Rate-Setting Methodology for Consolidated and Person/Family Directed Support Waiver-Funded and Base-Funded Services for Individuals Participating in the Office of Developmental Programs Service System
[47 Pa.B. 4919]
[Saturday, August 19, 2017]
The purpose of this notice is to announce the proposed payment methodology used to develop rates, effective July 1, 2017, for residential habilitation eligible, life sharing eligible and transportation trip services funded through the Consolidated and Person/Family Directed Support (P/FDS) waivers and for the same service that is provided with base funding in a waiver-funded service location.
Rate-Setting Methodology for Residential Eligible and Transportation (per Trip) Services
Rates for the following services delivered between July 1, 2017, and December 31, 2017, were developed utilizing a standardized cost-based methodology: Unlicensed Residential Habilitation in Community Homes; Licensed Residential Habilitation in Community Homes; Child Residential Services; Community Residential Rehabilitation Services; Unlicensed Life Sharing; and Licensed Life Sharing.
Rates for Transportation (per trip) services delivered on or after July 1, 2017, were also developed utilizing a standardized cost-based methodology. Transportation (per trip) providers are both private and local government agency providers.
Effective January 1, 2018, the rates for residential habilitation eligible and life sharing eligible services will be on the Medical Assistance (MA) fee schedule. Also effective January 1, 2018, Transportation (per trip) will be the only service remaining that utilizes the cost-based methodology.
The cost-based methodology requires providers to use a standardized cost report and follow instructions provided by the Department of Human Services (Department). Cost reports undergo a desk review in which the reported data is analyzed by the Department or its designee for completeness and accuracy based on cost report instructions and standardized review procedures. The Department uses only costs allowable for Federal financial participation from the cost report to develop the eligible rates.
Cost report data is adjusted to reflect changes in the service definitions, if necessary, to account for differences in service definitions between the historical reporting period and the period in which the rates will be in effect.
The proposed rates for the residential habilitation eligible and life sharing eligible services effective July 1, 2017, to December 31, 2017, were developed from expenses reported in the approved Year 9 cost reports (based on the Fiscal Year (FY) 2015-2016 Historical Expense Period) and authorizations included in the Home and Community Services Information System (HCSIS) as of December 31, 2016.
The residential habilitation eligible and life sharing eligible rates are subject to the adjustments described as follows, and are assigned at the Master Provider Index (MPI)—Service Location Code—Procedure Code/Modifier level based on the methodology outlined as follows.
Residential Outlier Review Process
The ''total unit cost'' for a provider and service is defined as the total expenses reported in the approved cost report for that provider and service divided by the total authorized units for that provider and service, including any applicable utilization adjustments. The total expenses are equal to Schedule A, Line 18 of the cost report. The total authorized units are equal to Schedule A, Line 19 (HCSIS Units Authorized) of the cost report, including any applicable utilization adjustments based on a review of the available HCSIS and Provider Reimbursement and Operations Management Information System (PROMISe) data, where available.
For all providers, the Department identified and adjusted for outliers at the total unit cost level for each of the providers' residential habilitation eligible and life sharing eligible services submitted in the Year 9 approved cost reports, as applicable. For all residential habilitation eligible and life sharing eligible services with 20 or more unique unit costs (unit costs by provider and service from separate, approved Year 9 cost reports), the Department applied the following process for each service:
• The average and standard deviation values were calculated, excluding extreme outliers, based on the total unit costs for all providers from the Year 9 cost report data.
• Total unit costs that were greater than the average plus one standard deviation or that were less than the average minus two standard deviations were flagged as outliers.
• Total unit costs that were flagged as outliers underwent a review, as described as follows.
Total Unit Cost Review
For all providers of residential habilitation and life sharing services, the Department performed a standardized review of all total unit cost outliers to ensure consistency across this Commonwealth. The review consisted of an evaluation of the Individual Support Plans (ISP) for waiver participants receiving services at the service locations impacted by the outlier unit cost. The review allowed the Department to determine whether the outlier unit cost was justified (such as an individual with complex needs) and the following was applied:
Total unit cost outliers that were supported by the ISP reviews were not adjusted.
Total unit cost outliers that were greater than the average unit cost plus one standard deviation and were not supported by the ISP reviews were adjusted to the maximum unit cost from an approved Year 9 cost report below the average plus one standard deviation for that service.
Total unit cost outliers that were less than the average minus two standard deviations and that were not supported by the ISP reviews were adjusted to the minimum unit cost from an approved Year 9 cost report above the average minus two standard deviations for that service.
For all residential habilitation eligible and life sharing eligible services with fewer than 20 unique unit costs, the Department did not perform the standardized outlier review on the total unit costs since there were not enough data points available to produce statistically valid ranges. However, the Department did perform a review of the unit costs for these services in an effort to standardize payment rates across services. The review consisted of a comparison of the following:
• Other unit costs for that service, as applicable.
• The average unit cost and range of unit costs for similar services with 20 or more unit costs.
• The FY 2016-2017 Statewide average unit cost for that service based on FY 2016-2017 approved cost report data and any utilization adjustment made.
If a unit cost appeared unreasonably high or low based on this review, the Department reviewed the ISP for the individual receiving services at the service location impacted by the high/low unit cost to determine if the unit cost was justified. Based on these reviews, no adjustments were made.
For the period July 1, 2017, through December 31, 2017, the Department will allow for a retention factor. The retention factor is a percentage addition to the provider's calculated FY 2017-2018 cost-based residential habilitation eligible and life sharing eligible rates. The retention factor can be up to a maximum of 2% of the difference between FY 2017-2018 unit cost and FY 2016-2017 unit costs, if the total unit cost for a service decreased from the provider's FY 2016-2017 unit cost. The application of the retention factor cannot cause the provider's FY 2017-2018 rate to exceed the provider's prior year's PROMISe paid rate.
An adjusted vacancy factor was incorporated into the FY 2016-2017 proposed rates to recognize that residential habilitation and life sharing providers may not deliver services at full capacity. The vacancy factor adjusts the full capacity rate to account for days when the residential habilitation or life sharing provider cannot bill due to a participant not receiving services. The provider cannot bill for days when a participant is not receiving services, but rather is paid a higher rate for days when the participant is receiving services.
After the unit costs for each residential habilitation eligible and life sharing eligible service were adjusted through the outlier review process a vacancy factor of 96% was applied to provider's payment rates to reflect payment to providers for an average number of vacant days. For example, a unit cost of $100 (after the outlier review) would be adjusted to a unit cost of $104.17 ($100/0.96) after the vacancy factor was applied.
Enhanced Communication Services
The Enhanced Communication Services modifier, U1, is available for residential habilitation eligible and life sharing eligible services. Enhanced Communication Services can be provided to individuals who meet all of the following:
• Enrolled in the Consolidated or P/FDS Waiver.
• Determined to need services that are provided by staff who are proficient in sign language.
Providers who wish to receive the Enhanced Communication Services Rate must be approved to do so by the Department. Requests for enhanced rates should be directed to the Deaf Services Coordinator at RA-ODPDeafServices@pa.gov.
Transportation Trip Services
The FY 2017-2018 proposed rates for transportation trip services were developed from expenses and utilization data reported in approved Year 9 transportation cost reports that are based on the FY 2015-2016 historical expense period, when the procedure codes submitted by providers are the same as those entered in the services and supports directory. The FY 2017-2018 transportation trip proposed rates will be effective for services delivered July 1, 2017, through June 30, 2018, are subject to the adjustments described as follows, and are assigned at the MPI—Service Location Code—Procedure Code/Modifier level based on the methodology outlined as follows.
Transportation Trip Outlier Review Process
The ''total unit cost'' for a provider and transportation trip service is defined as total expenses reported in the approved transportation cost report for that provider and service divided by the total utilization reported in the approved transportation cost report for that provider and service. The total expenses are equal to Schedule A, Line 12 (total net expenses). The total utilization is equal to Schedule A, Line 13. These proposed rates reflect consideration for trips with and without aides (as reported by the provider), which means each provider will be paid one payment rate for each trip service (that is, there will not be separate rates for trips with an aide versus without an aide).
The Department reviewed the development of each transportation trip unit cost submitted in approved transportation cost reports for accuracy, reasonableness, and to ensure compliance with the Department's allowable cost policies. To support the Department's efforts to continue to standardize rates for similar services, the Department performed a more detailed review of unit costs that were at the upper or lower end of the range of unit costs for each transportation trip service.
Cost of Living Adjustment (COLA)
After the unit costs for each residential habilitation eligible, life sharing eligible and transportation trip service were adjusted as previously described, a total COLA of 0.00% was applied to establish each provider's proposed rates for FY 2017-2018.
Rate Assignment Process
For the FY 2017-2018 residential habilitation eligible, life sharing eligible and transportation trip services, the Department assigned proposed payment rates to providers with approved Year 9 cost reports and Year 9 transportation cost reports using the following methodology:
The provider's cost-based payment rate for existing services and service locations submitted in the cost reports, based on the methodology previously described.
The average of the provider's cost-based payment rates for an existing service at a new service location if the provider submitted cost report data for that service at other service locations.
The average payment rate calculated based on all approved cost reports for a new service for which the provider did not deliver at any service location in FY 2015-2016.
The Department assigned payment rates to existing providers who do not have approved Year 9 cost reports based on the following methodology:
The lowest payment rates calculated based on all approved cost reports for providers using the methodology previously described for an existing service which the provider delivered at any service location in FY 2015-2016.
The average payment rate calculated based on all approved cost reports for providers using the methodology previously described for a new service which the provider did not deliver at any service location in FY 2015-2016.
The Department assigned to new providers who did not provide any services in FY 2015-2016 the average payment rate calculated based on all approved cost reports for providers using the methodology previously described.
The proposed payment rates should be used to process claims submitted to PROMISe in electronic format for services provided. A notice will be published announcing the final rates after the public comment period.
It is estimated that there will be an additional $21.297 million ($10.407 million in State funds) cost to the Commonwealth for FY 2017-2018.
Copies of this notice may be obtained at the local Mental Health/Intellectual Disability (MH/ID) County Program, Administrative Entity (AE) or regional Office of Developmental Programs in the corresponding regions:
• Western Region: Piatt Place, Room 4900, 301 5th Avenue, Pittsburgh, PA 15222, (412) 565-5144
• Northeast Region: Room 315, Scranton State Office Building, 100 Lackawanna Avenue, Scranton, PA 18503, (570) 963-4749
• Southeast Region: 801 Market Street, Suite 5071, Philadelphia, PA 19107, (215) 560-2242 or (215) 560-2245
• Central Region: P.O. Box 2675, DGS Annex Complex, Harrisburg, PA 17105 (717) 772-6507
Contact information for the local MH/ID County Program or AE may be found at https://www.hcsis.state.pa.us/hcsis-ssd/pgm/asp/PRCNT.ASP or contact the previously referenced regional Office of Developmental Programs.
Interested persons are invited to submit written comments regarding the proposed payment methodology to the Department of Human Services, Office of Developmental Programs, Division of Provider Assistance and Rate Setting, 4th Floor, Health and Welfare Building, 625 Forster Street, Harrisburg, PA 17120. Comments can also be sent to email@example.com, use subject header ''PN Fee Schedule.''
Persons with a disability who require an auxiliary aid or service may submit comments using the Pennsylvania AT&T Relay Service by dialing 711 or by using one of the toll free numbers: (800) 654-5984 (TDD users), (800) 654-5988 (voice users), (844) 308-9292 (Speech-to-Speech) or (844) 308-9291 (Spanish).
Comments received within 30 days of publication of this notice will be reviewed and considered for revisions to the proposed payment methodology.
Fiscal Note: 14-NOT-1172. (1) General Fund;
(7) ID—Community Waiver Program; (2) Implementing Year 2017-18 is $10,110,000; (3) 1st Succeeding Year 2018-19 through 5th Succeeding Year 2022-23 are $0; (4) 2016-17 Program—$1,349,000,000; 2015-16 Program—$1,202,000,000; 2014-15 Program—$1,074,000,000;
(7) ID—Community Base Program; (2) Implementing Year 2017-18 is $297,000; (3) 1st Succeeding Year 2018-19 through 5th Succeeding Year 2022-23 are $0; (4) 2016-17 Program—$149,950,000; 2015-16 Program—$148,229,000; 2014-15 Program—$149,681,000;
(8) recommends adoption. Funds have been included in the budget to cover this increase.
[Pa.B. Doc. No. 17-1382. Filed for public inspection August 18, 2017, 9:00 a.m.]
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