RELATES TO:
KRS
205.520,
42 C.F.R.
447.250,
42 U.S.C.
1396a, b, d
NECESSITY, FUNCTION, AND CONFORMITY: EO 2004-726, effective
July 9, 2004, reorganized the Cabinet for Health Services and placed the
Department for Medicaid Services and the Medicaid Program under the Cabinet for
Health and Family Services. The Cabinet for Health and Family Services has
responsibility to administer the program of Medical Assistance.
KRS
205.520(3) empowers the
cabinet, by administrative regulation, to comply with any requirement that may
be imposed, or opportunity presented, by federal law for the provision of
medical assistance to Kentucky's indigent citizenry. This administrative
regulation sets forth the method for determining amounts payable by the cabinet
for dual licensed pediatric facility services.
Section 1. Dual Licensed Pediatric
Facilities. The cabinet shall make payment to participating providers on the
following basis:
(1) Method of reimbursement.
A dual licensed pediatric facility shall be reimbursed on the basis of rates
which are reasonable and adequate to meet the costs which must be incurred by
efficiently and economically operated facilities in order to provide care and
services in conformity with applicable state and federal laws, regulations and
quality and safety standards. The payment shall be prospective in nature with
no year end adjustment for routine costs of care. The nursing facility services
payment principles as specified in
907
KAR 1:025 shall apply except for variations specified
in this administrative regulation. The cost of ancillaries shall be excluded
from the cost when computing the payment rate and shall be reimbursed
separately (in accordance with nursing facility services payment principles)
with a retroactive settlement.
(2)
Composite rate. The facility(ies) shall be paid at a composite rate for a
nursing facility day of care. The following procedures shall be followed in
establishing the composite rate:
(a) The
allowable cost for nursing facility days of care shall be determined based on
prior year actual costs (or, in the case of a new facility, projected costs
which are determined by the cabinet to be reasonable).
(b) The department shall set a uniform rate
year (July 1 - June 30) for facilities in this class in the same manner as for
nursing facilities, with allowable costs trended to the beginning of the rate
year. The trended allowable costs shall then be indexed for the rate year;
however, there shall be no administratively established upper limit. Fixed or
capital costs shall be neither trended nor indexed. Since projected costs for
new facilities reflect the best estimate of actual costs, these shall also be
neither trended nor indexed.
(c)
Allowable costs shall be then compared with the number of projected (for new
facilities) bed days or the number of bed days based on the prior year's actual
utilization to arrive at a per diem composite rate.
(d) An occupancy factor of ninety (90)
percent shall be applied. In the case of new facilities the occupancy factor
shall be waived during the first full fiscal year of participation in the
program.
(e) The cost incentive and
investment factor (CIIF) schedule shall be applied to prospective current year
per diem cost in determination of a final prospective rate for each facility.
The CIIF schedule shall be transmitted to appropriate providers.
(f) The component (cost center) limitations
specified in
907
KAR 1:025 shall not be
applicable.
Section
2. Rate Review and Adjustment. For a new facility, the composite
rate shall be reconsidered to determine if an adjustment is necessary after two
(2) full calendar quarters of actual experience in the program as specified in
the nursing facility payment principles.
Section
3. Eligibility for Reimbursement. A facility shall be eligible for
reimbursement from the department only when considered to be a participating
vendor, and reimbursement shall be made only for covered services rendered
Medicaid eligible recipients meeting patient status as determined in accordance
with applicable administrative regulations.