Md. Code Regs. 10.09.10.01

Current through Register Vol. 51, No. 12, June 14, 2024

Section 10.09.10.01 - Definitions

A. In this chapter, the following terms have the meanings indicated.

B. Terms Defined.

(1) "Accrual basis" means recording revenue in the period when earned, regardless of when collected, and recording expenses in the period when incurred, regardless of when paid.

(2) "Administrative day" means a day of care rendered to a recipient who no longer requires the level of care being provided.

(3) "Allowable cost" means costs that are includable in the per diem rate and that represent the provider's actual cost as verified by the Department or the Department's designee.

(4) "Appropriate facility" means a facility located within a 25-mile radius of the location of the facility currently rendering care to the recipient or a more distant facility if acceptable to the recipient, which facility is licensed and certified to render the recipient's required level of care.

(5) "Bad debts" means amounts considered to be uncollectible from accounts and notes receivable that were created or acquired in providing services. "Accounts receivable" and "notes receivable" are designations for claims arising from rendering services which, when made or entered, were considered collectible in money in the relatively near future.

(6) "Case mix index (CMI)" means a numeric score that identifies the average relative nursing resource needs for the residents classified under the Resource Utilization Group (RUG) based on the assessed nursing needs of the resident, whose values are set forth as CMI Set F01, located at https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment- Instruments/NursingHomeQualityInits/NHQMDS30TechnicalInform ation.html.

(7) "Centers for Medicare and Medicaid Services (CMS) " means the federal agency that is located in the U.S. Department of Health and Human Services that administers the Medicare and Medicaid programs.

(8) "Change of ownership" means:

(a) One of the following occurs:

(i) The merger of the provider into the acquiring entity and the acquiring entity's tax identification number remains;

(ii) The assignment, transfer, disposition, lease, or sale of all or substantially all of a provider's assets to another entity;

(iii) The consolidation of two or more providers, resulting in the creation of a new entity; or

(iv) The merger of the provider into another entity, or the consolidation of two or more entities, resulting in the creation of a new entity;

(b) A provider's Medical Assistance participating provider number dissolves or will no longer be utilized for purposes of billing the Program for covered services; and

(c) A new Medical Assistance participating provider number or tax identification number is used instead.

(9) "Cost center" means one of the groups into which similar categories of costs are assigned for reimbursement rate determination: Administrative and Routine, Other Patient Care, Nursing Service, and Capital.

(10) "Cost report period case mix index" means the simple average of the day weighted facility case mix indices for residents of all payer sources from the final quarterly resident rosters for a nursing facility, carried to four decimal places, for the quarterly resident roster periods that most closely match a cost reporting period

(11) "Credit balance" means:

(a) A third party payment, which is in addition to the Medicaid payment;

(b) The Medicaid payment in excess of the amount due the provider; or

(c) A duplicate payment.

(12) "Department" means the State Department of Health and Mental Hygiene, which is the single State agency designated to administer the Maryland Medical Assistance Program pursuant to Title XIX of the Social Security Act, 42 U.S.C. § 1396 et seq.

(13) "Facility" means a facility licensed under COMAR 10.07.02 and certified as meeting the requirements of Title XIX of the Social Security Act, 42 U.S.C. § 1396 et seq., for participation as a nursing facility.

(14) "Facility average Medicaid case mix index" means the day-weighted average case mix index for all identified Medicaid days from each nursing facility's final resident roster for each resident roster quarter calculated as the sum of the number of days each assessment associated with a Medicaid payer source is active times the assessment CMI divided by the sum of all Medicaid payer source days.

(15) "Final report" means the third party liability audit report issued to a provider stating the total amount due to the Department as a result of the completed audit.

(16) "Fiscal year" means a 12-month reporting period covering the same period as the facility's tax return, unless waived by the Department according to standards found in Medicare Provider Reimbursement Manual, HCFA Publication 15-1.

(17) "Indemnity bond" means a bond posted by the provider to ensure that the provider is able to fulfill any financial obligations to the Department upon sale of the facility.

(18) "Interim Working Capital Fund" means funding made available to providers on a temporary basis that shall be repaid to the Department.

(19) "Market basket index" means inflation indices from the latest Skilled Nursing Home without Capital Market Basket Index, published 2 months before the period in which rates are being calculated and which is available from CMS at www.cms.gov, or a comparable index available from, and used by, CMS, if this index ceases to be published by Global Insight, Inc. or its successor

(20) "Maryland Health Care Commission" means the agency established by Health-General Article, Title 19, Subtitle 1, Annotated Code of Maryland.

(21) "Medicaid" means Medical Assistance provided under the State Plan approved under Title XIX of the Social Security Act.

(22) "Medical Assistance Program" means a program of comprehensive medical and other health-related care for indigent and medically indigent persons.

(23) "Medicare upper payment limit" means that aggregate payments to nursing facilities may not exceed the limits established for such payment in 42 CFR § 447.272.

(24) "Minimum Data Set (MDS) " means the MDS required by 42 CFR § 483.20 and set forth in the Resident Assessment Instrument published by CMS, and available at www.cms.gov, incorporated herein by reference, as amended and supplemented, a core set of screening, clinical, and functional status elements, including common definitions and coding categories that forms the foundation of the assessment required for all residents in Medicare-certified or Medicaid-certified nursing facilities.

(25) "New facility" means:

(a) A facility that has not been a provider during the previous 12-month period or, for rates effective January 1, 2015 and after, does not have a cost report in the price database as set forth in Regulation .09B(1) of this chapter; and

(b)A facility not defined as a replacement facility.

(26) "Noncompliant" means:

(a) A provider fails to submit to the Department the required quarterly report of credit balances;

(b) A provider fails to submit a quarterly report which provides sufficient data relating to the credit balances it maintained during that quarter; or

(c) A random audit by the Department reveals errors or omissions in a provider's credit balance report.

(27) Nursing Facility (NF).

(a) "Nursing facility" means an institution which is primarily engaged in providing to residents:

(i) Skilled nursing care and related services for residents who require medical or nursing care;

(ii) Rehabilitation services for the rehabilitation of injured, disabled, or sick persons; or

(iii) On a regular basis, health-related care and services to individuals who, because of their mental or physical condition, require care and services (above the level of room and board) which can be made available to them only through institutional facilities.

(b) "Nursing facility" means an institution which is licensed by the Department under COMAR 10.07.02.

(c) "Nursing facility" does not include an institution which is primarily for the care and treatment of mental diseases, an intellectually disability or a developmental disability.

(28) "Nursing facility services" means services provided to individuals who do not require hospital care, but who, because of their mental or physical condition, require skilled nursing care and related services, rehabilitation services, or, on a regular basis, health-related care and services (above the level of room and board) which can be made available to them only through institutional facilities.

(29) "Owner" means a party or entity having any ownership interest in the facility.

(30) "Patient day" means care of one patient for 1 day of service. The day of admission is counted as 1 day of care, but the day of discharge is not counted. If a patient is discharged on his day of admission, 1 patient day will be counted.

(31) "Payroll-Based Journal" means a system for facilities to submit staffing information to meet the requirements of § 6106 of the Affordable Care Act (ACA) that requires facilities to electronically submit direct care staffing information (including agency and contract staff) based on payroll and other auditable data.

(32) "Predischarge plan" means:

(a) A written document describing who has operational responsibility for discharge planning;

(b) The manner in and methods by which that person will function;

(c) The time period in which each recipient's need for discharge planning will be determined;

(d) The maximum time period after which a reevaluation of each recipient's discharge plan will be made;

(e) The local resources available to the provider, the individual, and the attending physician to assist in developing and implementing individual discharge plans; and

(f) Provisions for periodic review and reevaluation of the provider's discharge planning program.

(33) "Program" means the Medical Assistance Program.

(34) "Prospective rate" means a facility-specific quarterly per diem rate based on the RUG classification system, and calculated as the sum of:

(a) Administrative and Routine rate as calculated in accordance with Regulation .09 of this chapter;

(b) Other Patient Care Rate as calculated in accordance with Regulation .10 of this chapter;

(c) Capital Rate as calculated in accordance with Regulation .11 of this chapter; and

(d) Nursing Rate as calculated in accordance with Regulation .12 of this chapter.

(35) "Provider" means a facility which has in effect a provider agreement with the Department.

(36) "Provider agreement" means the contract between the Department and the provider covering the obligations of the parties under the Medical Assistance Program.

(37) "Purchaser" means an entity that participates in a change of ownership with a provider by:

(a) Having a provider merge into the entity;

(b) Accepting the assignment, transfer, disposition, or sale of all or substantially all of a provider's assets; or

(c) Being a new entity that results from the consolidation of the provider with a third party.

(38) "Quality measure" means a specific performance criterion, as described in Regulation .15 of this chapter, used to assess a facility's performance level.

(39) "Random sample" means the selection for audit by the Department of representative share of the providers complying with the requirement of submitting a quarterly report of credit balances to the Department.

(40) "Recipient" means a person who is certified as eligible for, and is receiving, Medical Assistance benefits.

(41) "Recreational services" means those organized activities provided for the enjoyment of the patients that are designed to promote their physical, social, and mental well-being.

(42) "Reimbursement class" means the group of providers for which a separate per diem rate will be prepared in the Administrative and Routine, Other Patient Care, and Nursing Service cost centers based on geographic region as set forth in Regulation .30 of this chapter.

(43) "Relative of the owner" means the owner's husband, wife, natural parent, natural child, sibling, adopted child, adoptive parent, stepparent, stepchild, stepbrother, stepsister, father-in-law, mother-in-law, son-in-law, daughter-in-law, brother-in-law, sister-in-law, grandparent, or grandchild.

(44) "Replacement facility" means:

(a) A newly constructed nursing facility that replaces an existing licensed and certified facility; or

(b)A facility that was closed for significant renovation that reopens and is approved by the Department as a replacement facility.

(45) "Resident roster" means a list of all residents in a nursing facility for a calendar quarter based on MDS assessments and tracking forms, accurately and successfully transmitted by the nursing facility into the CMS-approved submission system, used for the calculated day-weighted case mix indices for Medicaid, Medicare, and other payment sources.

(46) "Resource" means that portion of a recipient's income available toward the cost of medical and remedial care as determined by the Department or its designee.

(47) "Resource Utilization Group (RUG) " means the version IV (RUG-IV), 48-Group classification system, that has been developed by CMS and set forth at https://www.cms.gov/Medicare/Quality-Initiatives-Patient- [File Link Not Available]Assessment-Instruments/NursingHomeQualityInits/NHQIMDS30TechnicalInform ation.html for grouping nursing facility residents according to the residents' functional status and anticipated uses of services and resources as identified from data supplied by the MDS.

(48) "Secretary" means the Secretary of Health and Mental Hygiene.

(49) "Special focus facility" means a facility identified by the Centers for Medicare and Medicaid Services as having:

(a) More problems than other nursing homes;

(b) More serious problems than other nursing homes; and

(c) A pattern of serious problems that has persisted over a long period of time.

(50) "Specialized rehabilitative therapy services" means those services furnished by a provider as an integral part of a patient's care plan ordered by a physician and provided in conjunction with continuous nursing care for the purpose of the restoration of normal form and function after injury or illness. The services shall be performed by a licensed physical therapist, licensed physical therapy assistant, or registered occupational therapist.

(51) "Standby letter of credit" means a written instrument prepared by a provider's bank authorizing the Department to draw on the bank, upon sale of the facility.

(52) "Statewide average case mix index" means the simple average of all of the cost report period case mix indices for the rate year

(53) "Statewide average Medicaid case mix index" means the Medicaid day weighted average of all nursing facilities' case mix indices for the Medicaid days identified on the final resident rosters for each resident roster quarter

(54) "Substandard quality of care" means that one or more requirements under 42 CFR § 483.13, 42 CFR § 483.15, or 42 CFR 483.25 were not met, to a degree constituting immediate jeopardy to resident health or safety, and a pattern of actual harm, widespread actual harm, or a widespread potential for more than minimal harm.

(55) "Substandard quality of care" means a finding of substandard care in accordance with 42 CFR § 488.301.

(56) "Third party liability audit" means a financial review of Medical Assistance payments to a provider to ascertain the legal liability of third parties to pay for care and services available under the Medical Assistance Program.

(57) "Third party liability review" means a financial review of the credit balances of a nursing facility to ascertain the legal liability of third parties to pay for care and services available under the Medical Assistance Program.

(58) "Uniform cost report" means the cost report format which each facility is required to use in the submission of its fiscal year cost and utilization data, including supplemental schedules and other balance sheet and administrative data.

Md. Code Regs. 10.09.10.01

Regulations .01U, HH, II, LL; amended effective December 14, 1979 (6:25 Md. R. 1980)
Regulation .01M-1 adopted effective July 1, 1980 (7:13 Md. R. 1278)
Regulations .01O, amended effective January 1, 1980 (6:26 Md. R. 2074)
Regulations .01JJ, KK; adopted effective December 14, 1979 (6:25 Md. R. 1980)
Regulation .01P repealed effective January 1, 1980 (6:26 Md. R. 2074)
Regulation .01B amended effective June 6, 1983 (10:11 Md. R. 975); August 10, 1987 (14:16 Md. R. 1773)
Regulation .01B amended as an emergency provision effective July 1, 1986 (13:14 Md. R. 1627); adopted permanently effective December 1, 1986 (13:21 Md. R. 2320)
Regulations .01, amended as an emergency provision effective January 14, 1992 (19:3 Md. R. 299); emergency status expired June 30, 1992
Regulations .01, amended as an emergency provision effective July 1, 1992 (19:14 Md. R. 1272); amended permanently effective November 1, 1992 (19:21 Md. R. 1891)
Regulations .01, amended as an emergency provision effective July 1, 2005 (32:19 Md. R. 1584); emergency status expired August 31, 2005
Regulation .01B amended effective March 19, 1990 (17:5 Md. R. 638); December 29, 1997 (24:26 Md. R. 1758)
Regulation .01B amended as an emergency provision effective May 1, 2004 (31:12 Md. R. 908); amended permanently effective August 16, 2004 (31:16 Md. R. 1255)
Regulation .01B amended effective May 9, 2005 (32:9 Md. R. 848); December 9, 2005 (32:24 Md. R. 1904)
Regulation .01B amended as an emergency provision effective July 16, 2009 (36:17 Md. R. 1310); amended permanently effective October 5, 2009 (36:20 Md. R. 1527)
Regulation .01B amended effective January 24, 2011 (38:2 Md. R. 84); October 3, 2011 (38:20 Md. R. 1202); October 14, 2013 (40:20 Md. R. 1652)
Regulations .01 amended effective 42:7 Md. R. 567, eff.4/13/2015; amended effective 45:13 Md. R. 664, eff. 7/2/2018; amended effective 48:12 Md. R. 472, eff. 6/14/2021