Payments to Nonpublic and County Nursing Facilities; Final Rates for State Fiscal Year 2015-2016
[46 Pa.B. 3358]
[Saturday, June 25, 2016]
This notice announces the Department of Human Services (Department) final annual case-mix per diem payment rates for State Fiscal Year (FY) 2015-2016 for nonpublic and county nursing facilities that participate in the Medical Assistance (MA) Program.
Nonpublic Nursing Facility Per Diem Rates
As required by the case-mix payment methodology in 55 Pa. Code Chapter 1187, Subchapter G (relating to rate setting), the Department sets an annual MA per diem rate for each nonpublic nursing facility provider. Each facility's annual per diem rate is comprised of four components: resident care; other resident related; administrative; and capital. For each quarter of FY 2015-2016, the Department will adjust the resident care component of each facility's rate by multiplying the resident care component by the facility's MA case-mix index for the appropriate picture date.
The Centers for Medicare & Medicaid Services (CMS) approved State Plan Amendment (SPA) 15-0024 on April 4, 2016, which includes the budget adjustment factor (BAF) formula the Department will use for nonpublic nursing facilities in FY 2015-2016. SPA 15-0024 states that the BAF will limit the estimated Statewide day-weighted average payment rate for MA nursing facility services for county and nonpublic nursing facilities so that the average payment rate in effect for the fiscal year is limited to the amount permitted by the funds appropriated by the General Appropriations Act for the fiscal year. For FY 2015-2016, the Department calculated a base BAF for nonpublic nursing facilities for July, October and January rates. The formula the Department used to determine a base BAF equals the target rate divided by the acuity-adjusted weighted average rate. For the April BAF, the weighted average April rate will be compared to the April target rate. If the difference between the weighted average April rate and the April target rate is more than 25¢, a BAF for the April—June 2016 calendar quarter will be determined by dividing the April target rate by the weighted average April rate at 100%. For the 2015-2016 rate year, July, October and January rates, the base BAF is 0.83105. The BAF for the April—June 2016 calendar quarter is 0.84094.
County Nursing Facility Per Diem Rates
As required by the rate methodology in 55 Pa. Code Chapter 1189, Subchapter D (relating to rate setting), the Department sets an annual MA per diem rate for each county nursing facility provider. As stated in 55 Pa. Code § 1189.91(b) (relating to per diem rates for county nursing facilities), for each rate year beginning on or after July 1, 2007, the per diem rate paid to a county nursing facility for a rate year will be the facility's prior rate year per diem multiplied by a BAF.
In addition, as required by 55 Pa. Code § 1189.91(d), the Department followed the formula set forth in the Commonwealth's approved State Plan to determine that the BAF for FY 2015-2016 for county nursing facilities is 1.0. CMS approved SPA 13-021 on November 7, 2013, which includes the BAF formula the Department will use for county nursing facilities in FY 2015-2016.
SPA 13-021 states that for rate setting year 2015-2016, the BAF shall limit the estimated Statewide day-weighted average payment rate for MA nursing facility services for county and nonpublic nursing facilities so that the average payment rate is limited to the amount permitted by the funds appropriated by the General Appropriations Act. The BAF as it applies to county nursing facilities is 1.0.
The final annual per diem rates for FY 2015-2016 rate year are available on the Department's web site at http://www.dhs.pa.gov/provider/longtermcarecasemixinformation/index.htm and at local county assistance offices (CAO) throughout this Commonwealth or by contacting Marilyn Yocum, Department of Human Services, Office of Long-Term Living at (717) 772-2549. As they become available, the adjusted quarterly rates will be accessible on the Department's web site, at CAOs or by contacting Marilyn Yocum.
On June 27, 2015, the Department published the notice Payment for Nursing Facility Services Provided by Nonpublic Nursing Facilities; Notice of Change in Formula for Calculating Budget Adjustment Factor at 45 Pa.B. 3425 (June 27, 2015) announcing the proposed change in the BAF formula for nonpublic nursing facilities. The Department also published a second notice Payments to Nonpublic and County Nursing Facilities; Proposed Rates for State Fiscal Year 2015-2016 at 45 Pa.B. 3427 (June 27, 2015) announcing that the proposed BAF-adjusted nursing facility per diem rates for FY 2015-2016 containing the BAFs that will be applied to county and nonpublic nursing facilities were available on the Department's web site. In response to the comments received, the Department decided to use the same nonpublic BAF formula that was used for FYs 2013-2014 and 2014-2015 for FY 2015-2016. The revised proposed FY 2015-2016 rates and BAF details were announced through the ListServ on September 29, 2015, and posted on the Department's web site. A comment letter was received from LeadingAge PA supporting this change.
Following publication of this notice, the Department will send rate letters to each MA nursing facility to notify the facilities of their final rates for FY 2015-2016. The rate letter will also advise each facility that it may file an administrative appeal if the facility believes that the Department made any errors or otherwise disagrees with its final rates for FY 2015-2016. A provider's appeal must be in writing and filed with the Department's Bureau of Hearings and Appeals, 2330 Vartan Way, 2nd Floor, Harrisburg, PA 17110-9721, within 33 days of the date of the Department's letter notifying the facility of its final rates. Facilities should refer to 67 Pa.C.S. Chapter 11 (relating to Medical Assistance hearings and appeals) and to the Department's regulations in 55 Pa. Code Chapter 41 (relating to Medical Assistance provider appeal procedures) for more detail regarding their appeal rights and the requirements related to written appeals.
There is no fiscal impact associated with this change.
Interested persons are invited to submit written comments regarding this notice to the Department of Human Services, Office of Long-Term Living, Bureau of Policy and Regulatory Management, Attention: Marilyn Yocum, P.O. Box 8025, Harrisburg, PA 17105-8025. Comments received within 30 days will be reviewed and considered for any subsequent revision of the notice.
Persons with a disability who require an auxiliary aid or service may submit comments using the Pennsylvania AT&T Relay Service at (800) 654-5984 (TDD users) or (800) 654-5988 (voice users).
Fiscal Note: 14-NOT-1035. No fiscal impact; (8) recommends adoption.
[Pa.B. Doc. No. 16-1096. Filed for public inspection June 24, 2016, 9:00 a.m.]
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