Section 405 IAC 1-14.6-9 - Rate components; rate limitations; profit add-onAuthority: IC 12-15-1-10; IC 12-15-21-2
Affected: IC 12-13-7-3; IC 12-15-13-6
Sec. 9.
(a) The Medicaid reimbursement system is based on recognition of the provider's allowable costs for the direct care, therapy, indirect care, administrative, and capital components, plus a potential profit add-on payment as defined below. The direct care, therapy, indirect care, administrative, and capital rate components are calculated as follows:(1) The direct care component is equal to the provider's normalized allowable per patient day direct care costs times the facility-average CMI for Medicaid residents, plus the allowed profit add-on payment as determined by the methodology in subsection (b).(2) The therapy component is equal to the provider's allowable Medicaid per patient day direct therapy costs.(3) The indirect care and capital components are equal to the provider's allowable per patient day costs for each component, plus the allowed profit add-on payment as determined by the methodology in subsection (b).(4) The administrative component shall be equal to one hundred percent (100%) of the average allowable cost of the median patient day.(b) The profit add-on payment will be calculated as follows: (1) For nursing facilities designated by the office as children's nursing facilities, the allowed direct care component profit add-on is equal to the profit add-on percentage contained in Table 1, times the difference (if greater than zero (0)) between: (A) the normalized average allowable cost of the median patient day for direct care costs times the facility average CMI for Medicaid residents times the profit ceiling percentage contained in Table 1; minus(B) the provider's normalized allowable per patient day costs times the facility average CMI for Medicaid residents. Table 1 |
Children's Nursing Facilities |
Effective Date | Direct Care Profit Add-on Percentage | Direct Care Profit Ceiling Percentage |
July 1, 2003, through June 30, 2019 | July 1, 2019, and after | July 1, 2003, through June 30, 2019 | July 1, 2019, and after |
Percentage | 30% | 52% | 110% | 105% |
(2) For nursing facilities that are not designated by the office as children's nursing facilities, the tentative direct care component profit add-on payment is equal to the profit add-on percentage contained in Table 2, times the difference (if greater than zero (0)) between: (A) the normalized average allowable cost of the median patient day for direct care costs times the facility average CMI for Medicaid residents times the profit ceiling percentage contained in Table 2; minus(B) the provider's normalized allowable per patient day costs times the facility average CMI for Medicaid residents. Table 2 |
Non-Children's Nursing Facilities |
Effective Date | Direct Care Profit Add-on Percentage | Direct Care Profit Ceiling Percentage |
July 1, 2003, through June 30, 2019 | July 1, 2019, and after | July 1, 2003, through June 30, 2019 | July 1, 2019, and after |
Percentage | 30% | 0% | 110% | 105% |
(3) For nursing facilities not designated by the office as children's nursing facilities, the allowed direct care component profit add-on payment is equal to the facility's tentative direct care component profit add-on payment times the applicable percentage contained in Table 3, based on the facility's total quality score. Table 3 |
Total Quality Score | Percentage |
84 - 100 | 100% |
19 - 83 | 100% + ((Total Quality Score - 84) / 66) |
18 and below | 0% |
In no event shall the allowed direct care profit add-on payment exceed ten percent (10%) of the average allowable cost of the median patient day.
(4) The tentative indirect care component profit add-on payment is equal to the profit add-on percentage contained in Table 4, times the difference (if greater than zero (0)) between:(A) the average allowable cost of the median patient day times the profit ceiling percentage contained in Table 4; minus(B) a provider's allowable per patient day cost. Table 4 |
Effective Date | Indirect Care Profit Add-on Percentage | Indirect Care Profit Ceiling Percentage |
July 1, 2003, through June 30, 2019 | July 1, 2019, and after | July 1, 2003, through June 30, 2019 | July 1, 2019, and after |
Percentage | 60% | 52% | 105% | 100% |
The allowed indirect care component profit add-on payment is equal to the facility's tentative indirect care component profit add-on payment times the applicable percentage contained in Table 3, based on the facility's total quality score.
(5) The tentative capital component profit add-on payment is equal to sixty percent (60%) times the difference (if greater than zero (0)) between: (A) the average allowable cost of the median patient day times the profit ceiling percentage contained in Table 5; minus(B) a provider's allowable per patient day cost. Table 5 |
Capital Component Profit Ceiling Percentage |
Effective Date | July 1, 2003, through June 30, 2019 | July 1, 2019, and after |
Percentage | 100% | 80% |
(C) The allowed capital component profit add-on payment is equal to the facility's tentative capital component profit add-on payment times the applicable percentage contained in Table 3, based on the facility's total quality score.(6) The therapy component profit add-on is equal to zero (0).(c) Notwithstanding subsections (a) and (b), in no instance shall a rate component exceed the overall rate ceiling defined as follows: (1) The normalized average allowable cost of the median patient day for direct care costs times the facility-average CMI for Medicaid residents times the overall rate ceiling percentage in Table 6. Table 6 |
Direct Care Component Overall Rate Ceiling Percentage |
Effective Date | July 1, 2003, through June 30, 2019 | July 1, 2019, and after |
Percentage | 120% | 110% |
(2) The average allowable cost of the median patient day for indirect care costs times the overall rate ceiling percentage in Table 7. Table 7 |
Indirect Care Component Overall Rate Ceiling Percentage |
Effective Date | July 1, 2003, through June 30, 2019 | July 1, 2019, and after |
Percentage | 115% | 100% |
(3) The average allowable cost of the median patient day for capital-related costs times the overall rate ceiling percentage in Table 8. Table 8 |
Capital Component Overall Rate Ceiling Percentage |
Effective Date | July 1, 2003, through June 30, 2019 | July 1, 2019, and after |
Percentage | 100% | 80% |
(4) For the therapy component, no overall rate component limit shall apply.(d) In order to determine the normalized allowable direct care costs from each facility's Financial Report for Nursing Facilities, the office shall determine each facility's CMI for all residents on a time-weighted basis. For a provider's financial report beginning in the month referenced in Table 9, column (a), the calendar quarters used for determining a facility's CMI will begin with the corresponding calendar quarter referenced in Table 9, column (b). The calendar quarters used in determining the facility's CMI will include quarters through the provider's financial report ending in the month referenced in Table 9, column (c), with the corresponding calendar quarter referenced in Table 9, column (d). Table 9 |
Cost Report Begin Date (a) | Beginning Calendar Quarter to Determine CMI (b) | | Cost Report End Date (c) | Ending Calendar Quarter to Determine CMI (d) |
January Year 1 | 1st Quarter Year 1 | | January Year 1 | 1st Quarter Year 1 |
February Year 1 | 2nd Quarter Year 1 | | February Year 1 | 1st Quarter Year 1 |
March Year 1 | 2nd Quarter Year 1 | | March Year 1 | 1st Quarter Year 1 |
April Year 1 | 2nd Quarter Year 1 | | April Year 1 | 2nd Quarter Year 1 |
May Year 1 | 3rd Quarter Year 1 | | May Year 1 | 2nd Quarter Year 1 |
June Year 1 | 3rd Quarter Year 1 | | June Year 1 | 2nd Quarter Year 1 |
July Year 1 | 3rd Quarter Year 1 | | July Year 1 | 3rd Quarter Year 1 |
August Year 1 | 4th Quarter Year 1 | | August Year 1 | 3rd Quarter Year 1 |
September Year 1 | 4th Quarter Year 1 | | September Year 1 | 3rd Quarter Year 1 |
October Year 1 | 4th Quarter Year 1 | | October Year 1 | 4th Quarter Year 1 |
November Year 1 | 1st Quarter Year 2 | | November Year 1 | 4th Quarter Year 1 |
December Year 1 | 1st Quarter Year 2 | | December Year 1 | 4th Quarter Year 1 |
(e) The office shall publish requirements for use in determining the time-weighted CMI. These requirements:(1) shall be published as a provider bulletin; and(2) may be updated by the office as needed. Any such updates shall be made effective no earlier than permitted under IC 12-15-13-6(a).
Office of the Secretary of Family and Social Services; 405 IAC 1-14.6-9; filed Aug 12, 1998, 2:27p.m.: 22 IR 75, eff Oct 1, 1998; filed Mar 2, 1999, 4:42 p.m.: 22 IR 2244; readopted filed Jun 27, 2001, 9:40 a.m.:24 IR 3822; filed Mar 18, 2002, 3:30 p.m.: 25 IR 2470; filed Oct 10, 2002, 10:47 a.m.: 26 IR 714; filed Jul 29, 2003, 4:00 p.m.: 26 IR 3874; filed Apr 24, 2006, 3:30 p.m.: 29 IR 2980; readopted filed Sep 19, 2007,12:16p.m.: 20071010-IR-405070311RFA;filed Nov 12, 2009, 4:01 p.m.: 20091209-IR-405090215FRA;filedMay31, 2013, 8:52 a.m.: 20130626-IR-405120279FRA; readopted filed Oct 28, 2013, 3:18 p.m.: 20131127-IR-405130241RFAFiled 4/29/2015, 3:38 p.m.: 20150527-IR-405150034FRAFiled 8/1/2016, 3:44 p.m.: 20160831-IR-405150418FRAFiled 10/13/2017, 12:09 p.m.: 20171108-IR-405160327FRAFiled 4/19/2018, 11:30 a.m.: 20180516-IR-405170552FRAReadopted filed 5/30/2023, 11:54 a.m.: 20230628-IR-405230292RFA