10 Colo. Code Regs. § 2505-10-8.440
Current through Register Vol. 47, No. 11, June 10, 2024
Section 10 CCR 2505-10-8.440 - [Effective until 6/30/2024] NURSING FACILITY BENEFITS1. "Acquisition Cost" means the actual allowable cost to the owners of a capital-related asset or any improvement thereto as determined in accordance with generally accepted accounting principles.2. "Actual cost" or "cost" means the audited cost of providing services.3. "Administration and General Services Costs" means costs as defined at Section 8.443.8.4. "Appraised value" means the determination by a qualified appraiser who is a member of an institute of real estate appraisers, or its equivalent, of the depreciated cost of replacement of a capital-related asset to its current owner. The depreciated replacement appraisal shall be based on the valuation system as determined by the Department. The depreciated cost of replacement appraisal shall be redetermined every four years by new appraisals of the nursing facilities. The new appraisals shall be based upon rules promulgated by the state board.
5. "Array of facility providers" means a listing in order from lowest per diem cost facility to highest for that category of costs or rates, as may be applicable, of all Medicaid-participating nursing facility providers in the state.6.a."Base value" means:
i. The appraised value of a capital-related asset for the fiscal year 1986-87 and every fourth year thereafter.ii. The most recent appraisal together with fifty percent of any increase or decrease each year since the last appraisal, as reflected in the index, for each year in which an appraisal is not done pursuant to subparagraph (a) of this paragraph (1).b. For the fiscal year 1985-86, the base value shall not exceed twenty-five thousand dollars per licensed bed at any participating facility, and, for each succeeding fiscal year, the base value shall not exceed the previous year's limitation adjusted by any increase or decrease in the index.c. An improvement to a capital-related asset, which is an addition to that asset, as defined by rules adopted by the state board, shall increase the base value by the acquisition cost of the improvement.7. "Capital-related asset" means the land, buildings, and fixed equipment of a participating facility.8. "Case-mix" means a relative score or weight assigned for a given group of residents based upon their levels of resources, consumption, and needs.9. "Case-mix adjusted direct health care services costs" means those costs comprising the compensation, salaries, bonuses, workers' compensation, employer-contributed taxes, and other employment benefits attributable to a nursing facility provider's direct care nursing staff whether employed directly or as contract employees, including but not limited to DONs, registered nurses, licensed practical nurses, certified nurse aides and restorative nurses.10. "Case-mix index" means a numeric score assigned to each nursing facility resident based upon a resident's physical and mental condition that reflects the amount of relative resources required to provide care to that resident.11. "Case-mix neutral" means the direct health care costs of all facilities adjusted to a common case-mix.12. "Case-mix reimbursement" means a payment system that reimburses each facility according to the resource consumption in treating its case-mix of Medicaid residents, which case-mix may include such factors as the age, health status, resource utilization, and diagnoses of the facility's Medicaid residents as further specified in this section.13. "Class I nursing facility provider" means a private for-profit or not-for-profit nursing facility provider or a facility provider operated by the state of Colorado, a county, a city and county, or special district that provides general skilled nursing facility care to residents who require twenty-four-hour nursing care and services due to their ages, infirmity, or health care conditions, including residents who are behaviorally challenged by virtue of serious mental illness or dementia. Swing bed facilities are not included as Class I nursing facility providers.14. "Core Component per diem rate" means the per diem rate for direct and indirect health care services costs, administrative and general services costs, and fair rental allowance for capital-related assets for Class 1 nursing facility providers.15. "Direct health care services costs" means those costs subject to case-mix adjusted direct health care services costs.16. "Direct or indirect health care services costs" means the costs incurred for patient support services as defined at Section 8.443.7.17. "Facility population distribution" means the number of Colorado nursing facility residents who are classified into each Case-Mix group as of a specific point in time.18. "Fair rental allowance" means the product obtained by multiplying the base value of a capital-related asset by the rental rate.19. "Improvement" means the addition to a capital-related asset of land, buildings, or fixed equipment.20. "Index" means the R. S. Means construction systems cost index or an equivalent index that is based upon a survey of prices of common building materials and wage rates for nursing home construction.21. "Index maximization" means classifying a resident who could be assigned to more than one category to the category with the highest case-mix index.22. "Median per diem cost" means the daily cost of care and services per patient for the nursing facility provider that represents the middle of all of the arrayed facilities participating as providers or as the number of arrayed facilities may dictate, the mean of the two middle providers.23. "Medicare patient day" means all days paid for by Medicare. For instance, a Medicare patient day includes those days where Medicare pays a Managed Care Organization for the resident's care.24. "Minimum data set" means a set of screening, clinical, and functional status elements that are used in the assessment of a nursing facility provider's residents under the Medicare and Medicaid programs.25. "MMIS per diem reimbursement rate" means the per diem rate used for Medicaid Management Information Systems (MMIS) claims-based reimbursement.26. "Normalization ratio" means the statewide average case-mix index divided by the facility's cost report period case-mix index.27. "Normalized" means multiplying the nursing facility provider's per diem case-mix adjusted direct health care services cost by its case-mix index normalization ratio for the purpose of making the per diem cost comparable among facilities based upon a common case-mix in order to determine the maximum allowable reimbursement limitation.28. "Nursing facility provider" means a facility provider that meets the state nursing facility licensing standards established pursuant to C.R.S. § 25-1.5-103, and is maintained primarily for the care and treatment of inpatients under the direction of a physician.29. "Nursing salary ratios" means the relative difference in hourly wages of registered nurses, licensed practical nurses, and nurse's aides.30. "Nursing weights" means numeric scores assigned to each category of the Case-Mix groups that measure the relative amount of resources required to provide nursing care to a nursing facility provider's residents.31. "Occupancy-imputed days" means the use of a predetermined number for patient days rather than actual patient days in computing per diem cost.32. "Per diem cost" means the daily cost of care and services per patient for a nursing facility provider.33. "Per diem fee" means the dollar amount of provider fee that the Department shall charge a nursing facility provider per non-Medicare day.34. "Provider fee" means a licensing fee, assessment, or other mandatory payment as specified under 42 C.F.R. § 433.55.35. "Raw food" means the food products and substances, including but not limited to nutritional supplements, that are consumed by residents.36. "Rental rate" means the average annualized composite rate for United States treasury bonds issued for periods of ten years and longer plus two percent. The rental rate shall not exceed ten and three-quarters percent nor fall below eight and one-quarter percent.37. "Statewide average per diem rate" means the average per diem rate for all Medicaid-participating nursing facility providers in the state.38. "Substandard Quality of Care" means one or more deficiencies related to participation requirements under 42 C.F.R § 483.12 Freedom from abuse, neglect, and exploitation, 42 C.F.R. § 483.24 Quality of life, or 42 C.F.R. § 483.25, Quality of care that constitute either immediate jeopardy to resident health or safety; a pattern of or widespread actual harm that is not immediate jeopardy; or a widespread potential for more than minimal harm, but less than immediate jeopardy, with no actual harm.39. "Supplemental Payment" means a lump sum payment that is made in addition to a nursing facility provider's MMIS per diem reimbursement rate. A supplemental Medicaid payment is calculated on an annual basis using historical data and paid as a fixed monthly amount with no retroactive adjustment.8.440.1SERVICES AND ITEMS INCLUDED IN THE PER DIEM PAYMENT8.440.1.A. Payment to nursing facilities, swing-bed facilities and intermediate care Facilities for Individuals with Intellectual Disabilities shall be an all-inclusive per diem rate, except as provided for within this rule. This rate covers thee necessary services to the resident, including room and board, as well as nursing and ordinary supplies and equipment related to the day-to-day care of the resident and the operation of the facility.8.440.1.B. The following general service areas shall be provided within the per diem rate: 1. Nursing services, therapies, aide services and medically related social services;4. Room/bed maintenance services;5. Routine personal hygiene items and services; and6. Laboratory services. a. Waivered laboratory services provided by nursing facilities enrolled in the Medicaid program are subject to the requirements of the Clinical Laboratory Improvement Amendments of 1988 (CLIA) as set forth in 42 C.F.R. part 493, October 1, 1994 edition.. Facilities that collect specimens, including drawing blood specimens, but do not perform testing of specimens, are not subject to CLIA requirements. A facility shall obtain a Certificate of Waiver from the Centers for Medicare and Medicaid or its designated agency if the facility only performs waivered tests as defined by CLIA.b. 42 C.F.R. part 493 (1994) is hereby incorporated by reference. The incorporation of 42 C.F.R. part 493 excludes later amendments to, or editions of, the referenced material. The Department maintains copies of this incorporated text in its entirety, available for public inspection during regular business hours at: Colorado Department of Health Care Policy and Financing, 1570 Grant Street, Denver, CO 80203. Certified copies of incorporated materials are provided at cost upon request.8.440.1.C. Each nursing facility shall furnish, within the per diem rate, equipment necessary to the operation of the facility and provide for necessary medical, nursing, respiratory and rehabilitation care. Such equipment includes, but is not limited to, the following:1. Adaptive equipment for activities of daily living;2. Air mattresses, other special mattresses, sheepskins and other devices for preventing/treating decubitus ulcers;3. Apnea monitors and necessary supplies and equipment;5. Autoclaves and sterilizers;6. Bath equipment, i.e., raised and/or padded toilet seats, trapeze benches, tub/shower stools or benches;7. Bedrails, footboards, trapeze bars, traction and fracture frames, bedside stands;9. Beds, including hospital beds;10. Blood glucose monitors;17. Gerry chairs, cushioned chairs;18. Ice bags or equivalent;19. Intermittent positive pressure breathing equipment, including Sodium Chloride or sterile water required for operation;20. Irrigating solutions, i.e., Acetic Acid, Potassium Permanganate, Sodium Chloride, and sterile water;21. Lifts, i.e., hydraulic, tub, slings;22. Lymphedema pumps and compressors;23. Medically necessary manual or power wheelchairs for intermittent and full-time use, including cushions and pads as required for the prevention or treatment of skin breakdown, if purchased by the nursing facilities.a. Wheelchairs, if required, shall meet the specific needs of the resident and shall be ordered by a physician. The Primary Care Physician shall concur that the wheelchair being prescribed for the resident is medically necessary.b. All costs associated with the purchase of the wheelchair shall be charged to the health care line of the nursing facility. Wheelchair expenses shall be reported in the appropriate health care line of the Med-13c. The wheelchair shall be sent with the resident in the event the resident is transferred to another facility or returns home. The transferring facility shall expense the remainder of the chair in the fiscal year during which the transfer occurs.25. Oxygen masks, regulators, humidifiers, hoses, nasal catheters, as needed, for the administration of oxygen;26. Percussors and respirators;29. Scissors, forceps, and nail files;31. Sphygmomanometers, stethoscopes, and other examination equipment;34. Suction apparatus and gavage tubing;35. Supplies and equipment necessary for delivery of special dietary needs;36. Surgical stockings for routine use;37. Ventilators and related equipment and supplies;38. Walkers, crutches, canes and medically necessary accessories for ambulatory devices;8.440.1.D. All supplies, including disposables, necessary for effective resident care shall be provided by the nursing facility within the per diem rate. Such supplies include, but are not limited to, the following: 1. Band-Aids, gauze pads, dressings and bandages;2. Bedside utensils, bedpans, basins;3. Catheters and related supplies, irrigating trays and accessories;5. Colostomy and ileostomy bags, supplies, and dressings, ostomy supplies;6. Disposable sterile nursing supplies including, but not limited to, cotton, face masks, gloves, tape, finger cots;7. Drinking tubes/straws, water pitchers/glasses;10. Hypodermic syringes and needles, including syringes and needles for insulin administration, intravenous supplies and equipment and related equipment;11. Minor medical surgical supplies;12. Miscellaneous applicators;13. Nebulizers, recreational/therapeutic equipment and supplies to conduct on-going activities program;17. Tracheostomy care kits, cleaning supplies;18. Urinals, urinary bags, and tubes and supplies.8.440.1.E. Routine personal hygiene items/services shall be provided by the nursing facility within the per diem rate. These items include, but are not limited to, hair hygiene services (i.e., simple trims, such as trimming bangs or cutting of some hair that may need minor cutting in the back) hair hygiene supplies (i.e., shampoo, hair conditioner, comb, brush); bath soap, disinfecting soaps or specialized cleaning agents when indicated to treat special skin problems or to fight infection; razors, shaving cream; toothbrush, toothpaste, mouthwash, denture adhesive, denture cleanser, dental floss; moisturizing lotion; tissues, cotton balls, cotton swabs; deodorant) incontinence care and supplies (i.e., pads, cloth and disposable diapers, pants, liners, sanitary napkins and related supplies) towels, washcloths; and hospital gowns; bathing; shaving; nail hygiene services (i.e., routine trimming, cleaning and filing, not polishing).8.440.1.F. Various over-the-counter (OTC) drugs and supplies as required to meet the residents' assessed needs shall be furnished by the facility, within the per diem rate, at no charge to the resident. OTC drugs/supplies including but not limited to: 2. Aspirin, acetaminophen, ibuprofen, and other non-prescription analgesics available now or in the future;3. Cough and cold supplies, i.e., cold tablets, decongestants, cough syrup/tablets;5. Evacuant suppositories, laxatives, stool softeners, enemas;6. First aid supplies, i.e., alcohol, hydrogen peroxide, merthiolate and other antiseptics/germicides, Betadine, Phisohex, chlorhexidene gluconate, providone/iodine solution and wash, epsom salt;7. Lubricants, rubbing compounds and ointments, i.e., petroleum jelly, bag balm, other body lotions for treatment of dry skin or skin breakdowns, bacitracin ointment and other ointments used in treatment of wounds;8. Vitamins (multi and single) and mineral supplements.8.440.1.G. The following services and provisions shall be provided by the facility within the per diem rate: 1. Food and dietary services, including special diets, supplements and nutrients ordered by the physician, in accordance with the needs of the residents and appropriate licensing requirements;2. Room for accommodation of the resident in accordance with licensing requirements, including storage for personal belongings, bedside equipment, suitable bed, clean and comfortable mattress, pillows and an adequate supply of clean linen;3. Maintenance of clean, comfortable and sanitary environment through provision of heat, light, ventilation and sanitation to meet health and aesthetic needs of the resident, in accordance with the physicians' orders and licensing regulations;4. Basic personal laundry, excluding dry-cleaning, mending, hand washing, or other specialties.5. Consultant services when the facility employs or contracts with consultants in an effort to meet regulations.6. Specialized rehabilitative services, including, but not limited to, physical therapy, speech-language pathology, occupational therapy and mental health rehabilitative services for mental illness and intellectual or developmental disability, when required in the resident's comprehensive plan of care. Specialized rehabilitative services shall be provided under the written order of a physician by qualified personnel. The facility shall provide the required services or obtain the required services from a provider of specialized rehabilitative services.7. Ongoing activities program directed by a qualified professional, to meet the interests and the physical, mental and psychosocial well-being of each resident. The nursing facility can charge for entertainment and social events that are outside the scope of the required activities program.8.440.2SERVICES AND ITEMS NOT INCLUDED IN THE PER DIEM PAYMENT8.440.2.A. The following general categories and examples of items and services are not included in the facility's per diem rate. Items 1 - 11 may be charged to the resident's personal needs account if requested, in writing by a resident and/or the responsible party (refer to Section 8.482 for policy guidance on resident personal needs account): 1. Cosmetic and grooming items and services in excess of those for which payment is allowed under the per diem rate, i.e., beauty permanents, hair relaxing, hair coloring, hair styling, hair curling, shaving lotion and cosmetics such as lipstick, perfume, eye shadow, rouge/blush, haircuts, beyond simple trimming, normally performed by licensed barbers or beauticians;2. Purchases on behalf of a resident if: a. The resident's basic financial needs must be covered before the purchase.b. The resident is able to approve the purchase or in the event the responsible party is making the purchase, the purchase is in line with what the resident wants or needs.c. The balance in the resident's personal needs account is sufficient to cover the purchase and the resident's personal needs account is not depleted below one month's personal needs allowance amount.d. Outstanding debt due the facility related to uncollectible patient payment for room and board is an allowable purchase.e. Reasonable funeral or burial expenses per 9 CCR 2503-5 section 3.570.43 are allowed.3. Non-covered special care services, i.e., a private duty nurse not employed by the nursing facility or non-medical leave expenses incurred in supporting or benefitting the resident.4. Items or services requested by the resident, including but not limited to, over the counter drugs/related items not prescribed by a physician, not included in the nursing care plan and not ordinarily furnished for effective patient care. In these instances, it is required that:a. The resident has made an informed decision supported by a statement in the resident personal needs account file that the resident/responsible party is willing to use personal needs funds.b. The balance in the resident's personal needs account is sufficient to cover the charge and does not deplete the account.5. Personal clothing and dry cleaning;6. Personal comfort items, including smoking materials, notions, novelties and confections/candies;7. Personal reading material, subscriptions;9. Social events and entertainment offered off premises and outside the scope of the regular facility activities program;10. The facility shall provide each resident with a nourishing, palatable, well-balanced diet that meets the daily nutritional and special dietary needs of each resident. If the resident refuses the prepared food the facility shall offer substitutes. Residents may be charged for specially prepared food only if they are informed that there will be a charge, and the charge may be only the difference in price between the requested item and the covered item pursuant to 42 C.F.R. 483.35.11. Telephone, television/radio for personal use, if not equally available to all residents.14. Ambulance and medical transport, including emergent and non-emergent.17. Non-nursing costs, including but not limited to direct and indirect outpatient therapy, assisted living, independent living, adult day care and meals-on-wheels.18. Non-Medicaid laboratory, radiology, physical therapy, occupational therapy, speech therapy and respiratory therapy.8.440.2.B. The Department's approval shall be required in order for a resident or their relatives to be billed for the following: 1. The physician orders that a full-time R.N. or L.P.N. is needed. The R.N. or L.P.N. is not employed by the nursing facility and has duties limited to the care of a particular resident, or two such residents in the same room.2. The physician orders a private room.3. The attending physician shall indicate the medical necessity on the resident's chart for either service above and shall submit to the Department a completed copy of Form 10013 (Physician's Request for Additional Benefits).4. Upon approval of the Form 10013, payment for such services may be received from the resident's personal needs account, relatives or others.8.440.2.C The following items are allowable costs for class II and class IV facilities only: 1. Eye/Hearing examinations2. Eyeglasses and repairs3. Hearing aids and batteries46 CR 13, July 10, 2023, effective 6/9/2023 (EMRGENCY)46 CR 17, September 10, 2023, effective 9/30/202347 CR 01, January 10, 2024, effective 1/30/202447 CR 07, April 10, 2024, effective 4/30/2024