Section 16.03.10.037 - GENERAL REIMBURSEMENT: PARTICIPANT SERVICESThe Department will evaluate provider reimbursement rates that comply with 42 U.S.C. 1396a(a)(30)(A). This evaluation will assure payments are consistent with efficiency, economy, and quality of care and safeguards against unnecessary utilization of care and services. Reimbursements will be sufficient to enlist enough providers so that care and services are available under the plan at least to the extent that such care and services are available to the general population in the geographic area.
01.Applicable Participant Services. Unless otherwise provided in this chapter of rules, the following types of services are reimbursed as provided in this rule: a. The Personal Care Services (PCS) described in Sections 300 -308 of these rules.b. The Aged and Disabled Waiver services described in Sections 320 -330 of these rules.c. The Children's Developmental Disabilities Home and Community-Based State Plan Option Services described in Sections 520 -528 of these rules.d. The Adult Developmental Disabilities Waiver services described in Sections 700 -706 of these rules.e. The Adult Developmental Disabilities Home and Community-Based State Plan Option Services described in Sections 645 -657 of these rules.02.Review Reimbursement Rates. The Department will review provider reimbursement rates and conduct cost surveys when an access or quality indicator reflects a potential access or quality issue described in this rule.03.Access. The Department will review annual statewide and regional access reports by service type comparing the previous twelve (12) months to the base-line year of State Fiscal Year 2012. The following measures will be used to determine when there is potential for access issues.a. Compare the change in total number of provider locations for service type to the change in eligible participants; orb. When participant complaints and critical incidence logs reveal outcomes that identify access issues for a service type.04.Quality. The Department will review quality reports required by each program used to monitor for patterns indicating an emerging quality issue.05.Cost Survey. The Department will survey one hundred percent (100%) of providers. Providers that refuse or fail to respond to the periodic state surveys may be disenrolled as Medicaid providers. The Department will derive reimbursement rates using direct care staff costs, employment related expenditures, program related costs, and indirect general and administrative costs in the reimbursement methodology, when these costs are incurred by a provider. The Department will conduct cost surveys customized for each of the services identified in this rule. a. Wage rates will be used in the reimbursement methodology when the expenditure is incurred by the provider type executing the program. Wages will be identified in the Bureau of Labor Statistics website at www.bls.gov when there is a comparable occupation title for the direct care staff. When there is no comparable occupation title for the direct care staff, then a weighted average hourly rate methodology will be used.b. For employer related expenditures: i. The Bureau of Labor Statistics's report for employer costs per hour worked for employee compensation and costs as a percent of total compensation for Mountain West Divisions will be used to determine the incurred employer related costs by each provider type. The website for access to this report is at www.bls.gov.ii. The Internal Revenue Service employer cost for social security benefit and Medicare benefit will be used to determine the incurred employer related costs by provider type. The website for access to this information is at www.irs.gov.c. Cost surveys to collect indirect general, administrative, and program related costs will be used when these expenditures are incurred by the provider type executing the program. The costs will be ranked by costs per provider, and the Medicaid cost used in the reimbursement rate methodology will be established at the seventy-fifth percentile in order to efficiently set a rate.Idaho Admin. Code r. 16.03.10.037