PURPOSE: This amendment updates the maximum allowable reimbursement for nurse assistant training to one thousand five hundred dollars ($1,500) per person and updates other outdated terms and references.
EMERGENCY STATEMENT: The Department of Social Services (DSS), MO HealthNet Division (MHD), by rule and regulation, must define the reasonable costs, manner, extent, quantity, quality, charges, and fees of medical assistance provided to MO HealthNet participants. The General Assembly included additional funds to nursing facilities' and HIV nursing facilities' reimbursements for nurse assistant training (NAT) in SFY 2024. MHD is carrying out the General Assembly's intent by providing for an increase in the maximum allowable reimbursement to nursing facilities and HIV nursing facilities for NAT to one thousand five hundred dollars ($1,500) per person. The increase is necessary to ensure that payments for NAT for nursing facilities and HIV nursing facilities are in line with the funds appropriated for that purpose. There are a total of four hundred eighty-four (484) nursing facilities and HIV nursing facilities currently enrolled in MO HealthNet that will receive an increase to its NAT reimbursement in SFY 2024. This emergency amendment will ensure payment for nursing facility and HIV nursing facility services to approximately twenty-two thousand (22,000) MO HealthNet participants in accordance with the appropriation authority. For the SFY 2024 payment to be made, MHD was required to submit a Medicaid State Plan Amendment (SPA) to the Centers for Medicare and Medicaid Services (CMS). CMS approved the SPA on December 18, 2023. This emergency amendment is necessary to protect the public health and welfare of MO HealthNet participants in nursing facilities and HIV nursing facilities. This emergency amendment is necessary to protect a government interest to reimburse nursing facilities and HIV nursing facilities as required by the General Assembly, and to provide MO HealthNet participants with quality nursing facility services. As a result, MHD finds an immediate danger to public health, safety, and/or welfare and a compelling governmental interest, which requires emergency action. MHD has a compelling government interest in providing continued cash flow for nursing facility and HIV nursing facility services. The scope of this emergency amendment is limited to the circumstances creating the emergency and complies with the protections extended by the Missouri and United States Constitutions. MHD believes this emergency amendment is fair to all interested persons and parties under the circumstances. A proposed amendment covering this same material will be published in the Missouri Register. This emergency amendment was filed February 26, 2024, effective March 11, 2024, and expires September 6, 2024.
(1) Definitions. (A) "Nurse assistant training agency" is an agency which is approved by the Department of Health and Senior Services under 19 CSR 30-84.010(7).(B) "Basic course" is the seventy-five (75) hours of classroom training, the one hundred (100) hours of on-the-job supervised training, and the final examination of the approved nurse assistant training course.(C) "Challenge the final examination" means taking the final examination of the basic course without taking the entire basic course.(D) "Cost report" is the Financial and Statistical Report for Nursing Facilities, required attachments, and all worksheets supplied by the division for this purpose per 13 CSR 70-10.015, effective January 1, 1995, through June 30, 2022, and 13 CSR 70-10.020, effective beginning July 1, 2022. The cost report details the cost of rendering both covered and noncovered services for the fiscal reporting period in accordance with the procedures prescribed by the division, and on forms provided by and/or approved by the division.(E) "Department of Health and Senior Services" is the department responsible for the survey, certification, and licensure as prescribed in Chapter 198, RSMo.(F) "Desk audit" is the MO HealthNet Division or its authorized agent's audit of a provider's cost report without a field audit.(G) "Division," unless otherwise specified, refers to the Department of Social Services, MO HealthNet Division that is charged with administration of MO HealthNet (Medicaid) Program.(H) "Facility fiscal year" is a facility's twelve- (12-) month fiscal reporting period.(I) "Field audit" is an on-site audit of the nursing facility's records performed by the department or its authorized agent.(J) "Nursing facility (NF)" is, effective October 1, 1990, skilled nursing facilities, skilled nursing facilities/intermediate care facilities and intermediate care facilities as defined in Chapter 198, RSMo participating in the Medicaid Program will all be subject to the minimum federal requirements found in section 1919 of the Social Security Act.(K) "Occupancy rate" is a facility's total actual patient days divided by the total bed days for the same period as determined from the desk audited and/or field audited cost report.(L) "Patient day" is the period of service rendered to a patient between the census-taking hour on two (2) consecutive days. Census shall be taken in all facilities at midnight each day and a census log maintained in each facility for documentation purposes. Patient day includes the allowable temporary leave-of-absence days per 13 CSR 70-10.015(5)(D), effective January 1, 1995, through June 30, 2022, and 13 CSR 70-10.020 (5)(C), effective beginning July 1, 2022, and hospital leave days per 13 CSR 70-10.070. The day of discharge is not a patient day for reimbursement purposes unless it is also the day of admission.(M) "Provider or facility" is a nursing facility with a valid Medicaid participation agreement with the Department of Social Services for the purpose of providing nursing facility services to Title XIX-eligible participants.(2) General Principles. (A) Provisions of this reimbursement plan shall apply only to nursing facilities with valid provider agreements certified by the Department of Social Services, Missouri Medicaid Audit and Compliance (MMAC) for participation in the MO HealthNet (Medicaid) Program.(B) The reimbursement determined by this regulation shall apply only to costs incurred for nurse assistant training and competency evaluations for nurse assistants beginning the training after February 26, 1993.(C) Program Approval-The Department of Health and Senior Services will approve or disapprove nurse assistant training programs in the state of Missouri. If the Department of Health and Senior Services withdraws approval of a formerly approved nurse assistant training program, the facility may continue to teach (and bill MO HealthNet for) those nurse assistants who had already begun the training program. However, that facility may not begin training (or bill the division) for any additional nurse assistants until it again receives approval from the Department of Health and Senior Services. Nursing facilities receiving a "level A" violation or extended or partially extended survey will be ineligible for reimbursement for a period of two (2) years after the date of exit interview by the Department of Health and Senior Services.(D) Training Agencies-Any nurse assistant training agency must be approved by the Department of Health and Senior Services per 19 CSR 30-84.010(7). This training agency must provide seventy-five (75) classroom hours of instruction and one hundred (100) hours on-the-job training. The seventy-five (75) classroom hours of instruction may include lecture, discussion, video/film usage, demonstration, and return demonstration by an approved registered nurse (RN) instructor who remains with and is always available to students to answer questions and to conduct the class. The one hundred (100) hours on-the-job training shall be done by an approved RN or licensed practical nurse (LPN) who meets 19 CSR 30-84.010 clinical supervisor qualifications and who directly observes their skills when checking their competencies. The one hundred (100) hours on-the-job training shall be devoted to the student; and the clinical supervisor or instructor must not have other job duties at the same time, such as but not limited to, charge nurse duties, medication pass duties and/or treatment duties. The facility will not be reimbursed in the per-diem rate for the salary/fringes of the RN and/or LPN for time spent teaching the nurse assistant training program.(E) Medicaid Cost Reports-Costs for nurse assistant training and competency evaluations are to be reported in the non-allowable column on the Medicaid cost report and are not to be covered in the per-diem rate. These costs include: any charge for training by an outside training agency, the cost of the competency evaluation, teacher salaries and fringes, necessary textbooks, and other required course materials. However, costs for salaries of nurse assistants in training or replacement nurse assistants for those in training or testing are to be reported in the allowable column on the Medicaid cost report and are to be covered in the per-diem rate.(F) Billing-Nursing facilities with valid provider agreements may bill the MO HealthNet Division for costs incurred for nurse assistant training and competency evaluations for nurse assistants beginning the training after February 26, 1993. Facilities may only bill for nurse assistants trained by an approved training agency and tested by an approved state examiner. This state examiner must be approved per 19 CSR 30-84.010(9) and must have a signed agreement with the Department of Health and Senior Services. Facilities may bill once a month on an approved nurse assistant training billing form.(G) Medicaid Utilization-Reimbursement will be allocated based on the ratio of Medicaid days to total patient days as reported on the latest Medicaid cost report filed by the facility with a year ending in the most recent year that all nursing facility Medicaid cost reports have been desk audited. If the facility did not have a Medicaid cost report ending in the most recent year that all nursing facility Medicaid cost reports have been desk audited, then the average ratio of Medicaid days to total patient days for all cost reports with ending dates in the most recent year that all nursing facility Medicaid cost reports have been desk audited will be used in calculating reimbursement.(3) Reimbursement for Nurse Assistants Employed at the Time of Training. If a nurse assistant is employed at a nursing facility and then passes an approved nurse assistant training and competency evaluation program, the division will reimburse a facility if all the following criteria are met:(A) The nurse assistant is on the Missouri Department of Health and Senior Services nurse assistant register;(B) The individual is employed by the billing nursing facility at the time of passing the competency evaluation (final exam);(C) The following reimbursement amounts will be prorated based on Medicaid utilization:1. One thousand five hundred dollars ($1,500) for a nurse assistant completing the entire basic course (all lesson plans, seventy-five (75) hours classroom training, and one hundred (100) hours on-the-job training) and passing the final exam, as follows: Classroom Training | $600 |
On-the-Job Training | $575 |
Textbook and Supplies | $200 |
Written Test | $30 |
Skills Test | $95 |
Total Allowable to be Prorated on Medicaid Utilization | $1,500 |
2. A percentage of the one thousand five hundred dollars ($1,500) for nurse assistants who only complete a portion of the lesson plans and pass the final exam will be paid. The percentage will be based on how many lesson plans were completed. For example: If no on-the-job training was provided, and if only lesson plans 1, 2, 4, 5, 6, 8, 9, 10, 11, 12, 41, 42, and 43 were completed, the percentage of the $1,500 allowable would be:
Classroom Training ($600 x 18.75 hours/75 hours) | $150 |
On-the-Job Training | $0 |
Textbook and Supplies | $200 |
Written Test | $30 |
Skills Test | $95 |
Total Allowable to be Prorated on Medicaid Utilization | $475 |
3. One hundred twenty-five dollars ($125) for nurse assistants who do not complete any lesson plans through a challenge and pass the final exam;(D) The facility which employs the nurse assistant must submit the bill for reimbursement to the division on the approved billing form; and(E) The facility must bill for nurse assistant training and/or competency exam within one (1) year after the nurse assistant passed the final exam. Nurse assistant training that was completed prior to one (1) year before the effective date of this regulation and began after February 26, 1993, will be allowed.(4) Reimbursement for Nurse Assistants Not Yet Employed at the Time of Training. If a nurse assistant is not employed at a nursing facility and that individual pays for the nurse assistant training and competency evaluation program, the division will reimburse a facility if all the following criteria are met: (A) The nurse assistant is on the Missouri Department of Health and Senior Services nurse assistant register;(B) The individual is employed by the billing nursing facility not later than twelve (12) months after passing the final exam;(C) The individual incurred costs for the training and testing, and the billing nursing facility submits to the division documentary evidence of those costs. The division will not reimburse costs if the nurse assistant received funding for the training through a grant or other funding source that is not required to be repaid by the nurse assistant;(D) The billing nursing facility must submit documentation that it has paid the nurse assistant for the cost it is submitting to the division;(E) The facility which employs the nurse assistant must submit the bill for reimbursement to the division on the approved billing form;(F) The division will prorate costs based on Medicaid utilization as follows: 1. One thousand five hundred dollars ($1,500) for a nurse assistant completing the entire basic course (all lesson plans, seventy-five (75) hours classroom training, and one hundred (100) hours on-the-job training) and passing the final exam;2. A percentage of the one thousand five hundred dollars ($1,500) for nurse assistants who only complete a portion of the lesson plans and pass the final exam. The percentage will be based on how many lesson plans were completed. See paragraph (3)(C)2. of this regulation; and3. One hundred twenty-five dollars ($125) for nurse assistants who do not complete any lesson plans through a challenge process and pass the final exam; and(G) The MO HealthNet Division will subtract one-twelfth (1/12) of allowable reimbursement for each month that the nurse assistant is not employed after passing the final exam.Adopted by Missouri Register February 15, 2019/Volume 44, Number 4, effective 4/1/2019Amended by Missouri Register April 1, 2024/volume 49, Number 07, effective 3/11/2024, exp. 9/6/2024 (Emergency).