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Pennsylvania Code



Subchapter E. PAYMENT CONDITIONS, LIMITATIONS AND ADJUSTMENTS


Sec.


1189.101.    General payment policy for county nursing facilities.
1189.102.    Utilizing Medicare as a resource.
1189.103.    Limitations on payment for reserved beds.
1189.104.    Limitations on payment during strike or disaster situations requiring resident evacuation.
1189.105.    Incentive payments.
1189.106.    Adjustments relating to sanctions and fines.
1189.107.    Adjustments relating to errors and corrections of county nursing facility payments.
1189.108.    County nursing facility supplementation payments.

§ 1189.101. General payment policy for county nursing facilities.

 (a)  Payment for nursing facility services provided by a county nursing facility will be made subject to the following conditions and limitations:

   (1)  This chapter and Chapter 1101 (relating to general provisions).

   (2)  Applicable State statutes.

   (3)  Applicable Federal statutes and regulations and the Commonwealth’s approved State Plan.

 (b)  A per diem rate payment for nursing facility services provided by a county facility will not be made if full payment is available from another public agency, another insurance or health program or the resident’s resources.

 (c)  Payment will not be made in whole or in part to a county nursing facility for nursing facility services provided during a period in which the nursing facility’s participation in the MA Program is terminated.

 (d)  Claims submitted by a county nursing facility for payment under the MA Program are subject to the utilization review procedures established in Chapter 1101. In addition, the Department will perform the reviews specified in this chapter for controlling the utilization of nursing facility services.

§ 1189.102. Utilizing Medicare as a resource.

 (a)  An eligible resident who is a Medicare beneficiary, is receiving care in a Medicare certified county nursing facility and is authorized by the Medicare Program to receive county nursing facility services shall utilize available Medicare benefits before payment will be made by the MA Program. If the Medicare payment is less than the county nursing facility’s MA per diem rate for nursing facility services, the Department will participate in payment of the coinsurance charge to the extent that the total of the Medicare payment and the Department’s and other coinsurance payments do not exceed the MA per diem rate for the county nursing facility. The Department will not pay more than the maximum coinsurance amount.

 (b)  If a resident has Medicare Part B coverage, the county nursing facility shall use available Medicare Part B resources for Medicare Part B services before payment is made by the MA Program.

 (c)  The county nursing facility may not seek or accept payment from a source other than Medicare for any portion of the Medicare coinsurance amount that is not paid by the Department on behalf of an eligible resident because of the limit of the county nursing facility’s MA per diem rate.

 (d)  The Department will recognize the Medicare payment as payment in full for each day that a Medicare payment is made during the Medicare-only benefit period.

 (e)  The cost of providing Medicare Part B type services to MA residents not eligible for Medicare Part B services which are otherwise allowable costs under this part are reported in accordance with §  1189.72 (relating to cost reporting for Medicare Part B type services).

Cross References

   This section cited in 55 Pa. Code §  1189.72 (relating to cost reporting for Medicare Part B type services).

§ 1189.103. Limitations on payment for reserved beds.

 (a)  A county facility may be eligible for payments for a reserved bed when the resident is absent from the nursing facility for a continuous 24-hour period because of hospitalization or therapeutic leave. A county nursing facility shall record each reserved bed for therapeutic leave on the nursing facility’s daily census record and MA invoice. When the bed reserved for a resident who is hospitalized is temporarily occupied by another resident, a county nursing facility shall record the occupied bed on the nursing facility’s daily MA census record and the MA invoice. During the reserved bed period the same bed shall be available for the resident upon the resident’s return to the nursing facility.

 (b)  The following limits on payment for reserved bed days apply:

   (1)  Hospitalization.

     (i)   A resident receiving nursing facility services is eligible for a maximum of 15 consecutive reserved bed days per hospitalization. The Department will pay a county nursing facility at a rate of 1/3 of the county nursing facility’s current per diem rate on file with the Department for a hospital reserved bed day.

     (ii)   A county nursing facility’s overall occupancy must meet the occupancy requirements in this subparagraph. For each rate quarter, the criteria for meeting the overall occupancy limits will be calculated and applied to the rate quarter based on the highest of the overall occupancy calculated for three picture dates. The three picture dates will be the picture date for the current rate quarter (July 1 rate quarter—February 1 picture date; October 1 rate quarter—May 1 picture date; January 1 rate quarter—August 1 picture date; and April 1 rate quarter—November 1 picture date) and the two picture dates directly preceding this picture date. Overall occupancy for each picture date will be calculated by dividing the total number of assessments listed in the facility’s CMI report for the picture date by the number of the facility’s certified beds on file with the Department on the picture date. The highest of the results will be used to determine whether the county nursing facility meets the overall occupancy criteria set forth as follows:

       (A)   During rate year 2009-2010, the county nursing facility’s overall occupancy rate for the rate quarter in which the hospital reserved bed day occurred must be equal or exceed 75%.

       (B)   Beginning with rate year 2010-2011 and thereafter, the county nursing facility’s overall occupancy rate for the rate quarter in which the hospital reserved bed day occurs must equal or exceed 85%.

     (iii)   County nursing facilities not submitting a valid CMI report for the three picture dates do not meet the criteria for payment for reserved bed days, unless subparagraph (iv) applies.

     (iv)   New county nursing facilities are eligible for payment for reserved bed days as set forth in subparagraph (i) until CMI Reports for the three picture dates used to calculate overall occupancy as set forth in subparagraph (ii) are available for the rate quarter.

     (v)   If the resident’s hospital stay exceeds 15 consecutive days, the county nursing facility shall readmit the resident to the nursing facility upon the first availability of a bed in the county nursing facility if, at the time of readmission, the resident requires the services provided by the county nursing facility.

     (vi)   If the resident’s hospital stay is less than or equal to 15 consecutive days, the county nursing facility shall readmit the resident to the same bed the resident occupied before the hospital stay regardless whether the county nursing facility is eligible for payment for hospital reserved beds under subparagraph (b)(1)(ii), if, at the time of readmission, the resident requires the services provided by the nursing facility.

     (vii)   Hospital reserved bed days may not be billed as therapeutic leave days and may not be billed to the resident if the resident’s hospital stay is less than or equal to 15 consecutive days regardless whether the county nursing facility is eligible for payment for hospital reserved beds under subparagraph (b)(1)(ii).

   (2)  Therapeutic leave. A resident receiving nursing facility services is eligible for a maximum of 30 days per calendar year of therapeutic leave outside the county nursing facility if the leave is included in the resident’s plan of care and is ordered by the attending physician. The Department will pay a county nursing facility the county nursing facility’s current per diem rate on file with the Department for a therapeutic leave day.

Source

   The provisions of this §  1189.103 amended November 26, 2010, effective November 27, 2010, 40 Pa.B. 6782. Immediately preceding text appears at serial page (320685).

§ 1189.104. Limitations on payment during strike or disaster situations requiring resident evacuation.

 Payment may continue to be made to a county nursing facility that has temporarily transferred residents, as the result or threat of a strike or disaster situation, to the closest medical institution able to meet the residents’ needs, if the institution receiving the residents is licensed and certified to provide the required services. If the county nursing facility transferring the residents can demonstrate that there is no certified nursing facility available for the safe and orderly transfer of the residents, the payments may be made so long as the institution receiving the residents is certifiable and licensed to provide the services required. The resident assessment submissions for the transferring nursing facility residents shall be maintained under the transferring county nursing facility provider number as long as the transferring county nursing facility is receiving payment for those residents. If the nursing facility to which the residents are transferred has a different per diem rate, the transferring county nursing facility shall be reimbursed at the lower rate. The per diem rate established on the date of transfer will not be adjusted during the period that the residents are temporarily transferred. The county nursing facility shall immediately notify the Department in writing of an impending strike or a disaster situation and follow with a listing of MA residents and the nursing facility to which they will be or were transferred.

§ 1189.105. Incentive payments.

 (a)  Disproportionate share incentive payment.

   (1)  A disproportionate share incentive payment will be made based on MA paid days of care times the per diem incentive to facilities meeting the following criteria for a 12-month facility cost reporting period:

     (i)   The county nursing facility shall have an annual overall occupancy rate of at least 90% of the total available bed days.

     (ii)   The county nursing facility shall have an MA occupancy rate of at least 80%. The MA occupancy rate is calculated by dividing the MA days of care paid by the Department by the total actual days of care.

   (2)  The disproportionate share incentive payments will be based on the following:

Overall MA Per Diem
Occupancy Occupancy (y) Incentive
Group A 90% ›= 90% y $3.32
Group B 90% 88% ‹= y ‹90% $2.25
Group C 90% 86% ‹= y ‹88% $1.34
Group D 90% 84% ‹= y ‹86% $0.81
Group E 90% 82% ‹= y ‹84% $0.41
Group F 90% 80% ‹= y ‹82% $0.29

   (3)  The disproportionate share incentive payments as described in paragraph (2) will be inflated forward using the first quarter issue CMS Nursing Home Without Capital Market Basket Index to the end point of the rate setting year for which the payments are made.

   (4)  These payments will be made annually within 120 days after the submission of an acceptable cost report provided that payment will not be made before 210 days of the close of the county nursing facility fiscal year.

   (5)  For the period July 1, 2005, to June 30, 2009, the disproportionate share incentive payment to qualified county nursing facilities shall be increased to equal two times the disproportionate share per diem incentive calculated in accordance with paragraph (3).

     (i)   For the period commencing July 1, 2005, through June 30, 2006, the increased incentive applies to cost reports filed for the fiscal period ending December 31, 2005.

     (ii)   For the period commencing July 1, 2006, through June 30, 2007, the increased incentive applies to cost reports filed for the fiscal period ending December 31, 2006.

     (iii)   For the period commencing July 1, 2007, through June 30, 2008, the increased incentive applies to cost reports filed for the fiscal period ending December 31, 2007.

     (iv)   For the period commencing July 1, 2008, through June 30, 2009, the increased incentive applies to cost reports filed for the fiscal period ending December 31, 2008.

 (b)  Pay for performance incentive payment. The Department will establish pay for performance measures that will qualify a county nursing facility for additional incentive payments in accordance with the formula and qualifying criteria in the Commonwealth’s approved State Plan. For pay for performance payment periods beginning on or after July 1, 2010, in determining whether a county nursing facility qualifies for a quarterly pay for performance incentive, the facility’s MA CMI for a picture date will equal the arithmetic mean of the individual CMIs for MA residents identified in the facility’s CMI report for the picture date. An MA resident’s CMI will be calculated using the RUG-III version 5.12 44 group values in Chapter 1187, Appendix A (relating to resource utilization group index scores for case-mix adjustment in the nursing facility reimbursement system) and the most recent classifiable assessment of any type for the resident.

 (c)  Supplemental ventilator care and tracheostomy care payments.

   (1)  Supplemental ventilator care payments.

     (i)   A supplemental ventilator care payment will be made each calendar quarter, effective July 1, 2012, through June 30, 2014, to county nursing facilities subject to the following:

       (A)   To qualify for the supplemental ventilator care payment, the county nursing facility shall satisfy both of the following threshold criteria on the applicable picture date:

         (I)   The county nursing facility shall have a minimum of ten MA-recipient residents who receive medically necessary ventilator care.

         (II)   The county nursing facility shall have a minimum of 10% of its MA-recipient resident population receiving medically necessary ventilator care.

       (B)   For purposes of subparagraph (i), the percentage of the county nursing facility’s MA-recipient residents who require medically necessary ventilator care will be calculated by dividing the total number of MA-recipient residents who receive medically necessary ventilator care by the total number of MA-recipient residents as described in subparagraph (ii)(A). The result of this calculation will be rounded to two percentage decimal points. (For example, 0.0945 will be rounded to 0.09 (or 9%); 0.1262 will be rounded to 0.13 (or 13%).)

       (C)   To qualify as an MA-recipient resident who receives medically necessary ventilator care, the resident shall be listed as an MA resident and have a positive response for the MDS item for ventilator use on the Federally-approved PA-specific MDS assessment listed on the county nursing facility’s CMI report for the applicable picture date.

       (D)   The number of total MA-recipient residents is the number of MA-recipient residents listed on the county nursing facility’s CMI report for the applicable picture date. MA-pending individuals or those individuals found to be MA eligible after the county nursing facility submits a valid CMI report for the picture date as provided under §  1187.33(a)(5) (relating to resident data and picture date reporting requirements) may not be included in the count and may not result in an adjustment of the percent of ventilator dependent MA residents.

       (E)   The applicable picture dates and the authorization of a quarterly supplemental ventilator care payment are as follows:

Picture Dates Authorization Schedule
February 1 September
May 1 December
August 1 March
November 1 June

       (F)   If a county nursing facility fails to submit a valid CMI report for the picture date as provided under §  1187.33(a)(5), the facility cannot qualify for a supplemental ventilator care payment.

     (ii)   A county nursing facility’s supplemental ventilator care payment is calculated as follows:

       (A)   The supplemental ventilator care per diem is ((number of MA-recipient residents who receive medically necessary ventilator care/total MA-recipient residents) x $69) x (the number of MA-recipient residents who receive medically necessary ventilator care/total MA-recipient residents).

       (B)   The amount of the total supplemental ventilator care payment is the supplemental ventilator care per diem multiplied by the number of paid MA facility and therapeutic leave days.

   (2)  Supplemental ventilator care and tracheostomy care payment.

     (i)   A supplemental ventilator care and tracheostomy care payment will be made each calendar quarter, effective July 1, 2014, to county nursing facilities subject to the following:

       (A)   To qualify for the supplemental ventilator care and tracheostomy care payment, the county nursing facility shall satisfy both of the following threshold criteria on the applicable picture date:

         (I)   The county nursing facility shall have a minimum of ten MA-recipient residents who receive medically necessary ventilator care or tracheostomy care.

         (II)   The county nursing facility shall have a minimum of 10% of its MA-recipient resident population receiving medically necessary ventilator care or tracheostomy care.

       (B)   For purposes of subparagraph (i), the percentage of the county nursing facility’s MA-recipient residents who require medically necessary ventilator care or tracheostomy care will be calculated by dividing the total number of MA-recipient residents who receive medically necessary ventilator care or tracheostomy care by the total number of MA-recipient residents as described in subparagraph (ii)(A). The result of this calculation will be rounded to two percentage decimal points. (For example, 0.0945 will be rounded to 0.09 (or 9%); 0.1262 will be rounded to 0.13 (or 13%).)

       (C)   To qualify as an MA-recipient resident who receives medically necessary ventilator care or tracheostomy care, the resident shall be listed as an MA resident and have a positive response for the MDS item for ventilator use or tracheostomy care on the Federally-approved PA-specific MDS assessment listed on the county nursing facility’s CMI report for the applicable picture date.

       (D)   The number of total MA-recipient residents is the number of MA-recipient residents listed on the county nursing facility’s CMI report for the applicable picture date. MA-pending individuals or those individuals found to be MA eligible after the county nursing facility submits a valid CMI report for the picture date as provided under §  1187.33(a)(5) may not be included in the count and may not result in an adjustment of the percent of ventilator dependent or tracheostomy care MA residents.

       (E)   The applicable picture dates and the authorization of a quarterly supplemental ventilator care and tracheostomy care payment are as follows:

Picture Dates Authorization Schedule
February 1 September
May 1 December
August 1 March
November 1 June

       (F)   If a county nursing facility fails to submit a valid CMI report for the picture date as provided under §  1187.33(a)(5), the facility cannot qualify for a supplemental ventilator care and tracheostomy care payment.

     (ii)   A county nursing facility’s supplemental ventilator care and tracheostomy care payment is calculated as follows:

       (A)   The supplemental ventilator care and tracheostomy care per diem is ((number of MA-recipient residents who receive medically necessary ventilator care or tracheostomy care/total MA-recipient residents) x $69) x (the number of MA-recipient residents who receive medically necessary ventilator care or tracheostomy care/total MA-recipient residents).

       (B)   The amount of the total supplemental ventilator care and tracheostomy care payment is the supplemental ventilator care and tracheostomy care per diem multiplied by the number of paid MA facility and therapeutic leave days.

   (3)  Waiver to 180-day billing requirement. If the Department grants a county nursing facility a waiver to the 180-day billing requirement, the MA-paid days that may be billed under the waiver and after the authorization date of the waiver will not be included in the calculation of the supplemental ventilator care payment under paragraph (1)(ii) or the supplemental ventilator care and tracheostomy care payment under paragraph (2)(ii). The Department will not retroactively revise the supplemental payment amount under paragraphs (1) and (2).

   (4)  Calculation of quarterly payments. The paid MA facility and therapeutic leave days used to calculate a qualifying facility’s supplemental ventilator care or supplemental ventilator care and tracheostomy care payments under paragraphs (1)(ii) and (2)(ii) will be obtained from the calendar quarter that contains the picture date used in the qualifying criteria as described in paragraphs (1) and (2).

   (5)  Quarterly payments. The supplemental ventilator care or supplemental ventilator care and tracheostomy care payments will be made quarterly in each month listed in paragraphs (1) and (2).

Authority

   The provisions of this §  1189.105 amended under sections 201(2), 206(2), 403(b) and 443.1 of the Public Welfare Code (62 P. S. § §  201(2), 206(2), 403(b) and 443.1).

Source

   The provisions of this §  1189.105 amended August 26, 2011, effective retroactive to July 1, 2010, 41 Pa.B. 4630; amended June 13, 2014, section 1189(c)(1) shall take effect upon publication and apply retroactively from July 1, 2012, through June 30. 2014, section 1189.105(c)(3)—(5) shall take effect upon publication and apply retroactively from July 1, 2012, section 1189.105(c)(2) takes effect July 1, 2014, 44 Pa.B. 3565. Immediately preceding text appears at serial pages (358397) and (358398).

§ 1189.106. Adjustments relating to sanctions and fines.

 County nursing facility payments shall be withheld, offset, reduced or recouped as a result of sanctions and fines in accordance with Chapter 1187, Subchapter I (relating to enforcement of compliance for nursing facilities with deficiencies).

§ 1189.107. Adjustments relating to errors and corrections of county nursing facility payments.

 County nursing facility payments shall be withheld, offset, increased, reduced or recouped as a result of errors, fraud and abuse or appeals under Chapter 1187, Subchapter I (relating to enforcement of compliance for nursing facilities with deficiencies) and §  1189.141 (relating to county nursing facility’s right to appeal and to a hearing).

§ 1189.108. County nursing facility supplementation payments.

 

   Supplementation payments are made according to a formula established by the Department to county nursing facilities, in which Medicaid funded resident days account for at least 80% of the facility’s total resident days and the number of certified MA beds is greater than 270 beds. Payment of the supplementation payments is contingent upon the determination by the Department that there are sufficient State and Federal funds appropriated to make these supplementation payments.



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