Idaho Admin. Code r. 16.03.10.012

Current through September 2, 2024

Section 16.03.10.012 - DEFINITIONS: L THROUGH O

For the purposes of these rules, the following terms are used as defined below:

01.Lease. A contract arrangement for use of another's property, usually for a specified time period, in return for period rental payments.

02.Leasehold Improvements. Additions, adaptations, corrections, etc., made to the physical components of a building or construction by the lessee for their use or benefit. Such additions may revert to the owner. Such costs are usually capitalized and amortized over the life of the lease.

03.Legal Representative. A parent with custody of a minor child, one who holds a legally-executed and effective power of attorney for health decisions, or a court-appointed guardian whose powers include the power to make health care decisions.

04.Level of Care. The classification in which a participant is placed, based on severity of need for institutional care.

05.Licensed Bed Capacity. The number of beds that are approved by the Licensure and Certification Agency for use in rendering patient care.

06.Licensed, Qualified Professionals. Individuals licensed, registered, or certified by national certification standards in their respective discipline, or otherwise qualified within the state of Idaho.

07.Lower of Cost or Charges. Payment to providers (other than public providers furnishing such services free of charge or at nominal charges to the public) is the lesser of the reasonable cost of such services or the customary charges with respect to such services. Public providers that furnish services free of charge or at a nominal charge are reimbursed fair compensation; which is the same as reasonable cost.

08.MAI Appraisal. An appraisal that conforms to the standards, practices, and ethics of the Appraisal Institute and is performed by a member of the Appraisal Institute.

09.Major Movable Equipment. Major movable equipment means such items as beds, wheelchairs, desks, furniture, vehicles, etc. The general characteristics of this equipment are:

a. A relatively fixed location in the building;

b. Capable of being moved, as distinguished from building equipment;

c. A unit cost of five thousand dollars ($5000) or more;

d. Sufficient size and identity to make control feasible by means of identification tags; and

e. A minimum life of three (3) years.

10.Margin Payment. A potential addition to each provider's cost for indirect costs and direct costs, if their cost is below the price set for each of these cost components. The margin payment will be separately calculated for indirect care costs and direct care cost and will be capped at an agreed upon maximum.

11.Medical Assistance. Payments for part or all of the cost of services funded by Titles XIX or XXI of the federal Social Security Act, as amended.

12.Medicaid. Idaho's Medical Assistance Program.

13.Medicaid Related Ancillary Costs. For the purpose of these rules, those services provided in nursing facilities considered to be ancillary by Medicare cost reporting principles. Medicaid related ancillary costs will be determined by apportioning direct and indirect costs associated with each ancillary service to Medicaid residents by dividing Medicaid charges into total charges for that service. The resulting percentage, when multiplied by the ancillary service cost, will be considered Medicaid related ancillaries.

14.Medical Care Treatment Plan. The problem list, clinical diagnosis, and treatment plan of care administered by or under the direct supervision of a physician.

15.Medical Necessity (Medically Necessary). A service is medically necessary if:

a. It is reasonably calculated to prevent, diagnose, or treat conditions in the participant that endanger life, cause pain, or cause functionally significant deformity or malfunction; and

b. There is no other equally effective course of treatment available or suitable for the participant requesting the service that is more conservative or substantially less costly.

c. Medical services must be of a quality that meets professionally recognized standards of health care, be substantiated by records including evidence of such medical necessity and quality, and be made available to the Department upon request.

16.Medical Supplies. Items excluding drugs and biologicals and equipment furnished incident to a physician's professional services commonly furnished in a physician's office or items ordered by a physician for the treatment of a specific medical condition. These items are generally not useful to an individual in the absence of an illness and are consumable, nonreusable, disposable, and generally have no salvage value. Surgical dressings, ace bandages, splints and casts, and other devices used for reduction of fractures or dislocations are considered supplies.

17.Medicare Savings Program. The program formerly known as "Buy-In Coverage," where the state pays the premium amount for participants eligible for Medicare Parts A and B of Title XVIII.

18.Minimum Data Set (MDS). A set of screening, clinical, and functional status elements, including common definitions and coding categories, that forms the foundation of the comprehensive assessment for all residents of long term care facilities certified to participate in Medicare or Medicaid. The version of the assessment document used for rate setting is version 2.0. Subsequent versions of the MDS will be evaluated and incorporated into rate setting as necessary.

19.Minor Movable Equipment. Minor movable equipment includes such items as wastebaskets, bedpans, syringes, catheters, silverware, mops, buckets, etc. Oxygen concentrators used in lieu of bottled oxygen may, at the facility's option, be considered minor movable equipment with the cost reported as a medical supply. The general characteristics of this equipment are:

a. No fixed location and subject to use by various departments of the provider's facility;

b. Comparatively small in size and unit cost under five thousand dollars ($5000);

c. Subject to inventory control;

d. Fairly large quantity in use; and

e. A useful life of less than three (3) years.

20.Necessary. The purchase of goods or services that is required by law, prudent management, and for normal, efficient and continuing operation of patient related business.

21.Negotiated Service Agreement (NSA). The plan reached by the resident and their representative, or both, and the facility or certified family home based on the assessment, physician or authorized provider's orders, admissions records, and desires of the resident. The NSA must outline services to be provided and the obligations of the facility or certified family home and the resident.

22.Net Book Value. The historical cost of an asset, less accumulated depreciation.

23.Nominal Charges. A public provider's charges are nominal where aggregate charges amount to less than one-half (1/2) of the reasonable cost of the related services.

24.Nonambulatory. Unable to walk without assistance.

25.Nonprofit Organization. An organization whose purpose is to render services without regard to gains.

26.Normalized Per Diem Cost. Refers to direct care costs that have been adjusted based on the nursing facility's case mix index for purposes of making the per diem cost comparable among nursing facilities. Normalized per diem costs are calculated by dividing the nursing facility's direct care per diem costs by its nursing facility-wide case mix index, and multiplying the result by the statewide average case mix index.

27.Nurse Practitioner. A licensed registered nurse (RN) who meets all the applicable requirements to practice as nurse practitioner under Title 54, Chapter 14, Idaho Code, and IDAPA 24.34.01, "Rules of the Idaho Board of Nursing."

28.Nursing Facility (NF). An institution, or distinct part of an institution, that is primarily engaged in providing skilled nursing care and related services for participants. It is an entity licensed as a nursing facility and federally certified to provide care to Medicaid and Medicare participants. The participants require medical or nursing care, or rehabilitation services for injuries, disabilities, or illness.

29.Nursing Facility Inflation Rate. See the definition of Inflation Factor in Subsection 011.20 of these rules.

30.Ordinary. Ordinary means that the costs incurred are customary for the normal operation of the business.

31.Out-of-State Care. Medical service that is not provided in Idaho or bordering counties is considered out-of-state. Bordering counties outside Idaho are considered out-of-state for the purpose of authorizing long term care.

Idaho Admin. Code r. 16.03.10.012

Effective March 17, 2022