Section 16.03.10.038 - SPECIALIZED REIMBURSEMENT: CERTAIN HOME AND COMMUNITY-BASED SERVICESThe Department will review provider reimbursement rates to ensure compliance with 42 U.S.C. 1396a(a)(30)(A). This review will assure payments are consistent with efficiency, economy, quality of care, and safeguard 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 Home and Community-Based Services. The home and community-based services provided by the following types of providers are reimbursed as described in this rule: a. Developmental Disability Agencies providing services to adults;b. Developmental Disability Agencies providing services to children;c. Residential Habilitation Agencies;d. Supported Employment Agencies; ande. Targeted Service Coordination Agencies.02.Timing, Description, and Results of Rate Reviews.a. Standard Rate Reviews. The Department will conduct a cost survey and review reimbursement rates at least once every five (5) years for each type of provider specified in this rule. Cost surveys will be conducted in the order and on the schedule established by the Department.b. Interim Rate Reviews. The Department will prepare an annual trigger analysis and publish the report on its Medicaid Providers webpage, http://healthandwelfare.idaho.gov/Providers/MedicaidProviders/tabid/214/Default.aspx. This annual report will describe the triggers for interim rate review, a summary of the data reviewed for each trigger, and the Department's determination and rationale of whether each trigger was met. The Department will conduct an interim rate review upon the occurrence of one (1) or more of the following triggers:i. When substantiated participant complaints, critical incidents, or both, related to a lack of qualified providers indicate an emerging access issue;ii. When quality reports prepared by the Department or substantiated participant complaints and critical incidents related to the quality of services provided indicate an emerging quality issue; oriii. When the federal or Idaho state minimum wage requirement in effect at the time of the standard rate review significantly increases or decreases.c. No Obligation to Revise Rates. The Department is not required to revise reimbursement rates each time a rate review or cost survey is conducted. The results of a rate review or cost survey do not guarantee a change to the reimbursement rate.03.Cost Survey Procedures. a. Participation. The Department will survey one hundred percent (100%) of providers. A provider who refuses or fails to respond to the periodic cost surveys may be disenrolled as a Medicaid provider.b. Customization. The Department will conduct cost surveys customized for each type of provider identified in this rule.c. Independent Consultant. The Department will engage an independent cost survey consultant with expertise and experience in fee-for-service home and community-based services, including services for individuals with developmental disabilities.d. Provider Engagement.i. The Department will establish reimbursement advisory workgroups to advise on matters related to the specialized reimbursement specified in this rule, including notice and development of cost surveys, recommendation of Bureau of Labor and Statistics occupation profile or profiles utilized when setting new reimbursement rates, and other reimbursement-related matters presented by the Department. The Department will retain final decision-making authority over all matters presented to or reviewed by the workgroups.ii. The Department will provide reasonable prior notice of pending cost surveys to impacted providers.iii. The Department or its cost survey consultants will train providers how to complete the cost survey, and provide technical assistance to providers during the cost survey response period.04.Reimbursement Rate Setting Methodology. Reimbursement rates will be derived using a combination of four (4) cost components - direct care staff wages or targeted service coordinator wages, employee-related expenses, program-related expenses, and general and administrative expenses. Each provider must demonstrate that the average percent of wage and benefits paid to their direct care staff (or targeted service coordinators) meets or exceeds the percent of wages and employee-related expenses utilized in establishing the reimbursement rate for the service type. The Department will utilize the reimbursement advisory workgroup established in this rule to collaboratively develop monitoring and enforcement procedures for this minimum allocation requirement. The cost components and new reimbursement rate are established in accordance with the following:a. Direct Care Staff Wages and Targeted Service Coordinator Wages. i. Direct care staff and targeted service coordinator wages are wages paid to individuals employed or contracted by an agency who perform duties described in the applicable service coverage description for at least seventy-five percent (75%) of the total annual amount of time they are compensated.ii. The wage component (Wage) used to establish the new reimbursement rate is set using the mean hourly wage of one (1) or more occupation profiles from the most current Bureau of Labor and Statistics (BLS) State Occupational Employment and Wage Estimates table for the state of Idaho found on the BLS website at www.bls.gov. The BLS occupation profile that most closely aligns with the duties, education level, and supervision requirements of the direct care staff (or targeted service coordinator) providing the service is utilized. If more than one (1) occupation profile aligns with the duties, education level, and supervision requirements of the direct care staff (or the targeted service coordinator) providing the service, then a weighted average of the mean hourly wage of multiple BLS occupation profiles is utilized.iii. When there is no comparable occupation profile or profiles for the direct care staff (or targeted service coordinator), then the wage component used to establish the new reimbursement rate is set using the weighted average hourly rate (WAHR) of the surveyed wages included in the final cost survey results.iv. The Department will make the final determination of BLS occupation profile or profiles after consideration of advice from the relevant Reimbursement Advisory Workgroup.v. The Department will evaluate an appropriate wage inflation factor based on the economic data available at the time the reimbursement rate is set.b. Employee-Related Expenses (ERE). i. ERE are the expenses incurred by the provider agency for the benefit of the direct care staff (or targeted service coordinators) of an agency in the following six (6) categories: (4) workers' compensation,(5) insurance coverage, and(6) retirement contributions.ii. The ERE component percentage (ERE%) used to establish the new reimbursement rate is set using the cumulative percentage of employer costs for employee compensation from the most current BLS Employer Costs for Employee Compensation table for the West Region in the Mountain Division and IRS Publication 15.c. Program-Related Expenses (PRE). i. PRE are wages and other expenses that support the objectives and provision of the service but cannot be tied to any particular person receiving the service. Requirements related to the delivery of services in accordance with statute and rule are PRE.ii. Program-related staff are individuals employed by an agency who perform program-related duties as required by statute or rule for at least seventy-five percent (75%) of the total annual amount of time they are compensated.iii. Utilizing data in the final cost survey results, each agency's PRE component percentage (PRE%) is calculated by dividing the agency's total PRE by the agency's total wages. Each agency's PRE% is ranked, and the PRE% used to calculate the new reimbursement rate is set at the mean of the agency PRE%.d. General and Administrative (G&A) Expenses. i. G&A expenses are wages and other expenses related to day-to-day operations common across all businesses.ii. G&A staff are individuals employed by an agency who perform administrative duties for at least seventy-five percent (75%) of the total annual amount of time they are compensated.iii. Utilizing data in the final cost survey results, each agency's G&A component percentage (G&A%) is calculated by dividing the agency's total G&A expenses by the sum of the agency's total wages, plus the total ERE, plus the total PRE, plus the total G&A expenses. Each agency's G&A% is ranked, and the G&A% used to calculate the new reimbursement rate is set at the mean of the agency G&A%.iv. The G&A% used to calculate the new reimbursement rate will not exceed ten percent (10%) of the total reimbursement rate per staff hour.e. Total Reimbursement Rate Per Staff Hour of Service = ((Wage + (ERE% x Wage) + (PRE% x Wage)) /(1- (G&A%)).f. The Department is not obligated to make budget requests based on the total reimbursement rate per staff hour. The Department will take into consideration the factors of efficiency, economy, quality of care, and access to care when determining rates. Reimbursement rates may be set at a percentage of the total reimbursement rate per staff hour. All reimbursement rate increases are subject to approval by the Idaho State Legislature.05.Quality Performance Incentives. a. Based on the quality of services provided to its Medicaid participants, a provider may become eligible to receive incentive payments.b. Quality measures and associated payment percentages will be established by the Department, in collaboration with the Idaho Council on Developmental Disabilities and Disability Rights Idaho (or such other organization designated by the Governor as the state's protection and advocacy system), and will be described in the Idaho Medicaid Provider Handbook available at www.idmedicaid.com. The Department will provide sixty (60) days prior notice of any substantive changes to the quality measures and associated payment percentages described in its provider handbook.c. Incentive payments will be subject to the availability of State and federal funds, and may be rescinded if the quality of services declines.Idaho Admin. Code r. 16.03.10.038