Oregon Bulletin
Rule Caption: Medicaid Nursing Facilities.
Adm. Order No.: SPD 22-2011
Filed with Sec. of State: 10-7-2011
Certified to be Effective: 11-1-11
Notice Publication Date: 9-1-2011
Rules Amended: 411-070-0442, 411-070-0452
Rules Repealed: 411-070-0442(T), 411-070-0452(T)
Subject: The Department of Human Services is permanently
amending OAR 411-070-0442 and 411-070-0452 to maintain Medicaid-certified long
term care facility reimbursement rates at their current level as of June 30,
2011 in accordance with the legislatively adopted budget and Senate Bill 939
(2011).
Rules Coordinator: Christina Hartman—(503) 945-6398
411-070-0442
Per Diem
Rate Setting For the Rate Period Beginning July 1, 2003 Calculation of the
Basic Rate and Complex Medical Add-on Rate
(1) The
rates are determined for the first year of each biennium, the rebasing year,
and the second year of each biennium, the non-rebasing year.
(a) The
Rebasing Year.
(A) The
basic rate is based on the statements received by the Department by September
(or postmarked by October 31, if an extension of filing has been approved by
the Department) for the fiscal reporting period ending on June 30 of the
previous even-numbered year. For example, for the biennium beginning July 1,
2003, statements for the period ending June 30, 2002 are used. The Department
desk reviews or field audits these statements and determines the allowable
costs for each nursing facility. The costs include both direct and indirect
costs. The costs and days relating to pediatric beds are excluded from this
calculation. The Department shall only use financial reports of facilities that
have been in operation for at least 180 days and are in operation as of June 30
of even numbered years for biennial rebasing.
(B) For the
2009 rebasing period only, the Department shall limit the administrative and
property cost components as follows:
(i)
Administrative and general costs per facility, less provider tax and employee
benefits, equals the lesser of the facility’s allowable cost or the 50th
percentile over all facilities; and
(ii)
Allowable property expenses shall be limited by the Medicaid occupancy
percentage when the facility has an occupancy rate of less than 60 percent.
(C) For
each facility, its allowable costs after any limitations as set forth in
subsection (1)(a)(B) of this section are applied, less the costs of its
self-contained pediatric unit (if any) is inflated from the mid-point of its
fiscal reporting period to the mid-point of the first year of the biennium,
hereafter referred to as the base year (e.g., for the biennium beginning July
1, 2003, the base year is the fiscal period ending June 30, 2004) by the annual
change in the DRI Index, or its successor index, as measured in the previous
4th quarter.
(D) For
each facility, its allowable costs after any limitations as set forth in
subsection (1)(a)(B) of this section are applied, per Medicaid day is
determined using the allowable costs as inflated and resident days, excluding
pediatric days as reported in the statement.
(E) The
facilities are ranked from highest to lowest by the facility’s allowable costs
after any limitations as set forth in subsection (1)(a)(B) of this section are
applied, per Medicaid day.
(F) The
basic rate will be determined by ranking the allowable costs after any
limitations as set forth in subsection (1)(a)(B) of this section are applied,
per Medicaid day by facility and identifying the allowable cost per day at the
applicable percentage. If there is no allowable cost per day at the applicable
percentage, the basic rate is determined by interpolating the difference
between the allowable costs per day that are just above and just below the
applicable percentage to arrive at a basic rate at the applicable percentage.
(i) The
applicable percentage for the period beginning July 1, 2003 through June 30,
2005 is at the 63rd percentile.
(ii) The
applicable percentage for the period beginning July 1, 2005 through June 30,
2007 is at the 70th percentile.
(iii) The
applicable percentage for the period beginning July 1, 2007 is at the 63rd
percentile.
(b) The
Non-Rebasing Year. On July 1 of each non-rebasing year, the basic flat rate shall
be inflated by the annual change in the DRI Index, or its successor index, as
measured in the previous 4th quarter.
(2) The
complex medical add-on rate is 40 percent of the basic rate for the rebasing
year and the non-rebasing year.
(3) The
Department shall add a standard payment to fund implementation of certified
nursing assistant staffing requirements contained in OAR 411-086-0100 in
accordance with the Legislatively Adopted Budget.
(4) For
services rendered between July 1, 2011 and June 30, 2012, the Department shall
pay a daily rate equal to the following:
(a) Basic
rate: $212.12 per day;
(b) Complex
medical rate: $295.59 per day; and
(c)
Pediatric rate: $358.38 per day.
Stat.
Auth.: ORS 410.070
Stats.
Implemented: ORS 410.070, 2003 OL Ch. 736, 2007 OL Ch. 780, 2009 OL Ch. 827
& 2011 OL Ch. 630
Hist.: SPD
36-2004, f. 12-23-04, cert. ef. 12-28-04; SPD 15-2007(Temp), f. & cert. ef.
9-10-07 thru 3-8-08; SPD 2-2008, f. 2-29-08, cert. ef. 3-1-08; SPD
6-2009(Temp), f. & cert. ef. 7-1-09 thru 12-28-09; SPD 15-2009, f.
11-30-09, cert. ef. 12-1-09; SPD 17-2011(Temp), f. & cert. ef. 7-1-11 thru
12-28-11; SPD 22-2011, f. 10-7-11, cert. ef. 11-1-11
411-070-0452
Pediatric
Nursing Facilities
(1)
PEDIATRIC NURSING FACILITY.
(a) A
pediatric nursing facility is a licensed nursing facility at least 50 percent
of whose residents entered the facility before the age of 14 and all of whose
residents are under the age of 21.
(b) A
nursing facility that meets the criteria of subsection (1)(a) of this section
shall be reimbursed as follows:
(A) The
pediatric rate is a prospective rate and is not subject to settlement. The
Department shall only use financial reports of facilities that have been in
operation for at least 180 days and are in operation as of June 30 of even numbered
years for biennial rebasing.
(B) The
facility specific pediatric cost per resident day shall be inflated by the
annual change in the DRI Index as measured in the previous 4th quarter. The
Oregon Medicaid pediatric days are multiplied by the inflated facility specific
cost per resident day for each pediatric facility. The totals are summed and
divided by total Oregon Medicaid days to establish the weighted average cost
per pediatric resident day. The rebase relationship percentage (90.18%),
determined in the implementation of the flat rate system in 1997, is applied to
the weighted average cost to determine the pediatric rate.
(C) On July
1 of each non-rebasing year after 1999, the pediatric rate shall be increased
by the annual change in the DRI Index, as measured in the previous 4th quarter.
Beginning in 2001 rate rebasing shall occur in alternate years. Rebasing of
pediatric nursing facility rates shall be calculated using the method described
in subsection (1)(b)(B) of this section.
(D) For
services rendered between July 1, 2011 and June 30, 2012, the Department shall
pay the pediatric rate of $358.38 per day.
(c) Even
though pediatric facilities shall be reimbursed in accordance with subsection
(1)(b) of this section, pediatric facilities must comply with all requirements
relating to the timely submission of Nursing Facility Financial Statements.
(2)
LICENSED NURSING FACILITY WITH A SELF-CONTAINED PEDIATRIC UNIT.
(a) A
nursing facility with a self-contained pediatric unit is a licensed nursing
facility that provides services for pediatric residents (individuals under the
age of 21) in a separate and distinct unit within or attached to the facility
with staffing costs separate and distinct from the rest of the nursing
facility. All space within the pediatric unit must be used primarily for
purposes related to the services of pediatric residents and alternate uses must
not interfere with the primary use.
(b) A
nursing facility that meets the criteria of subsection (2)(a) of this section
shall be reimbursed for its pediatric residents served in the pediatric unit at
the per diem rate described in section (1)(b) of this rule commencing on July
1, 1999 or at the per diem rate described in section (1)(b)(D) of this rule
commencing on July 1, 2011.
(c)
Licensed nursing facilities with a self-contained pediatric unit must comply
with all requirements relating to the timely submission of Nursing Facility
Financial Statements and must file a separate attachment, on forms prescribed
by the Department, related to the costs of the self-contained pediatric unit.
Stat.
Auth.: ORS 410.070
Stats.
Implemented: ORS 410.070 & 2011 OL Ch. 630
Hist.: SSD
4-1988, f. & cert. ef. 6-1-88; SSD 8-1991, f. & cert. ef. 4-1-91; SSD
14-1991(Temp), f. 6-28-91, cert. ef. 7-1-91; SSD 18-1991, f. 9-27-91, cert. ef.
10-1-91; SSD 6-1993, f. 6-30-93, cert. ef. 7-1-93; SSD 6-1995, f. 6-30-95,
cert. ef. 7-1-95; SSD 6-1996, f. & cert. ef. 7-1-96; SDSD 10-1999,
f.11-30-99, cert.ef. 12-1-99; SPD 9-2006, f. 1-26-06, cert. ef. 2-1-06; SPD
15-2007(Temp), f. & cert. ef. 9-10-07 thru 3-8-08; SPD 2-2008, f. 2-29-08,
cert. ef. 3-1-08; SPD 15-2009, f. 11-30-09, cert. ef. 12-1-09; SPD
17-2011(Temp), f. & cert. ef. 7-1-11 thru 12-28-11; SPD 22-2011, f.
10-7-11, cert. ef. 11-1-11
Notes
1.) This online version of the OREGON BULLETIN is provided for convenience of reference and enhanced access. The official, record copy of this publication is contained in the original Administrative Orders and Rulemaking Notices filed with the Secretary of State, Archives Division. Discrepancies, if any, are satisfied in favor of the original versions. Use the OAR Revision Cumulative Index found in the Oregon Bulletin to access a numerical list of rulemaking actions after November 15, 2010.
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