Utah Admin. Code R414-504-3 - Principles of Facility Case Mix Rates and Other Payments
The following principles apply to the payment of freestanding and provider-based nursing facilities for services provided to qualified Medicaid patients, as defined in Rule R414-502. This rule does not affect the system for reimbursement for intensive-skilled Medicaid patient add-on amounts.
(1) A portion of total
payments to nursing facilities for qualified Medicaid patients is based on a
prospective facility case mix rate. In addition, these facilities shall be paid
a flat basic operating expense payment. The balance of the total payments will
be paid in aggregate to facilities as required by Section
R414-504-3 based on other
authorized factors, including property and behaviorally complex residents, in
the proportion that the facility qualifies for the factor.
(2) Each quarter, the Department shall
calculate a new case mix index for each nursing facility. The case mix index is
based on three months of MDS assessment data. The newly calculated case mix
index is applied to a new rate at the beginning of a quarter according to the
following schedule:
(a) January, February,
and March MDS assessments are used for July 1 rates.
(b) April, May, and June MDS assessments are
used for October 1 rates.
(c) July,
August, and September MDS assessments are used for January 1 rates.
(d) October, November, and December MDS
assessments are used for April 1 rates.
(3) MDS and optional state assessment (OSA)
data is used in calculating each facility's case mix index and upper payment
limit (UPL) gap. Beginning July 1, 2023, each facility must complete an OSA in
conjunction with any Omnibus Budget Reconciliation Act or prospective payment
system assessments. This information is required by the state to calculate the
case mix index. The MDS and OSA data is submitted by each facility and each
facility is responsible for the accuracy of its data. Each facility shall
ensure needed sections of the MDS and OSA are completed so that a PDPM or
resource utilization group score may be calculated. The Department may exclude
inaccurate or incomplete MDS data from calculations.
(4)
(a) MDS
assessments for patients who are eligible for the intensive skilled add-on are
excluded from the case mix calculation.
(b) The state average case mix index excludes
the following:
(i) a facility with less than
20% of its total census days as Medicaid fee-for-service paid days, as reported
on its FCP or FRV data report; or
(ii) a facility having less than six months
of data reported under Rule R414-401.
(c) The state average case mix index is used
to set the rate for the following facilities:
(i) a facility with less than 20% of its
total census days as Medicaid fee-for-service paid days, as reported on its FCP
or FRV data report; or
(ii) a
facility having less than six months of data reported under Rule
R414-401.
(5) A
facility may apply for a special add-on rate for behaviorally complex residents
by filing a written request with the Division of Integrated Healthcare (DIH).
The Department may approve an add-on rate if an assessment of the acuity and
needs of the patient demonstrates that the facility is not adequately
reimbursed by the case mix score for that patient. The rate is added on for the
specific resident's payment and is not subsumed as part of the facility case
mix rate. The Office of Long -Term Services and Supports determines
qualification for any additional payment. DIH shall determine the amount of any
add-on.
(6) The Department pays
property costs separately from the case mix rate.
(7) Reimbursement for nursing home rates is
in accordance with Attachment 4.19-D of the Medicaid State Plan, which is
incorporated by reference in Section
R414-1-5.
(8) A provider may challenge the rate set
pursuant to this rule using the appeal in Rule R410-14. This applies to which
rate methodology is used as well as to the specifics of implementation of the
methodology. A provider must exhaust administrative remedies before challenging
rates in any other forum.
(9) The
Department reimburses swing beds, transitional care unit beds, and small health
care facility beds that are used as nursing facility beds, using the prior
calendar year statewide average of the daily nursing facility rate.
(10) Unless specified otherwise, the
Department may withhold Title XIX payments from providers if:
(a) there is a shortage in a resident trust
account managed by the facility;
(b) the facility fails to submit a complete
and accurate FCP as required by Attachment 4.19-D of the Medicaid State
Plan;
(c) the facility fails to
submit timely, accurate MDS and OSA data;
(d) the facility owes money to DIH because of
an overpayment, nursing care facility assessment, civil money penalty, or other
offset; or
(e) the facility fails
to respond within ten business days to a written request for
information.
(11) The
Department shall provide written notice before withholding payments.
(12) When the Department rescinds withholding
of payments to a provider, it will, without notice, resume payments according
to the regular claims payment cycle.
(a) For
ongoing operations, the Department shall provide notice before withholding
payments. The Department and provider may negotiate a repayment schedule
acceptable to the Department for monies owed to the Department listed in
Subsection R414-504-3(10).
The repayment schedule may not exceed 180 days.
(b) When the Department rescinds withholding
of payments to a facility, it will resume payments according to the regular
claims payment cycle.
Notes
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