907 KAR 1:025 - Payment for services provided by an intermediate care facility for individuals with an intellectual disability, a dually-licensed pediatric facility, an institution for mental diseases, or a nursing facility with an all-inclusive rate unit
RELATES TO: KRS 142.363, 202B.010, 42 C.F.R. 413.9, 413.17, 413.85, 413.90, 413.94, 413.98, 413.106, 413.153, 435.1010, 447.204, 447.272, 483.10, 42 U.S.C. 1395x, 1396a, 1396d
NECESSITY, FUNCTION, AND CONFORMITY: The Cabinet for Health and Family Services, Department for Medicaid Services has responsibility to administer the Medicaid Program. KRS 205.520(3) authorizes the cabinet by administrative regulation, to comply with any requirement that may be imposed, or opportunity presented, by federal law to qualify for federal Medicaid funds. This administrative regulation establishes the method for determining amounts payable by the Medicaid Program for nursing facility services provided by an intermediate care facility for individuals with an intellectual disability, a dually-licensed pediatric facility, an institution for mental diseases, or a nursing facility with an all-inclusive rate unit.
Section 1. Definitions.
(1) "Allowable cost" means that portion of a
facility's cost that is allowed by the department in establishing the
reimbursement rate.
(2) "Calculated
rate" means the rate effective July 1, 1999 and each July 1 thereafter for:
(a) An intermediate care facility for
individuals with an intellectual disability (ICF-IID); or
(b) A nursing facility certified as:
1. A dually-licensed pediatric facility;
or
2. An institution for mental
diseases.
(3)
"Cost-based facility" means a facility that:
(a) The department reimburses for all
allowable costs; and
(b) Is either:
1. A dually-licensed pediatric
facility;
2. An intermediate care
facility for individuals with an intellectual disability; or
3. An institution for mental
diseases.
(4)
"Cost report" means Cost-based Facility Reimbursement Cost Report Instructions
and Cost-based Facility Reimbursement Cost Report.
(5) "Department" means the Department for
Medicaid Services or its designee.
(6) "Dually-licensed pediatric facility"
means any facility providing both high intensity and low intensity nursing
facility services to:
(a) Children under age
twenty-one (21);
(b) Residents who
were admitted to the facility prior to reaching the age of twenty-one (21) and
who remain as residents in the facility after reaching the age of twenty-one
(21); or
(c) Residents who were
admitted to the facility prior to reaching the age of twenty-one (21) and who
were discharged to a different facility and who, but for being older than
twenty-one (21), continue to meet the level of care of the dually-licensed
pediatric facility.
(7)
"IHS Markit Index" means an indication of changes in health care costs from
year to year developed by IHS Markit, or its successor organization.
(8) "Institution for mental diseases" or
"IMD" is defined by 42
C.F.R. 435.1010.
(9) "Intermediate care facility for
individuals with an intellectual disability" or "ICF-IID" is defined by
KRS
202B.010(10).
(10) "Nursing facility" or "NF" means that:
(a) The state survey agency has:
1. Granted an NF license to the facility;
and
2. Recommended the NF to the
department for certification as a Medicaid provider; and
(b) The department has granted certification
for Medicaid participation to the NF.
(11) "Nursing facility with an all-inclusive
rate unit" means:
(a) A nursing facility with
a distinct part ventilator unit; or
(b) A nursing facility with a distinct part
brain injury unit.
(12)
"Occupancy factor" means a percentage representing:
(a) A facility's actual occupancy level;
or
(b) A minimum occupancy level
assigned to a facility if its occupancy level is below the minimum level
established in Section 3(17) of this administrative regulation.
(13) "Prospective rate" means a
payment rate for routine services based on allowable costs and other factors
that, except as specified in Section 3 of this administrative regulation, shall
not be retroactively adjusted, either in favor of the facility or the
department.
(14) "Routine services"
means services covered by the Medicaid Program pursuant to
42 C.F.R.
483.10(f)(11)(i).
(15) "State survey agency" means the Cabinet
for Health and Family Services, Office of Inspector General, Division of Health
Care.
(16) "Upper payment limit"
means the aggregate payment amount as described in
42 C.F.R.
447.272 for inpatient services furnished by
state-owned or operated ICF-IIDs.
Section 2. Certified Bed Requirements. Except
for an intermediate care facility for individuals with an intellectual
disability or a nursing facility with an all-inclusive rate unit, a facility
that provides services pursuant to this administrative regulation and desires
to participate in the Medicaid Program shall comply with the following
requirements:
(1) If the facility has less
than ten (10) beds, all of its beds shall participate in the Medicare Program;
or
(2) If the facility has ten (10)
or more beds, the facility shall have the greater of:
(a) Ten (10) of its Medicaid-certified beds
participating in the Medicare Program; or
(b) Twenty (20) percent of its
Medicaid-certified beds participating in the Medicare Program.
Section 3. Payment
System for a Cost-based Facility. The department's reimbursement system shall
include the specific policies, components, or principles established in this
section.
(1)
(a) Except as specified in this section,
prospective payment rates for routine services shall:
1. Be set by the department on a
facility-specific basis; and
2. Not
be subject to retroactive adjustment.
(b) Prospective rates shall be determined on
a cost basis annually, and may be revised on an interim basis by the
department.
(c) An adjustment to a
prospective rate (subject to the maximum payment for that type of facility)
shall be considered if:
1. The facility's
increased costs are attributable to:
a. A
governmentally imposed minimum wage increase, staffing ratio increase, or level
of service increase; and
b. The
increase was not included in the IHS Markit Index;
2. A new licensure requirement or new
interpretation of an existing requirement by the appropriate governmental
agency as issued in an administrative regulation results in changes that affect
all facilities within the class; or
3. The facility experiences a
governmentally-imposed displacement of residents.
(d)
1. The
amount of any prospective rate adjustment resulting from a
governmentally-imposed minimum wage increase or licensure requirement change or
interpretation as cited in paragraph (c)2. of this subsection shall not exceed
the amount by which the cost increase resulting directly from the governmental
action exceeds on an annualized basis the inflation allowance amount included
in the prospective rate for the general cost area in which the increase occurs.
For purposes of this determination, costs shall be classified into the
following two (2) general areas:
a. Salaries;
and
b. Other.
2. The effective date of an interim rate
adjustment shall be the first day of the month in which the adjustment is
requested or in which the cost increase occurred, whichever is later.
(2)
(a) The state shall set a uniform rate year
for a cost-based facility (July 1 - June 30) by taking the latest available
cost data available as of May 16 of each year and trending the facility costs
to July 1 of the rate year. If the latest available cost report data has not
been audited or desk-reviewed prior to rate setting for the universal year
beginning July 1, a prospective rate based on a cost report that has not been
audited or desk-reviewed shall be subject to adjustment when the audit or desk
review is completed.
(b) Partial
year or budget cost data shall be used if a full year's data is unavailable.
Unaudited reports shall be subject to an adjustment to the audited
amount.
(c) Other factors relating
to costs.
1. If the department has made a
separate rate adjustment as compensation to a facility for a minimum wage
update, the department shall:
a. Not pay the
facility twice for the same costs; and
b. Adjust downward the trending and indexing
factors to the extent necessary to remove from the factors costs relating to
the minimum wage updates already provided for by the separate rate
adjustment.
2. If the
trending and indexing factors include costs related to a minimum wage increase:
a. The department shall not make a separate
rate adjustment; and
b. The minimum
wage costs shall not be deleted from the trending and indexing
factors.
3. The maximum
payment amounts for the prospective universal rate year shall be adjusted each
July 1 so that the maximum payment amount in effect for the rate year shall be
related to the cost reports used in setting the facility rates for the rate
year.
4. For purposes of
administrative ease in computations, normal rounding shall be used in
establishing the maximum payment amount, with the maximum payment amount
rounded to the nearest five (5) cents.
(3)
(a)
Except as provided in paragraph (b) of this subsection, interest expense used
in setting a prospective rate shall be an allowable cost if permitted pursuant
to 42 C.F.R.
413.153 and if the interest expense:
1. Represents interest on:
a. Long term debt existing at the time the
provider enters the program; or
b.
New long-term debt, if the proceeds are used to purchase fixed assets relating
to the provision of the appropriate level of care.
(i) If the debt is subject to variable
interest rates found in balloon-type financing, renegotiated interest rates
shall be allowable; and
(ii) The
form of indebtedness may include mortgages, bonds, notes, and debentures if the
principal is to be repaid over a period in excess of one (1) year;
or
2. Is for
working capital and operating needs that directly relate to providing patient
care. The form of indebtedness may include notes, advances, and various types
of receivable financing.
(b) Interest on a principal amount used to
purchase goodwill or other intangible assets shall not be considered an
allowable cost.
(4) The
allowable cost for a service or good purchased by a facility from a related
organization shall be the cost to the related organization, unless it is
demonstrated that the related organization is equivalent to a second party
supplier.
(a) Except as provided in paragraph
(b) of this subsection, an organization shall be considered a related
organization if an individual possesses five (5) percent or more of ownership
or equity in the facility and the supplying business.
(b) An organization shall not be considered a
related organization if fifty-one (51) percent or more of the supplier's
business activity of the type carried on with the facility is transacted with
persons and organizations other than the facility and its related
organizations.
(5)
(a) Except as provided in paragraph (b) of
this subsection, the amount allowable for leasing costs shall not exceed the
amount that would be allowable based on the computation of historical
costs.
(b) The department shall
determine the allowable costs of an arrangement based on the costs of the
original lease agreement if:
1. A cost-based
facility entered into a lease arrangement as an intermediate care facility
prior to April 22, 1976;
2. An
intermediate care facility for individuals with an intellectual disability
entered into a lease arrangement prior to February 23, 1977; or
3. A nursing facility entered into a lease
arrangement as a skilled nursing facility prior to December 1, 1979.
(6) A cost shall be
allowable and eligible for reimbursement if the cost is:
(a) Reflective of the provider's actual
expenses of providing a service; and
(b) Related to Medicaid patient care pursuant
to 42 C.F.R.
413.9.
(7) The following costs shall be allowable:
(a) Costs to related organizations pursuant
to 42 C.F.R.
413.17;
(b) Costs of educational activities pursuant
to 42 C.F.R.
413.85;
(c) Research costs pursuant to
42 C.F.R.
413.90;
(d) Value of services of nonpaid workers
pursuant to 42 C.F.R.
413.94;
(e) Purchase discounts and allowances, and
refunds of expenses pursuant to
42 C.F.R.
413.98;
(f) Depreciation on buildings and equipment
if a cost is:
1. Identifiable and recorded in
the provider's accounting records;
2. Based on historical cost of the asset or,
if donated, the fair market value; or
3. Prorated over the estimated useful life of
the asset using the straight-line method;
(g) Interest on current and capital
indebtedness; or
(h) Professional
costs of services of full-time or regular part-time employees not to exceed
what a prudent buyer would pay for comparable services.
(8) The following shall not be allowable
costs:
(a) The value of services provided by
nonpaid members of an organization if there is an agreement with the provider
to furnish the services at no cost;
(b) Political contributions;
(c) Legal fees for unsuccessful lawsuits
against the Cabinet for Health and Family Services;
(d) Travel and associated costs outside the
Commonwealth of Kentucky to conventions, meetings, assemblies, conferences, or
any related activities that are not related to NF training or educational
purposes; or
(e) Costs related to
lobbying.
(9) To
determine the gain or loss on the sale of a facility for purposes of
determining a purchaser's cost basis in relation to depreciation and interest
costs, the methods established in this subsection shall be used for changes of
ownership occurring before July 18, 1984.
(a)
1. The actual gain on the sale of the
facility shall be determined; and
2. There shall be added to the seller's
depreciated basis two-thirds (2/3) of one (1) percent of the gain for each
month of ownership since the date of acquisition of the facility by the seller
to arrive at the purchaser's cost basis.
(b) Gain shall be the amount in excess of a
seller's depreciated basis as computed under program policies at the time of a
sale, excluding the value of goodwill included in the purchase price.
(c) A sale shall be any bona fide transfer of
legal ownership from an owner to a new owner for reasonable compensation, which
shall usually be fair market value. A lease purchase agreement or other similar
arrangement that does not result in a transfer of legal ownership from the
original owner to the new owner shall not be considered a sale until legal
ownership of the property is transferred.
(d) If an enforceable agreement for a change
of ownership was entered into prior to July 18, 1984, the purchaser's cost
basis shall be determined pursuant to paragraphs (a) through (c) of this
subsection.
(10)
Valuation of capital assets.
(a) An increase
in valuation in relation to depreciation and interest costs shall not be
allowed for a change of ownership occurring after July 18, 1984 and before
October 1, 1985.
(b) For a bona
fide change of ownership entered into on or after October 1, 1985, the
depreciation and interest costs shall be increased in valuation in accordance
with 42 U.S.C.
1395x(v)(1)(O)(i).
(11)
(a) A
facility shall maintain and make available any records and data necessary to
justify and document:
1. Costs to the
facility; and
2. Services performed
by the facility.
(b) The
department shall have unlimited on-site access to all of a facility's fiscal
and service records for the purpose of:
1.
Accounting;
2. Auditing;
3. Medical review;
4. Utilization control; and
5. Program planning.
(12) The requirements established
in this subsection shall apply to an annual cost report.
(a) A year-end cost report shall contain
information relating to prior year cost, and shall be used in establishing
prospective rates and setting ancillary reimbursement amounts.
(b) A new item or expansion representing a
departure from current service levels for which the facility requests prior
approval by the department shall be so indicated with a description and
rationale as a supplement to the cost report.
(c) Department approval or rejection of a
projection or expansion shall be made on a prospective basis in the context
that, if an expansion and related costs are approved, they shall be considered
when actually incurred as an allowable cost. Rejection of an item or costs
shall represent notice that the costs shall not be considered as part of the
cost basis for reimbursement. Unless otherwise specified, approval shall relate
to the substance and intent rather than the cost projection.
(d) If a request for prior approval of a
projection or expansion is made, absence of a response by the department shall
not be construed as approval of the item or expansion.
(13)
(a)
The department shall perform a desk review of each year-end cost report and
ancillary service cost to determine the necessity for and scope of an audit in
relation to routine and ancillary service cost.
(b) If a field audit is not determined to be
necessary, the cost report shall be settled without an audit.
(c) A desk review or field audit shall be
used for purposes of verifying cost to be used in setting the prospective rate
or for purposes of adjusting prospective rates that have been set based on
unaudited data.
(d) Audits may be
conducted annually or at less frequent intervals.
(14) A year-end adjustment of the prospective
rate and a retroactive cost settlement shall be made if:
(a) An incorrect payment has been made due to
a computational error (other than an omission of cost data) discovered in the
cost basis or establishment of the prospective rate;
(b) An incorrect payment has been made due to
a misrepresentation on the part of a facility (whether intentional or
unintentional);
(c) A facility is
sold and the funded depreciation account is not transferred to the purchaser;
or
(d) The prospective rate has
been set based on unaudited cost reports and the prospective rate is to be
adjusted based on audited reports with the appropriate cost settlement made to
adjust the unaudited prospective payment amounts to the correct audited
prospective payment amounts.
(15) A facility shall provide the services
mandated in 42 C.F.R.
483.10(f)(11)(i).
(16) A facility shall submit to the
department the data required for determining the prospective rate no later than
sixty (60) days following the close of the facility's fiscal year. This time
limit may be extended at the specific request of the facility with the
department's concurrence.
(17)
Allowable prior year cost, trended to the beginning of the rate year and
indexed for inflation, shall be subject to adjustment based on a comparison of
costs with a non-state, privately-owned facility's occupancy factor.
(a) An occupancy factor shall not be less
than actual bed occupancy, except that it shall not exceed ninety-eight (98)
percent of certified bed days (or ninety-eight (98) percent of actual bed usage
days, if more, based on prior year utilization rates).
(b) A minimum occupancy factor shall be
ninety (90) percent of certified bed days for a nonstate, privately-owned
facility with less than ninety (90) percent certified bed occupancy.
(c) The department may impose a lower
occupancy factor for a newly constructed or newly participating nonstate,
privately-owned facility, or for an existing nonstate, privately-owned facility
suffering a patient census decline as a result of a newly constructed or opened
competing facility serving the same area.
(d) The department may impose a lower
occupancy factor during the first two (2) full fiscal years an existing
cost-based nonstate, privately-owned facility participates in the program under
this payment system.
(18)
A provider tax on a cost-based facility shall be considered an allowable
cost.
(19) All other costs shall
be:
(a) Other care-related costs;
(b) Other operating costs;
(c) Capital costs; or
(d) Indirect ancillary costs.
(20) Basic per diem costs for each
major cost category (nursing services costs and all other costs) shall be the
calculated rate arrived at after otherwise allowable costs are trended and
adjusted in accordance with the:
(a) IHS
Markit Index inflation factor; and
(b) Occupancy factor for a nonstate,
privately owned facility.
(21) Maximum allowable costs shall be the
maximum amount that may be allowed to a facility as reasonable cost for the
provision of a supply or service while complying with limitations expressed in
related federal or state administrative regulations.
(22) Nursing services costs shall be the
direct costs associated with nursing services.
(23) State-owned or operated ICF-IID
reimbursement for noncapital routine services shall be subject to an upper
payment limit. The upper payment limit shall:
(a) Be an aggregate limit on ICF-IID
reimbursement paid by the department;
(b) Equal 112 percent of the average of
aggregate cost for a state fiscal year;
(c) Be revised annually by the IHS Markit
Index using the most recent full year of Medicaid paid days;
(d) Not be rebased more frequently than every
three (3) years; and
(e) Use as its
base year the State Fiscal Year 2005.
(24) The department shall retroactively cost
settle state-owned or operated ICF-IID reimbursement for non-capital routine
services beginning with the cost report period November 1, 2005 through June
30, 2006, as mandated by the Centers for Medicare and Medicaid Services in
accordance with 42 U.S.C.
1396a(a)(30). Retroactive
settlement shall entail:
(a) Comparing
interim payments with the properly apportioned cost of Medicaid services
rendered. Cost report data shall be used to determine properly apportioned
costs;
(b) A tentative cost report
settlement based upon:
1. Eighty (80) percent
of any amount due the facility after a preliminary review is performed;
or
2. 100 percent settlement of any
liability due the department; and
(c) A final cost report settlement after the
allowed billing period has elapsed for the dates of service identified within
the cost report.
(25) The
department, regarding state-owned or operated ICF-IID reimbursement for
noncapital routine services, shall:
(a) Use
projected data in order to approximate as closely as possible an interim rate
expected to correspond to post-settlement cost; and
(b) Adjust interim rates up or down if
necessary to approximate a rate corresponding as close as possible to
anticipated post-settlement cost.
Section 4. Prospective Rate Computation for a
Cost-based Facility. The prospective rate for a cost-based facility shall
reflect:
(1) The adjusted allowable cost for
the facility; and
(2) Except for a
state-owned or operated facility, the facility's occupancy factor. A
state-owned or operated facility's occupancy factor shall not be factored into
the facility's prospective rate.
Section 5. Ancillary Services.
(1) Except for an intermediate care facility
for individuals with an intellectual disability, an ancillary service shall be
a direct service for which a charge is customarily billed separately from a per
diem rate including:
(a) Ancillary services
pursuant to
907 KAR 1:023; or
(b) Laboratory procedures or x-rays if
ordered by a:
1. Physician;
2. An advanced practice registered nurse
(APRN) if the laboratory test or x-ray is within the scope of the APRN's
practice; or
3. Physician assistant
if:
a. Authorized by the supervising
physician; and
b. The laboratory
test or x-ray is within the scope of the physician assistant's
practice.
(2) For an intermediate care facility for
individuals with an intellectual disability, an ancillary service shall be a
direct service for which a charge is customarily billed separately from a per
diem rate including:
(a) Ancillary services
pursuant to
907 KAR 1:023;
(b) Laboratory procedures or x-rays if
ordered by a:
1. Physician;
2. An APRN if the laboratory test or x-ray is
within the scope of the APRN's practice; or
3. Physician assistant if:
a. Authorized by the supervising physician;
and
b. The laboratory test or x-ray
is within the scope of the physician assistant's practice; or
(c) Psychological or
psychiatric therapy.
(3)
Ancillary service.
(a) Reimbursement shall be
subject to a year-end audit, retroactive adjustment, and final
settlement.
(b) Costs shall be
subject to allowable cost limits pursuant to
42 C.F.R.
413.106.
(4) For ancillary services, the department
shall utilize an NF's prior year cost-to-charge ratio, based on the prior
year's cost report as of May 31, as the percentage to be used for interim
reimbursement purposes for the following year. (For example, if an NF's
cost-to-charge ratio for SFY 2001 is seventy-five (75) percent, the department
shall reimburse the NF, on an interim basis, seventy-five (75) percent of
billed charges for SFY 2002.)
(5)
An NF without a prior year cost report may submit to the department a
percentage to be used for interim reimbursement purposes for ancillary
services.
(6) If an NF has been
reimbursed for ancillary services at an interim percentage above its allowable
cost-to-charge ratio for a given year, the department shall decrease the
interim percentage for the following year by no more than twenty-five (25)
percentage points unless:
(a) A retroactive
adjustment of an NF's reimbursement for the prior year reveals an overpayment
by the department exceeding twenty-five (25) percent of billed charges;
or
(b) An evaluation of an NF's
current billed charges indicates that the NF's charges exceed, by greater than
twenty-five (25) percent, average billed charges for other comparable
facilities serving the same area.
Section 6. Reimbursement for a Nursing
Facility With a Distinct Part Ventilator Unit.
(1)
(a)
Except as provided by paragraph (b) of this subsection, a nursing facility with
a distinct part ventilator unit shall be paid at an all-inclusive fixed rate
for services provided in the distinct part ventilator unit.
(b) The all-inclusive fixed rate required by
paragraph (a) of this subsection shall not include payment for drugs, which
shall be reimbursed through the pharmacy program established in 907 KAR Chapter
23.
(2) A distinct part
ventilator unit shall:
(a) Have a minimum of
twenty (20) beds;
(b) Maintain a
census of fifteen (15) patients; and
(c) Base the patient census upon:
1. The quarter preceding the beginning of the
rate year; or
2. The quarter
preceding the quarter for which certification is requested if the facility did
not qualify for participation as a distinct part ventilator unit at the
beginning of the rate year.
(3)
(a) The
fixed rate for a hospital-based facility shall be $583.82 per day effective for
SFY 2006, and shall be increased or decreased pursuant to subsection (4) of
this section.
(b) The department
shall reimburse a freestanding facility:
1. A
fixed rate of $317.29 per day effective for SFY 2006, and shall be increased or
decreased pursuant to subsection (4) of this section; and
2. An add-on to the fixed rate in accordance
with KRS
142.363.
(4) The fixed rates established in subsection
(3) of this section shall be increased or decreased based on the IHS Markit
Index rate of inflation indicator for the nursing facility services for each
rate year.
(5) Costs of a distinct
part ventilator unit in a nursing facility shall be excluded from allowable
costs for purposes of rate setting and settlement of cost-based nursing
facility cost reports.
Section
7. Reimbursement for a Nursing Facility with a Distinct Part Brain
Injury Unit.
(1) In order to participate in
the Medicaid Program as a brain injury provider, a nursing facility with a
distinct part brain injury unit shall:
(a) Be
Medicare and Medicaid certified;
(b) Designate as a brain injury unit at least
ten (10) certified beds that are physically contiguous and
identifiable;
(c) After the first
year of participation, be accredited by:
1.
The Commission on Accreditation of Rehabilitation Facilities (CARF);
or
2. The Joint Commission;
and
(d) Establish written
policies regarding administration and operations, the facility's governing
authority, quality assurance, and program evaluation.
(2)
(a)
Except as provided in subsection (3) of this section and paragraph (b) of this
subsection, a nursing facility with a distinct part brain injury unit providing
preauthorized specialized rehabilitation services for persons with brain
injuries shall be paid at an all-inclusive fixed rate, which shall be set at
$530 per diem for services provided in the brain injury unit.
(b) The all-inclusive fixed rate required by
paragraph (a) of this subsection shall not include payment for drugs, which
shall be reimbursed through the pharmacy program established in 907 KAR Chapter
23.
(3)
(a) Except as provided by paragraph (b) of
this subsection, a facility providing preauthorized specialized rehabilitation
services for persons with brain injuries with rehabilitation complicated by
neurobehavioral sequelae shall be paid an all-inclusive negotiated rate, which
shall not exceed the facility's usual and customary charges.
(b) The all-inclusive fixed rate required by
paragraph (a) of this subsection shall not include payment for drugs, which
shall be reimbursed through the pharmacy program established in 907 KAR Chapter
23.
(c) The negotiated rate
established pursuant to paragraph (a) of this subsection shall be:
1. A minimum of the approved rate for a
Medicaid certified brain injury unit;
2. A maximum of the lesser of the average
rate paid by all payers for this service; or
3. The facility's usual and customary
charges.
Section
8. Appeal Rights. A participating facility may appeal department
decisions as to the application of this administrative regulation as it impacts
the facility's reimbursement in accordance with
907 KAR 1:671, Sections 8 and
9.
Section 9. Reimbursement for
Required Services Under the Preadmission Screening Resident Review (PASRR) for
a Nursing Facility with a Distinct Part Ventilator Unit, a Nursing Facility
with a Distinct Part Brain Injury Unit, an IMD, or a Dually-licensed Pediatric
Facility.
(1) Prior to an admission of an
individual, a facility shall conduct a level I PASRR in accordance with
907 KAR 1:755, Section
4.
(2) The department shall
reimburse a facility for a covered service delivered to an individual if the
facility complies with the requirements of
907 KAR 1:755.
(3) Failure to comply with
907 KAR 1:755 may be grounds for
termination of a facility's participation in the Medicaid
Program.
Section 10.
Reimbursement Provisions.
(1) Each of the
following types of facilities participating in the Medicaid Program shall be
reimbursed in accordance with this administrative regulation:
(a) A nursing facility with a distinct part
brain injury unit;
(b) A nursing
facility with a distinct part ventilator unit;
(c) A nursing facility designated as an
institution for mental diseases;
(d) A dually-licensed pediatric facility;
or
(e) An intermediate care
facility for individuals with an intellectual disability.
(2) A payment made to a facility governed by
this administrative regulation shall:
(a) Be
made in accordance with the requirements established in
907 KAR 1:022; and
(b) Be subject to the limits established in
42 C.F.R.
447.272.
Section 11. Supplemental Payments to
Dually-licensed Pediatric Facilities.
(1)
Beginning July 1, 2002 and annually thereafter, the department shall establish
a pool of $550,000 to be distributed to facilities qualifying for supplemental
payments in accordance with subsection (2) of this section.
(2) Based upon its pro rata share of Medicaid
patient days compared to total patient days of all qualifying facilities, a
dually-licensed pediatric facility shall qualify for a supplemental payment if:
(a) Funding is available; and
(b) The facility:
1. Is located within the Commonwealth of
Kentucky;
2. Has a Medicaid
occupancy rate at or above eighty-five (85) percent;
3. Only provides services to:
a. Children under age twenty-one (21);
and
b. Residents who were admitted
to the facility prior to reaching the age of twenty-one (21) and who remain as
residents in the facility after reaching the age of twenty-one (21);
or
c. Residents who were admitted
to the facility prior to reaching the age of twenty-one (21) and who were
discharged to a different facility and who, but for being older than twenty-one
(21), continue to meet the level of care of the dually-licensed pediatric
facility; and
4. Has
forty (40) or more licensed beds.
(3) A supplemental payment to a facility
meeting the criteria established in subsection (2) of this section shall:
(a) Apply to services provided on or after
July 1, 2002;
(b) Be made on a
quarterly basis; and
(c) Not be
subject to the cost settlement provisions established in Section 3 of this
administrative regulation.
Section 12. Incorporation by Reference.
(1) The following material is incorporated by
reference:
(a) "Cost-based Facility
Reimbursement Cost Report Instructions", April 2000 Edition; and
(b) "Cost-based Facility Reimbursement Cost
Report", April 2000 Edition.
(2) This material may be inspected, copied,
or obtained, subject to applicable copyright law:
(a) At the Department for Medicaid Services,
275 East Main Street, Frankfort, Kentucky 40621, Monday through Friday, 8 a.m.
to 4:30 p.m.; or
(b) Online at the
department's Web site located at
https://www.chfs.ky.gov/agencies/dms/dpo/bpb/Pages/nursingfacilities.aspx.
Notes
STATUTORY AUTHORITY: KRS 142.363(3), 194A.030(2), 194A.050(1), 205.520(3)
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