471 Neb. Admin. Code, ch. 45, § 007

Current through June 17, 2024

Section 471-45-007 - RATE DETERMINATION

The Department determines rates for facilities under the following cost-based prospective methodology.

007.01RATE PERIODS. The Rate Periods are defined as July 1 through December 31, and January 1 through June 30. Rates paid during the rate periods are determined from base year cost reports. For purposes of this section, base year cost reports means full and part-year cost reports filed with a base year report period ending date of June 30.

007.02REPORT PERIOD. Each facility must file a cost report each year for the reporting period of July 1 through June 30 or part-year cost reports, when applicable.

007.03CARE CLASSIFICATIONS. A portion of each individual facility's rate may be based on the urban or rural location of the facility.

007.04PROSPECTIVE RATES. Subject to the allowable, unallowable, and limitation provisions of this chapter, the Department determines facility-specific prospective per diem rates, one rate corresponding to each level of care, based on the facility's allowable costs incurred and documented during the base year report period. The rates are based on financial, acuity, and statistical data submitted by facilities, and are subject to the component maximums and minimums. Component maximums and minimums are computed using audited data following the initial desk audits and are not revised based on subsequent changes to the data. Only cost reports with a full year's data are used in the computations. Cost reports from providers entering or leaving Medicaid during the immediately preceding report period are not used in the computations. Each facility's prospective rates are the sum of the following components; the direct nursing component adjusted by the inflation factor and weighted for level of care; the support services component adjusted by the inflation factor; the fixed cost component; the nursing facility quality assessment component; and the quality measures component. The direct nursing component and the support services component are subject to maximum and minimum per diem payments based on Median or Maximum computations. For each care classification, the median for the direct nursing component is computed using nursing facilities within that care classification with an average occupancy of 40 or more residents, excluding waivered, or facilities with partial or initial or final full year cost reports. For each care classification, the median for the support services component is computed using nursing facilities within that care classification with an average occupancy of 40 or more residents, excluding hospital based, waivered, or facilities with partial or initial or final full year cost reports. The Department will reduce the direct nursing component median by 2% for facilities that are waivered from the 24-hour nursing requirement to take into account those facilities' lowered nursing care costs. The maximum per diem is computed as 105% of the median direct nursing component, and 100% of the median support services component. The Department will reduce the direct nursing component maximum by 2% for facilities that are waivered from the 24-hour nursing requirement to take into account those facilities' lowered nursing care costs. The minimum per diem is computed as 77% of the median direct nursing component, and 72% of the median support services component. The fixed cost component is subject to a maximum Per Diem of $27.00, excluding personal property and real estate taxes.

007.04(A)DIRECT NURSING COMPONENT. This component of the prospective rate is computed by dividing the base year allowable direct nursing costs, lines 94 through 103 of Form FA-66, Long Term Care Cost Report, by the base year weighted resident days for each facility. The resulting quotient is the facility's computed base year per diem. The computed base year per diem is subject to the component maximum per diem and minimum per diem for rate determination purposes.

007.04(B)SUPPORT SERVICES COMPONENT. This component of the prospective rate is computed by dividing the base year allowable costs for support services, lines 34, 63, 78, 93, 104 through 127, 163, 184, and 185 from the FA-66; Resident Transportation -Medical from the Ancillary Cost Center, line 219 from the FA-66; and respiratory therapy from the Ancillary Cost Center, line 210 from the FA-66, by the total base year inpatient days for each facility. The computed base year per diem is subject to the component maximum per diem and minimum per diem for rate determination purposes.

007.04(C)FIXED COST COMPONENT. This component of the prospective rate is computed by dividing the facility's base year allowable interest, depreciation, amortization, long-term rent or lease payments, personal property tax, real estate tax, and other fixed costs by the facility's total base year inpatient days. Rate determination for the Fixed Cost Component for an individual facility is computed using the lower of its own per diem as computed above, plus any prior approved increase under 471 NAC 45-007.05, or a maximum per diem of $27.00 excluding personal property and real estate taxes.

007.04(D)NURSING FACILITY QUALITY ASSESSMENT COMPONENT. The Nursing Facility Quality Assessment component shall not be subject to any cost limitation or revenue offset. For purposes of this section, facilities exempt from the quality assurance assessment are state-operated veterans' homes; nursing facilities and skilled nursing facilities with twenty-six or fewer licensed beds; and continuing care retirement communities. the quality assessment component rate will be determined by calculating the anticipated tax payment' during the rate year and then dividing the total anticipated tax payments by total anticipated nursing facility or skilled nursing facility patient days, including bed hold days and Medicare patient days. for each rate year, July 1 through the following June 30, total facility patient days, including bed hold days, less Medicare days, for the four most recent calendar quarters available at the time rates are determined will be used to calculate the anticipated tax payments. Total facility patient days, including bed hold days and Medicare days, for the same four calendar quarters will be used to calculate the anticipated nursing facility or skilled nursing facility patient days. For new providers entering the Medicaid program to operate a nursing facility not previously enrolled in Medicaid, for the rate period beginning on the Medicaid certification date through the following June 30, the quality assessment rate component is computed as the quality assurance assessment amount due from the provider's first quality assurance assessment form covering a full calendar quarter, divided by total resident days in licensed beds from the same quality assurance assessment form. for existing providers changing from exempt to non-exempt status, for the rate period beginning on the first day of the first full month the provider is subject to the quality assurance assessment through the following June 30, the quality assessment rate component is computed as the quality assurance assessment amount due from the provider's first quality assurance assessment form covering a full calendar quarter, divided by total resident days in licensed beds from the same quality assurance assessment form. For existing providers changing from non-exempt to exempt status, for rate periods beginning with the first day of the first full month the provider is exempt from the quality assurance assessment, the quality assessment rate component will be $0.00 (zero dollars).

007.04(E)BASE YEAR REPORT PERIOD AND INFLATION FACTOR. For the Rate Periods July 1 through December 31 and January 1 through June 30, the base year is updated no less frequently than every 5 years. The inflation factor is updated annually.

007.04(F)QUALITY MEASURES COMPONENT. This component of the prospective rate is based on the quality measures component of the Centers for Medicare & Medicaid nursing facility star rating system. The published rating as of May 1 is used to determine the rate component for the following July 1 through December 31 rate period. The published rating as of November 1 is used to determine the rate component for the following January 1 through June 30 rate period. Per Diem amounts corresponding to the quality measures rating are: 5 star rating = $10.00 a day; 4 star rating = $6.75 a day; 3 star rating = $3.50 a day; 1 star, 2 star, or NR (no rating) = $0.00 (zero dollars). This component applies to all nursing facility care levels (101-180).

007.05EXCEPTION PROCESS. An individual facility may request, on an exception basis, the Medicaid Director or designee, to consider specific facility circumstance or circumstances, which warrant an exception to the facility's rate computed for its fixed cost component. For existing facilities, an exception may only be requested if the facility's total annualized fixed costs, total costs, not per diem rate, as compared to the annualized base year costs, have increased by twenty percent or more. Facilities without a base year cost report, and with 1,000 or more annualized Medicaid days, may only request an exception if the facility's fixed costs per day, computed using an 85% minimum occupancy, exceeds the care classification average fixed cost component by 20% or more. In addition, the facility's request must include: Specific identification of the increased cost or costs that have caused the facility's total fixed costs to increase by 20% or more, with justification for the reasonableness and necessity of the increase; Whether the cost increase or increases are an ongoing or a one-time occurrence in the cost of operating the facility; and If applicable, preventive management action that was implemented to control past and future cause or causes of identified cost increase or increases. Approved increases from July 1 through December 31, will be effective the following January 1. Approved increases from January 1 through June 30, will be effective the following July 1.

007.06RATE PAYMENT FOR ASSISTED LIVING LEVELS OF CARE. The payment rate for Levels of Care 201 and 202 is the applicable rate in effect for assisted living services under the Home and Community-Based Waiver Services for Aged Persons or Adults or Children with Disabilities adjusted to include the nursing facility quality assessment component and quality measures component.

007.07OUT-OF-STATE FACILITIES. The Department pays out-of-state facilities participating in Medicaid at the rates established by that state's Medicaid program for nursing facility days, bed hold days and therapeutic leave days at the time of establishment of the Medicaid provider agreement. The rates are periodically updated to align with the current and applicable rates assigned by the out-of-state facility's State Medicaid program..

007.08RATES FOR PROVIDERS WITHOUT A BASE YEAR COST REPORT. A provider without a base year cost report is an individual or entity which obtains their initial, facility-specific provider agreement to operate an existing nursing facility, meaning the business operation, not the physical property, due to a change in ownership, or to operate a nursing facility not previously enrolled in Medicaid, after the base year cost report end date; or a provider with 1,000 or fewer Medicaid inpatient days in the base year. Prospective Medicaid rates for providers without a base year cost report are the sum of the following components:

(A) The applicable urban or rural average direct nursing base rate component of all other providers in the same care classification, adjusted by the inflation factor; and weighted for level of care;

(B) The applicable urban or rural average support services base rate component of all other providers in the same care classification, adjusted by the inflation factor;

(C) The applicable urban or rural average fixed cost base rate component of all other providers in the same care classification;

(D) The Nursing Facility Quality Assessment component; and

(E) The quality measures component.

007.09PROVIDERS LEAVING THE MEDICAID. Providers leaving Medicaid as a result of change of ownership or exit from the program shall comply with provisions of this chapter.

007.10SPECIAL FUNDING PROVISIONS FOR GOVERNMENTAL FACILITIES. City and county-owned and operated nursing facilities are eligible to receive the federal financial participation share of allowable costs exceeding the rates paid for the direct nursing, support services, and fixed cost Components for all Medicaid residents. The reimbursement is subject to the payment limits of 42 CFR 447.272.

007.10(A)CITY OR COUNTY OWNED FACILITIES. City or county-owned facilities with a 40% or more Medicaid mix of inpatient days are eligible to receive the federal financial participation share of allowable costs exceeding the applicable maximums for the direct nursing, support services, and fixed cost components. This amount is computed after desk audit and determination of final rates for a report period by multiplying the current Medicaid federal financial participation percentage by the facility's allowable costs above the respective maximum for the direct nursing, support services, and fixed cost components. Verification of the eligibility of the expenditures for federal financial participation is accomplished during the audit process.

007.11SPECIAL FUNDING PROVISIONS FOR INDIAN HEALTH SERVICES NURSING FACILITY PROVIDERS. Indian Health Services nursing facility providers are eligible to receive the federal financial participation share of allowable costs exceeding the rates paid for the direct nursing, support services, and fixed cost components for all Medicaid residents.

007.11(A)INDIAN HEALTH SERVICES. Indian Health Services providers may receive quarterly, interim Special Funding payments by filing quarterly cost reports, FA-66, for periods ending September 30, December 31, or March 31. Quarterly, interim special funding payments are retroactively adjusted and settled based on the provider's corresponding annual cost report for the period ending June 30. Quarterly, interim payments and the retroactive settlement amount are calculated in accordance with section (ii) below. If the average daily census from a quarterly cost report meets or exceeds 85% of licensed beds, this shall be the final quarterly cost report filed by the provider. Subsequent quarterly, interim special funding payments shall be based on the final quarterly cost report. Quarterly, interim Special Funding payments may also be revised based on data from the annual cost reports.

(i) Quarterly, interim special funding payments shall be made within 30 days of receipt of the quarterly cost report or requested supporting documentation. Quarterly, interim special funding payments subsequent to the payment for the final quarterly cost report shall be made on or about 90-day intervals following the previous payment.

(ii) The special funding amount is computed after desk audit and determination of allowable costs for the report period. The amount is calculated by adding the following two figures:

(1) The allowable federal medical assistance percentage for Indian Health Services-eligible Medicaid residents multiplied by the difference between the allowable costs for all Indian Health Services-eligible Medicaid residents and the total amount paid for all Indian Health Services-eligible Medicaid residents, if greater than zero; and

(2) The allowable federal medical assistance percentage for non-Indian Health Services-eligible Medicaid residents multiplied by the difference between the allowable costs for all non-Indian Health Services-eligible Medicaid residents and the total amount paid for all non-Indian Health Services-eligible Medicaid residents, if greater than zero.

471 Neb. Admin. Code, ch. 45, § 007

Adopted effective 6/6/2022

Amended effective 6/2/2024