Md. Code Regs. 10.09.10.07-2

Current through Register Vol. 51, No. 22, November 1, 2024

Section 10.09.10.07-2 - Prospective Rates Effective January 1, 2015

A. For dates of service from January 1, 2015 through December 31, 2016, a 2012 final per diem rate shall be determined based on the following from each nursing facility's cost report ending in 2012 and shall be adjusted by the nursing facility budget changes implemented from the settled 2012 rate through and including December 31, 2016:

(1) The Administrative and Routine final per diem rate identified under Regulation .08B of this chapter;

(2) The Other Patient Care final per diem rate identified under Regulation .09B of this chapter;

(3) The kosher kitchen add-ons identified under Regulations .08H and .09H of this chapter;

(4) The total amount of therapy payments identified under Regulation .09-1 of this chapter divided by the total Medicaid days excluding hospital bed hold days for the cost reporting period;

(5) The Capital component calculated as:

(a) Capital payments identified under Regulation .10 of this chapter, less the Nursing Facility Quality Assessment expense; and

(b) Divided by the total Medicaid days excluding hospital bed hold days; and

(6) The Nursing payments identified under Regulation .11C of this chapter divided by the total Medicaid days less Hospital Bed Hold Days and Therapeutic Leave Days.

B. Per diem rates paid for services beginning January 1, 2015, shall be calculated as follows:

(1) Rates paid for services January 1, 2015, through December 31, 2015, shall be calculated as the sum of:

(a) 75 percent of the 2012 final per diem rate in accordance with §A of this regulation;

(b) 25 percent of the prospective rate; and

(c) The Nursing Facility Quality Assessment add-on identified in Regulation .10-1E of this chapter;

(2) Rates paid for services January 1, 2016, through June 30, 2016, shall be calculated as the sum of:

(a) 50 percent of the 2012 final per diem rate in accordance with §A of this regulation;

(b) 50 percent of the prospective rate; and

(c) The Nursing Facility Quality Assessment add-on identified in Regulation .10-1E of this chapter;

(3) Rates paid for services July 1, 2016, through December 31, 2016, shall be calculated as the sum of:

(a) 25 percent of the 2012 final per diem rate in accordance with §A of this regulation;

(b) 75 percent of the prospective rate; and

(c) The Nursing Facility Quality Assessment add-on identified in Regulation .10-1E of this chapter; and

(4) Rates paid for services after December 31, 2016, shall be calculated as 100 percent of the prospective rate plus the Nursing Facility Quality Assessment add-on identified in Regulation .10-1E of this chapter.

C. Hold Harmless.

(1) For each provider, the Department shall determine the difference between the rate calculated in §A of this regulation excluding any budget changes implemented after June 30, 2014 and the rate calculated under §B(1)(a) and (b) of this regulation.

(2) If a provider's rate determined under §B(1)(a) and (b) of this regulation is less than the rate under §A of this regulation excluding any budget changes implemented after June 30, 2014, the provider shall be paid the rate determined under §B(1) of this regulation plus 100 percent of the amount calculated in §C(1) of this regulation.

(3) During implementation of §B(2) of this regulation, providers identified in §C(2) of this regulation shall be paid the rate determined under §B(2) of this regulation plus 50 percent of the amount calculated in §C(1) of this regulation.

D. Hold Harmless Offset.

(1) The Department shall determine the total aggregate amount under §C(1) of this regulation for all facilities for which the rate determined under §B(1)(a) and (b) of this regulation is less than the rate under §A of this regulation excluding any budget changes implemented after June 30, 2014.

(2) The Department shall determine the total aggregate amount under §C(1) of this regulation for all facilities for which the rate determined under §B(1)(a) and (b) of this regulation is greater than the rate under §A of this regulation excluding any budget changes implemented after June 30, 2014.

(3) The Department shall determine the percentage of the amount in §D(2) of this regulation that is equal to the amount calculated under §D(1) of this regulation.

(4) The Department shall identify all facilities that have a rate determined under §B(1)(a) and (b) of this regulation that is greater than the rate identified under §A of this regulation excluding any budget changes implemented after June 30, 2014.

(5) For each facility identified in §D(4) of this regulation, the Department shall multiply the amount by which §B(1)(a) and (b) of this regulation is greater than the rate identified under §A of this regulation, excluding any budget changes implemented after June 30, 2014, by the percentage determined in §D(3) of this regulation.

(6) During implementation of §B(1) of this regulation, providers identified in §D(4) of this regulation shall be paid the amount determined under §B(1) of this regulation, minus 100 percent of the amount determined under §D(5) of this regulation.

(7) During implementation of §B(2) of this regulation, providers identified in §D(4) of this regulation shall be paid the amount determined under §B(2) of this regulation, minus 50 percent of the amount determined under §D(5) of this regulation.

E. When necessary, each facility's per diem rate paid for services January 1, 2015 and after shall be reduced by the same percentage to maintain compliance with the Medicare upper payment limit requirement.

F. Power wheelchairs and bariatric beds are not included in either the 2012 final per diem rate or the prospective rate, but may be preauthorized for payment in accordance with COMAR 10.09.12.

G. Support Surfaces.

(1) Support surfaces are not included in either the 2012 final per diem rate or the prospective rate.

(2) A provider shall be paid a per diem rate for providing appropriate specialized support surfaces to patients with pressure ulcers or in recovery from myocutaneous flap or graft surgery for a pressure ulcer.

(3) A Class A support surface is a mattress replacement which has been approved as a Group 2 Pressure Reducing Support Surface by the Medical Policy of the Medicare Durable Medical Equipment Regional Carrier. A Class A support surface shall be reimbursed per day at the Medicare Durable Medical Equipment Regional Carrier Maryland monthly fee cap, in effect at the beginning of the State fiscal year, for HCPCS Code E0277 multiplied by 12 and then divided by the number of days in the State fiscal year.

(4) A Class B support surface is an air fluidized bed which has been approved as a Group 3 Pressure Reducing Support Surface by the Medical Policy of the Medicare Durable Medical Equipment Regional Carrier. A Class B support surface shall be reimbursed per day at the Medicare Durable Medical Equipment Regional Carrier Maryland monthly fee cap, in effect at the beginning of the State fiscal year, for HCPCS Code E0194 multiplied by 12 and then divided by the number of days in the State fiscal year.

H. Negative pressure wound therapy is not included in either the 2012 final per diem rate or the prospective rate, but is reimbursed in accordance with rates established under COMAR 10.09.12. Reimbursement shall include the cost of pumps, dressings, and containers associated with this procedure.

I. Nursing facilities that are owned and operated by the State are not paid in accordance with the provisions of §§A-C of this regulation, but are reimbursed reasonable costs based upon Medicare principles of reasonable costs as described at 42 CFR Part 413 . Aggregate payments for these facilities may not exceed Medicare upper payment limits as specified at 42 CFR § 447.272. If the Medicare upper payment limit is above aggregate costs for this ownership class, the State may elect to make supplemental payments to increase payments up to the Medicare upper payment limit.

J. Final facility rates for the period July 1, 2015 through December 31, 2015 shall be each nursing facility's quarterly rate reduced by the budget adjustment factor of 1.96 percent plus the Nursing Facility Quality Assessment add-on identified in Regulation .10-1E of this chapter.

K. Final facility rates for the period January 1, 2016 through June 30, 2016 shall be each nursing facility's quarterly rate reduced by the budget adjustment factor of 3.28 percent plus the Nursing Facility Quality Assessment add-on identified in Regulation .10-1E of this chapter.

L. Final facility rates for the period July 1, 2016 through December 31, 2016 shall be each nursing facility's quarterly rate, exclusive of the amount identified in Regulation .11-8A (2) of this chapter, reduced by the budget adjustment factor of 6.076 percent, plus the Nursing Facility Quality Assessment add-on identified in Regulation .10-1E of this chapter and the ventilator care add-on amount identified in Regulation .11-8A (2) of this chapter when applicable.

M. Final facility rates for the period January 1, 2017 through June 30, 2017 shall be each nursing facility's quarterly rate, exclusive of the amount identified in Regulation .11-8A (2) of this chapter, reduced by the budget adjustment factor of 8.212 percent, plus the Nursing Facility Quality Assessment add-on identified in Regulation .10-1E of this chapter and the ventilator care add-on amount identified in Regulation .11-8A (2) of this chapter when applicable.

N. Final facility rates for the period July 1, 2017, through June 30, 2018, shall be each nursing facility's quarterly rate, exclusive of the amount identified in Regulation .11-8A (2) of this chapter, reduced by the budget adjustment factor of 9.652 percent, plus the Nursing Facility Quality Assessment add-on identified in Regulation JO-IE of this chapter and the ventilator care add-on amount identified in Regulation .11-8A (2) of this chapter when applicable.

Md. Code Regs. 10.09.10.07-2

Regulation .07-2 adopted effective July 1, 1980 (7:13 Md. R. 1278)
Regulations .07-2 amended as an emergency provision effective January 14, 1992 (19:3 Md. R. 299); emergency status expired June 30, 1992
Regulations .07-2 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 .07-2 amended and new Regulation effective October 1, 1999 (26:23 Md. R. 1775); adopted permanently effective January 9, 2000 (26:27 Md. R. 2015)
Regulations .07-2 amended as an emergency provision effective December 1, 2001 (29:1 Md. R. 17)
Regulations .07-2 amended as an emergency provision effective July 1, 1995 (22:15 Md. R. 1114); emergency status expired November 1, 1995; amended permanently effective November 6, 1995 (22:22 Md. R. 1658)
Regulations .07-2 adopted effective 42:7 Md. R. 567, eff.4/13/2015; amended effective 43:4 Md. R. 331, eff.2/29/2016; amended effective 43:25 Md. R. 1384, eff. 12/19/2016; amended effective 44:26 Md. R. 1214, eff. 1/1/2018; amended effective 45:13 Md. R. 664, eff. 7/2/2018