The supplemental cost reporting schedules designated
by TennCare. The Medicaid supplemental cost report form is available on
TennCare's main website under the LTSS subsection.
(22) Medicaid Nursing Facility-Wide
Semi-Annual Average Case Mix Index- The calendar day weighted average, carried
to four (4) decimal places, of all indices for each resident MDS assessment
transmitted and accepted by CMS that is considered active within a given
semiannual rate period and where Medicaid is determined to be the primary per
diem payer source. The resident case mix indices are calculated utilizing the
time-weighted acuity measurement system. Any MDS assessments or MDS assessment
periods which coincide with a federally or state declared public health
emergency period may be excluded from or have BC1-Delinquent records removed
from the calculation of the Medicaid Nursing FacilityWide Semi-Annual Average
Case Mix Index. In the event that less than three (3) months of MDS assessment
information is available for the semi-annual case mix index calculation after
exclusion, the most recently preceding Medicaid Nursing Facility-Wide
Semi-Annual Average Case Mix Index which contains three (3) or more months of
MDS assessment information will be utilized for rate setting.
(23) Minimum Data Set (MDS)- A core set of
screening and assessment data, including common definitions and coding
categories that form the foundation of the comprehensive assessment for all
residents of long-term care NF providers certified to participate in the
Medicaid program. The Tennessee reimbursement system will employ the current
MDS assessment as approved by CMS.
(24) Neutralized- The process of removing
cost variations associated with case mix. Neutralized cost is determined by
dividing a provider's inflated per diem direct care case mix adjusted costs by
its cost report period average case mix index (CMI).
(25) New Nursing Facility Provider- A
provider whose licensed beds have not previously been certified for
participation by the Medicaid program for NF level of care.
(26) Nursing Facility Cost Report Period Case
Mix Index - The calendar day weighted average of all applicable NF-wide
semi-annual average case mix indices, carried to four (4) decimal places. The
case mix index periods used in this weighted average will be the periods that
most closely coincide with the NF provider's cost reporting period that is used
for rate setting. The average will be determined by weighting the applicable
semi-annual case mix index periods by the number of days the MDS assessments
were active during the cost reporting period. The semi-annual rate period case
mix index averages will be calculated using the time-weighted acuity
measurement system, and be inclusive of MDS assessments available as of the
date of the applicable FCIRs. Any MDS assessments, BC1-Delinquent records, or
MDS assessment periods excluded from the semi-annual rate setting process will
also be excluded from the calculation of the Nursing Facility Cost Report
Period Case Mix Index.
For example, a NF provider with a 1/1/2018 to 12/31/2018 cost
reporting period would have a nursing facility cost report period case mix
index calculated by the following: ((7/1/2018- 12/31/2018 Rate Period CMI * 59
days)+ (1/1/2019- 6/30/2019 Rate Period CMI * 184 days)+ (7/1/2019- 12/31/2019
Rate Period CMI * 122 days))/ 365 days, rounded to 4 decimals.
Portion of CostReport
Year
|
CMI
Period
|
Rate Period
Utilizing CMI
|
Days for
WeightedCalculation
|
1/1/2018
through2/28/2018
|
9/1/2017
through2/28/2018
|
7/1/2018
through12/31/2018
|
59
|
3/1/2018
through8/31/2018
|
3/1/2018
through8/31/2018
|
1/1/2019
through6/30/2019
|
184
|
9/1/2018
through12/31/2018
|
9/1/2018
through2/28/2019
|
7/1/2019
through12/31/2019
|
122
|
(27)
Nursing Facility-Wide Semi-Annual Average Case Mix Index - The calendar day
weighted average, carried to four (4) decimal places, of all indices for all
resident MDS assessments transmitted and accepted by CMS that are considered
active within a given semi-annual rate period. The resident case mix indices
are calculated utilizing the time-weighted acuity measurement system. Any MDS
assessments or MDS assessment periods which coincide with a federally or state
declared public health emergency period may be excluded from or have
BC1-Delinquent records removed from the calculation of the Nursing
Facility-Wide Semi-Annual Average Case Mix Index. In the event that less than
three (3) months of MDS assessment information is available for the semi-annual
case mix index calculation after exclusion, the most recently preceding Nursing
Facility-Wide Semi-Annual Average Case Mix Index which contains three (3) or
more months of MDS assessment information will be utilized for rate
setting.
(28) Preliminary Case Mix
Index Report (PCIR) - The preliminary report that reflects the acuity of the
residents in the NF. Resident acuity will be measured for each semi-annual rate
period, utilizing the time-weighted acuity measurement system.
(29) Quality Informed- A descriptor of any
component of the NF reimbursement methodology that is adjusted based on the NF
provider's Quality Tier (e.g., Direct Care Case Mix Adjusted Cost Component and
Direct Care Non-Case Mix Adjusted Cost Component) or other specified
performance measures (e.g., Fair Rental Value).
(30) Quality Tier- The NF provider's
classification within a specified range of scores on quality outcome
measures.
(31) Rate Year- A
one-year period from July 1 through June 30 during which a particular set of
rates are in effect, corresponding to a state fiscal year.
(32) Rebase- The process of reestablishing
cost component medians and reimbursement rates by incorporating the most
recently audited or reviewed qualifying cost reports.
(33) Resource Utilization Group-IV (RUG-IV)
Resident Classification System- The resource utilization group used to classify
residents. When a resident classifies into more than one RUG-IV group, or
RUG-IV successor group, the RUG with the greatest CMI will be utilized to
calculate the NF provider's all residents average CMI and Medicaid residents
average CMI. The nursing-only weights RUG-IV Version 1.03 Grouper, or its
successor, will be utilized for rate determination purposes.
(34) Sales Comparison Approach- Based upon
the principle of substitution, when a property is replaceable in the market its
value tends to be set at the cost of acquiring an equally desirable substitute
property, assuming no costly delay in making the substitution. Since two (2)
properties are rarely identical, the necessary adjustments for differences in
quality, location, size, services, and market appeal are a function of
appraisal experience and judgment. Land is valued via the sales comparison
approach.
(35) Semi-Annual Rate
Period- A six (6) month period beginning July 1 or January 1 for which new
reimbursement rates will be calculated. The semi-annual rate period will use
all active MDS assessments for the time period beginning ten (10) months prior
and ending four (4) months prior to the begin date of the semi-annual rate
period. Any active MDS assessments or active MDS assessment periods which
coincide with a federally or state declared public health emergency period may
be excluded from or have BC1-Delinquent records removed from the calculation of
the applicable case mix index averages. In the event that less than three (3)
months of active MDS assessment information is available for use in the
semiannual rate period calculation after exclusion, the most recently preceding
applicable case mix index averages which contain three (3) or more months of
MDS assessment information will be utilized for rate setting.
For example, the July 1, 2018, semi-annual rate period will
use active MDS assessment records from September 1, 2017, through February 28,
2018.
(36) TennCare - The
program administered by the Single State Agency as designated by the State and
CMS pursuant to Title XIX of the Social Security Act and the Section 1115
Research and Demonstration Waiver granted to the State of Tennessee; the name
of the Division within the Tennessee Department of Finance and Administration
encompassing all the health care related agencies located within F and, the
name of the Bureau which directly administers the program.
(37) Time-Weighted Acuity Measurement System
(TW) - The case mix index calculation methodology that is compiled from the
collection of all resident MDS assessments transmitted and accepted by CMS that
are considered active within a given semi-annual rate period. The resident MDS
assessments will be weighted based on the number of calendar days that the
assessment is considered an active assessment within a given semi-annual rate
period.
(38) Weighted Construction
Year Age- The construction age is determined by subtracting the year the
building or building addition was constructed as denoted in the appraisal
report from the year the appraisal was performed by TennCare's certified
appraisal firm. The average of the construction year is weighted by the
finished square footage associated with each separate building or addition as
denoted in the appraisal report produced by TennCare's certified appraisal
firm.