Section R414-504-3 - Principles of Facility Case Mix Rates and Other PaymentsThe following principles apply to the payment of freestanding and provider-based nursing facilities for services provided to qualified Medicaid patients, as defined in Rule R414-502. This rule does not affect the system for reimbursement for intensive-skilled Medicaid patient add-on amounts.
(1) A portion of total payments to nursing facilities for qualified Medicaid patients is based on a prospective facility case mix rate. In addition, these facilities shall be paid a flat basic operating expense payment. The balance of the total payments will be paid in aggregate to facilities as required by Section R414-504-3 based on other authorized factors, including property and behaviorally complex residents, in the proportion that the facility qualifies for the factor.(2) Each quarter, the Department shall calculate a new case mix index for each nursing facility. The case mix index is based on three months of MDS assessment data. The newly calculated case mix index is applied to a new rate at the beginning of a quarter according to the following schedule: (a) January, February, and March MDS assessments are used for July 1 rates.(b) April, May, and June MDS assessments are used for October 1 rates.(c) July, August, and September MDS assessments are used for January 1 rates.(d) October, November, and December MDS assessments are used for April 1 rates.(3) MDS and optional state assessment (OSA) data is used in calculating each facility's case mix index and upper payment limit (UPL) gap. Beginning July 1, 2023, each facility must complete an OSA in conjunction with any Omnibus Budget Reconciliation Act or prospective payment system assessments. This information is required by the state to calculate the case mix index. The MDS and OSA data is submitted by each facility and each facility is responsible for the accuracy of its data. Each facility shall ensure needed sections of the MDS and OSA are completed so that a PDPM or resource utilization group score may be calculated. The Department may exclude inaccurate or incomplete MDS data from calculations.(4)(a) MDS assessments for patients who are eligible for the intensive skilled add-on are excluded from the case mix calculation.(b) The state average case mix index excludes the following:(i) a facility with less than 20% of its total census days as Medicaid fee-for-service paid days, as reported on its FCP or FRV data report; or(ii) a facility having less than six months of data reported under Rule R414-401.(c) The state average case mix index is used to set the rate for the following facilities: (i) a facility with less than 20% of its total census days as Medicaid fee-for-service paid days, as reported on its FCP or FRV data report; or(ii) a facility having less than six months of data reported under Rule R414-401.(5) A facility may apply for a special add-on rate for behaviorally complex residents by filing a written request with the Division of Integrated Healthcare (DIH). The Department may approve an add-on rate if an assessment of the acuity and needs of the patient demonstrates that the facility is not adequately reimbursed by the case mix score for that patient. The rate is added on for the specific resident's payment and is not subsumed as part of the facility case mix rate. The Office of Long -Term Services and Supports determines qualification for any additional payment. DIH shall determine the amount of any add-on.(6) The Department pays property costs separately from the case mix rate.(7) Reimbursement for nursing home rates is in accordance with Attachment 4.19-D of the Medicaid State Plan, which is incorporated by reference in Section R414-1-5.(8) A provider may challenge the rate set pursuant to this rule using the appeal in Rule R410-14. This applies to which rate methodology is used as well as to the specifics of implementation of the methodology. A provider must exhaust administrative remedies before challenging rates in any other forum.(9) The Department reimburses swing beds, transitional care unit beds, and small health care facility beds that are used as nursing facility beds, using the prior calendar year statewide average of the daily nursing facility rate.(10) Unless specified otherwise, the Department may withhold Title XIX payments from providers if: (a) there is a shortage in a resident trust account managed by the facility;(b) the facility fails to submit a complete and accurate FCP as required by Attachment 4.19-D of the Medicaid State Plan;(c) the facility fails to submit timely, accurate MDS and OSA data;(d) the facility owes money to DIH because of an overpayment, nursing care facility assessment, civil money penalty, or other offset; or(e) the facility fails to respond within ten business days to a written request for information.(11) The Department shall provide written notice before withholding payments.(12) When the Department rescinds withholding of payments to a provider, it will, without notice, resume payments according to the regular claims payment cycle.(a) For ongoing operations, the Department shall provide notice before withholding payments. The Department and provider may negotiate a repayment schedule acceptable to the Department for monies owed to the Department listed in Subsection R414-504-3(10). The repayment schedule may not exceed 180 days.(b) When the Department rescinds withholding of payments to a facility, it will resume payments according to the regular claims payment cycle.Utah Admin. Code R414-504-3
Amended by Utah State Bulletin Number 2017-22, effective 11/1/2017Amended by Utah State Bulletin Number 2019-2, effective 1/1/2019Amended by Utah State Bulletin Number 2020-02, effective 1/1/2020Amended by Utah State Bulletin Number 2020-19, effective 10/1/2020Amended by Utah State Bulletin Number 2023-14, effective 7/1/2023