Kan. Admin. Regs. § 129-10-18 - Per diem rates of reimbursement
(a) Per diem rates for existing nursing
facilities.
(1) The determination of per diem
rates shall be made, at least annually, using base-year cost information
submitted by the provider and retained for cost auditing and analysis.
(A) The base year utilized for cost
information shall be reestablished at least once every seven years.
(B) A factor for inflation may be applied to
the base-year cost information.
(C)
For each provider currently in new enrollment, re-enrollment, or change of
ownership status, the base year shall be determined in accordance with
subsections (c), (d), and (e), respectively.
(2) Per diem rates shall be limited by cost
centers, except where there are special level-of-care facilities approved by
the United States department of health and luman services. The upper payment
limits shall be determined by the median in each cost center plus a percentage
of the median, using base-year cost information. The percentage factor applied
to the median shall be determined by the agency.
(A) The cost centers shall be as follows:
(i) Operating;
(ii) indirect health care; and
(iii) direct health care.
(B) The property component shall
consist of the real and personal property fee as specified in K.A.R. 129-1025
.
(C) The upper payment limit for
the direct health care cost center shall be a statewide base limit calculated
on each facility's base-year costs adjusted for case mix.
(i) A facility-specific, direct health care
cost center upper payment limit shall be calculated by adjusting the statewide
base limit by that facility's average case mix index.
(ii) Resident assessments used to determine
additional reimbursement for ventilator-dependent residents shall be excluded
from the calculation of the facility's average case mix index.
(3) Each provider shall
receive an annual per diem rate to become effective July 1 and, if there are
any changes in the facility's average medicaid case mix index, an adjusted per
diem rate to become effective January 1.
(4) Resident assessments that cannot be
classified shall be assigned to the lowest case mix index.
(5) To establish a per diem rate for each
provider, a factor for incentive may be added to the allowable per diem
cost.
(6)
(A) Resident days shall be determined from
census information corresponding to the base-year cost information submitted by
the provider.
(B) The total number
of resident days shall be used to calculate the per diem costs used to
determine the upper payment limit and rates in the direct health care cost
center. The total number of resident days shall be used to calculate the per
diem costs used to determine the upper payment limit and rates for food and
utilities in the indirect health care cost center.
(C) For homes with more than 60 beds, the
number of resident days used to calculate the upper payment limits and rates in
the operating cost center and indirect health care cost center, less food and
utilities, shall be subject to an 85 percent minimum occupancy requirement
based on the following:
(i) Each provider
that has been in operation for 12 months or longer and has an occupancy rate of
less than 85 percent for the cost report period, as specified in
K.A.R.
129-10-17, shall have the number of resident
days calculated at the minimum occupancy of 85 percent.
(ii) The 85 percent minimum occupancy
requirement shall be applied to the number of resident days and costs reported
for the 13th month of operation and after. The 85 percent minimum occupancy
requirement shall be applied to the interim rate of a new provider, unless the
provider is allowed to file a projected cost report.
(iii) The minimum occupancy rate shall be
determined by multiplying the total number of licensed beds by 85 percent. In
order to participate in the Kansas medical assistance program, each nursing
facility provider shall obtain proper certification for all licensed
beds.
(iv) Each provider with an
occupancy rate of 85 percent or greater shall have actual resident days for the
cost report period, as specified in
K.A.R.
129-10-17, used in the rate
computation.
(7) Each provider shall be given a detailed
listing of the computation of the rate determined for the provider's
facility.
(8) The effective date of
the rate for existing providers shall be in accordance with K.A.R. 129-10-19
.
(b) Per diem rate
limitations based on comparable service private-pay charges.
(1) Rates of reimbursement shall not be
limited by private-pay charges.
(2)
The agency shall maintain a registry of private-pay per diem rates submitted by
providers.
(A) Each provider shall notify the
agency of any change in the private-pay rate and the effective date of that
change so that the registry can be updated.
(i) Private-pay rate information submitted
with the cost reports shall not constitute notification and shall not be
acceptable.
(ii) Providers may send
private-pay rate notices by certified mail so that there is documentation of
receipt by the agency.
(B) The private-pay rate registry shall be
updated based on the notification from the providers.
(C) The effective date of the private-pay
rate in the registry shall be the later of the effective date of the
private-pay rate or the first day of the following month in which complete
documentation of the private-pay rate is received by the agency.
(i) If the effective date of the private-pay
rate is other than the first day of the month, the effective date in the
registry shall be the first day of the closest month. If the effective date is
after the 15th, the effective date in the register shall be the first day of
the following month.
(ii) For new
facilities or new providers coming into the medicaid program, the effective
date of the private-pay rate shall be the date on which certification is
issued.
(3)
The average private-pay rate for comparable services shall be included in the
registry. The average private-pay rate may consist of the following variables:
(A) Room rate differentials. The weighted
average private-pay rate for room differentials shall be determined as follows:
(i) Multiply the number of private-pay
residents in private rooms, semiprivate rooms, wards, and all other room types
by the rate charged for each type of room. Sum the resulting products of each
type of room. Divide the sum of the products by the total number of private-pay
residents in all rooms. The result, or quotient, is the weighted average
private-pay rate for room differentials.
(ii) Each provider shall submit documentation
to show the calculation of the weighted average private-pay rate if there are
room rate differentials.
(iii)
Failure to submit the documentation shall limit the private-pay rate in the
registry to the semiprivate room rate.
(B) Level-of-care rate differentials. The
weighted average private-pay rate for level-of-care differentials shall be
determined as follows:
(i) Multiply the
number of private-pay residents in each level of care by the rate they are
charged to determine the product for each level of care. Sum the products for
all of the levels of care. Divide the sum of the products by the total number
of private-pay residents in all levels of care. The result, or quotient, is the
weighted average private-pay rate for the level-of-care
differentials.
(ii) Each provider
shall submit documentation to show the calculation of the weighted average rate
when there are level-of-care rate differentials.
(iii) Failure to submit the documentation may
delay the effective date of the average private-pay rate in the registry until
the complete documentation is received.
(C) Extra charges to private-pay residents
for items and services may be included in the weighted average private-pay rate
if the same items and services are allowable in the Kansas medical assistance
program rate.
(i) Each provider shall submit
documentation to show the calculation of the weighted average extra
charges.
(ii) Failure to submit the
documentation may delay the effective date of the weighted average private-pay
rate in the registry until the complete documentation is received.
(4) The weighted
average private-pay rate shall be based on what the provider receives from the
resident. If the private-pay charges are consistently higher than what the
provider receives from the residents for services, then the average private-pay
rate for comparable services shall be based on what is actually received from
the residents.
The weighted average private-pay rate shall be reduced by the amount of any discount received by the residents.
(5) The private-pay rate for medicare skilled
beds shall not be included in the computation of the average private-pay rate
for nursing facility services.
(6)
When providers are notified of the effective date of the Kansas medical
assistance program rate, the following procedures shall be followed:
(A) If the private-pay rate indicated on the
agency register is lower, then the Kansas medical assistance program rate,
beginning with its effective date, shall be calculated as follows:
(i) If the average medicaid case mix index is
greater than the average private-pay case mix index, the Kansas medical
assistance program rate shall be the lower of the private-pay rate adjusted to
reflect the medicaid case mix or the calculated Kansas medical assistance
rate.
(ii) If the average medicaid
case mix index is less than or equal to the average private-pay case mix index,
the Kansas medical assistance program rate shall be the average private-pay
rate.
(B) Providers who
are held to a lower private pay rate and subsequently notify the agency in
writing of a different private-pay rate shall have the Kansas medical
assistance program rate adjusted on the later of the first day of the month
following the date upon which complete private-pay rate documentation is
received or the effective date of a new private-pay rate.
(c) Per diem rate for new
construction or a new facility to the program.
(1) The per diem rate for any newly
constructed nursing facility or a new facility to the Kansas medical assistance
program shall be based on a projected cost report submitted in accordance with
K.A.R.
129-10-17.
(2) The cost information from the projected
cost report and the first historic cost report covering the projected cost
report period shall be adjusted to the base-year period.
(3) The provider shall remain in new
enrollment status until the base year is reestablished. During this time, the
adjusted cost data shall be used to determine all rates for the
provider.
(4) Each factor for
inflation that is applied to cost data for established providers shall be
applied to the adjusted cost data for each provider in new enrollment
status.
(5) No rate shal be paid
until a nursing facility financial and statistical report is received and
processed to determine a rate.
(d) Change of provider.
(1) The payment rate for the first 24 months
of operation shall be based on the base-year historical cost data of the
previous owner or provider. If base-year data is not available, data for the
most recent calendar year available preceding the base-year period shall be
adjusted to the base-year period and used to determine the rate. If the 85
percent minimum occupancy requirement was applied to the previous provider's
rate, the 85 percent minimum occupancy requirement shall also be applied to the
new provider's rate.
(2) Beginning
with the first day of the 25th month of operation, the payment rate shall be
based on the historical cost data for the first calendar year submitted by the
new provider. The data shall be adjusted to the base-year period.
(3) The provider shall remain in
change-of-provider status until the base year is reestablished. During this
time, the adjusted cost data shall be used to determine all rates for the
provider.
(4) Each factor for
inflation that is applied to cost data for established providers shall be
applied to the adjusted cost data for each provider in change-of-provider
status.
(e)
Determination of the per diem rate for nursing facility providers reentering
the medicaid program.
(1) The per diem rate
for each provider reentering the medicaid program shall be determined from
either of the following:
(A) A projected cost
report if the provider has not actively participated in the program by the
submission of any current resident service billings to the program for 24
months or more; or
(B) the
base-year cost report filed with the agency or the most recent cost report
filed preceding the base year, if the provider has actively participated in the
program during the most recent 24 months.
(2) If the per diem rate for a provider
reentering the program is determined in accordance with paragraph (e)(1)(A),
the cost data shall be adjusted to the base-year period.
(3) The provider shall remain under
reenrollment status until the base year is reestablished. During this time, the
cost data used to determine the initial rates shall be used to determine all
subsequent rates for the provider.
(4) Each factor for inflation that is applied
to cost data for established providers shall be applied to the cost data for
providers in reenrollment status.
(5) If the per diem rate for a provider
reentering the program is determined in accordance with paragraph (e)(1)(A), a
settlement shall be made in accordance with subsection (f).
(f) Per diem rate errors.
(1) If the per diem rate, whether based upon
projected or historical cost data, is audited by the agency and found to
contain an error, a direct cash settlement shall be required between the agency
and the provider for the amount of money overpaid or underpaid. If a provider
with an identified overpayment is no longer enrolled in the medicaid program,
the settlement shall be recouped from a facility owned or operated by the same
provider or that provider's corporation, unless other arrangements have been
made to reimburse the agency. A net settlement may occur if a provider has more
than one facility involved in settlements. In all cases, settlements shall be
recouped within 12 months of the implementation of the corrected rates, or
interest may be assessed.
(2) The
per diem rate for a provider may be increased or decreased as a result of a
desk review or audit of the provider's cost reports. Written notice of this per
diem rate change and of the audit findings shall be sent to the provider.
Retroactive adjustment of the rate paid from a projected cost report shall
apply to the same period of time covered by the projected rate.
(3) Each provider shall have 30 days from the
date of the audit report cover letter to request an administrative review of an
audit adjustment that results in an overpayment or underpayment. The request
shall specify the finding or findings that the provider wishes to have
reviewed.
(4) An interim
settlement, based on a desk review of the historical cost report covering the
projected cost report period, may be determined after the provider is notified
of the new rate determined from the cost report. The final settlement shall be
based on the rate after an audit of the historical cost report.
(5) A new provider that is not allowed to
submit a projected cost report, as specified in
K.A.R.
129-10-17, for an interim rate shall not be
entitled to a retroactive settlement for the first year of operation.
(g) Out-of-state providers.
(1) The per diem rate for out-of-state
providers certified to participate in the Kansas medical assistance program
shall be the rate approved by the agency.
(2) Each out-of-state provider shall obtain
prior authorization by the agency.
(h) Reserve days. Reserve days as specified
in K.A.R.
30-10-21 shall be paid at 67 percent of the
Kansas medical assistance program per diem rate.
(i) Determination of rate for
ventilator-dependent resident.
(1) The
request for additional reimbursement for a ventilator-dependent resident shall
be submitted to the agency in writing for prior approval. Each request shall
include the following:
(A) Sections A, I, and
O in the nursing home comprehensive "minimum data set" ("MDS") of the centers
for medicare and medicaid services (CMS);
(B) a current client assessment, referral,
and evaluation (CARE) plan for the resident;
(C) a physician's order for ventilator use,
including the frequency of ventilator use and a diagnosis that requires use of
a ventilator; and
(D) a treatment
administration record or respiratory therapy note showing the number of minutes
used for the ventilator per shift.
(2) All of the following conditions shall be
met in order for a resident to be considered ventilator-dependent:
(A) The resident is not able to breathe
without mechanical ventilation.
(B)
The resident uses a ventilator for life support 24 hours a day, seven days a
week.
(C) The resident has a
tracheostomy or endotracheal tube.
(3) The provider shall be reimbursed at the
Kansas medical assistance program daily rate determined for the nursing
facility plus an additional amount approved by the agency for the
ventilator-dependent resident.
(4)
No additional amount above that figured at the Kansas medical assistance
program daily rate shall be allowed until the service has been authorized by
the agency.
(5) The criteria shall
be reviewed quarterly to determine if the resident is ventilator-dependent. If
a resident is no longer ventilator-dependent, the provider shall not receive
additional reimbursement beyond the Kansas medical assistance program daily
rate determined for the facility.
(6) The additional reimbursement for the
ventilator-dependent resident shall be offset to the cost center of benefit on
the nursing facility financial and statistical report.
(j) Rate modification; secretary's
discretion.
(1) Any of the requirements of
this regulation may be waived by the secretary and a nursing facility's or
nursing facility for mental health's per diem rate of reimbursement may be
modified by the secretary if the secretary determines that both of the
following conditions are met:
(A) Exceptional
circumstances place residents of nursing facilities and nursing facilities for
mental health in jeopardy of losing the availability of, or access to, "routine
services and supplies," "ancillary services and other medically necessary
services," "specialized mental health rehabilitation services," or "specialized
services," as defined in
K.A.R.
30-10-1a.
(B) The jeopardy can likely be avoided or
reduced by modifying the per diem rate of reimbursement for a nursing facility
or nursing facility for mental health.
(2) If the secretary exercises discretion
pursuant to this subsection, the increase in the per diem rate of reimbursement
shall not exceed the state average rate for reimbursement.
Notes
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