The purpose of the amendment to Rule 59G-6.010, Florida Administrative Code, is to incorporate the reimbursement methodology for Nursing Home Services using the prospective payment methodology in accordance with section 409.908 (2)(b), F.S.

 

AGENCY FOR HEALTH CARE ADMINISTRATION

Medicaid

RULE NO.:RULE TITLE:

59G-6.010Payment Methodology for Nursing Home Services

PURPOSE AND EFFECT: The purpose of the amendment to Rule 59G-6.010, Florida Administrative Code, is to incorporate the reimbursement methodology for Nursing Home Services using the prospective payment methodology in accordance with section 409.908 (2)(b), F.S.

SUMMARY: The amendment specifies that the rule is applicable to all nursing facility providers, updates existing language, and incorporates statutory changes.

SUMMARY OF STATEMENT OF ESTIMATED REGULATORY COSTS AND LEGISLATIVE RATIFICATION:

The Agency has determined that this will not have an adverse impact on small business or likely increase directly or indirectly regulatory costs in excess of $200,000 in the aggregate within one year after the implementation of the rule. A SERC has not been prepared by the Agency.

The Agency has determined that the proposed rule is not expected to require legislative ratification based on the statement of estimated regulatory costs or if no SERC is required, the information expressly relied upon and described herein: A checklist was prepared by the Agency to determine the need for a SERC. Based on this information at the time of the analysis and pursuant to section 120.541, Florida Statutes, the rule will not require legislative ratification.

Any person who wishes to provide information regarding a statement of estimated regulatory costs, or provide a proposal for a lower cost regulatory alternative must do so in writing within 21 days of this notice.

RULEMAKING AUTHORITY: 409.919, 409.9082 FS.

LAW IMPLEMENTED: 409.908, 409.9082, 409.913 FS.

A HEARING WILL BE HELD AT THE DATE, TIME AND PLACE SHOWN BELOW:

DATE AND TIME: December 6, 2019 from 1:00 p.m. to 1:30 p.m.

PLACE: Agency for Health Care Administration, 2727 Mahan Drive, Building 3, Tallahassee, Florida 32308-5407.

Pursuant to the provisions of the Americans with Disabilities Act, any person requiring special accommodations to participate in this workshop/meeting is asked to advise the agency at least 48 hours before the workshop/meeting by contacting: Rebekah Falk. If you are hearing or speech impaired, please contact the agency using the Florida Relay Service, 1(800)955-8771 (TDD) or 1(800)955-8770 (Voice).

THE PERSON TO BE CONTACTED REGARDING THE PROPOSED RULE IS: Rebekah Falk, Bureau of Medicaid Program Finance, 2727 Mahan Drive, Mail Stop 23, Tallahassee, Florida 32308-5407, telephone: [phone], e-mail: [e-mail].

Official comments to be entered into the rule record will be received until 5:00 p.m., December 9, 2019. Comments may be e-mailed to [e-mail]. For general inquiries and questions about the rule, please contact the person specified above.

 

THE FULL TEXT OF THE PROPOSED RULE IS:

 

59G-6.010 Payment Methodology for Nursing Home Services

(1) This rule applies to all nursing facility providers rendering Florida Medicaid nursing facility services in accordance with 59G-4.200 Florida Administrative Code. Reimbursement to participating nursing homes for services provided shall be in accordance with the Florida Title XIX Long-Term Care Reimbursement Plan (the Plan), Version XLV, effective date July 1, 2017, available at http://www.flrules.org/Gateway/reference.asp?No=Ref-09139, incorporated by reference. A copy of the Plan, as revised, may be obtained by writing to the Bureau of Medicaid Program Finance, Agency for Health Care Administration, 2727 Mahan Drive, Mail Stop #23, Tallahassee, Florida 32308. The Plan incorporates Provider Reimbursement Manual (CMS Pub. 15-1). The Plan is applicable to all providers of Florida Medicaid nursing facility services who are enrolled in or registered with the Florida Medicaid program.

(2) Definitions.

(a) Adjusted Facility Sq Ft - Component of the FRVS Calculation defined in section 409.908(2)(b)1.g., F.S.

(b) Allowable Medicaid Costs – Are defined in CMS Publication 15-1 chapter 21 under reasonable costs and costs related and not related to patient care.

(c) Budget Neutrality Factor - Budget neutrality multipliers shall be incorporated into the Prospective Payment System (PPS) to ensure that total reimbursement is as required through the General Appropriations Act. Quality Incentive Payments, Direct Care Staffing and Ventilator add-ons, and the Nursing Facility Quality Assessment are excluded.

(d) Depreciation Factor- Component of the FRVS Calculation defined in section 409.908(2)(b)1.g., F.S.

(e) Direct Care Cost Component- The direct patient care component shall include the Medicaid allowable portion of salaries and benefits of direct care staff providing nursing services including registered nurses, licensed practical nurses, and certified nursing assistants who deliver care directly to residents in the nursing facility, allowable therapy costs, and dietary costs adjusted for inflation.  

(f) Equipment Cost - Component of the FRVS Calculation defined in section 409.908(2)(b)1.g., F.S. 

(g) Exempt Providers – Pediatric, facilities operated by the Florida Department of Veterans Affairs, and government-operated facilities are exempt from reimbursement under the prospective payment methodology and shall be reimbursed on a cost-based prospective payment system, as defined in  section 409.908(2)(b)8, Florida Statutes (F.S.). Reimbursement of direct care, indirect care, and operating costs are subject to reimbursement ceilings and targets.

(h) Fair Rental Rate - Component of the FRVS Calculation defined in section 409.908(2)(b)1.g., F.S.

(i) Floors – Floors are calculated for the direct care and indirect care cost components for each peer group and are equal to the price times the floor percentage as defined in section 409.908(2)(b)1.c., F.S.

(j) Floor Reduction – The difference between the floor and the provider’s inflated per day cost component, if a provider’s cost is below the floor.

(k) FRVS Rate - A Fair Rental Value (FRV) system is used to reimburse providers for their facility related capital costs. A provider must submit an FRV survey to the Agency for Health Care Administration (AHCA) using the electronic form and instructions on the Florida Nursing Home: Fair Rental Value Survey web page. The survey information is used to compute an adjusted age for each provider, based on the most recent survey received by April 30 of each year for the subsequent rate period. The nursing facility provider’s FRV survey will be used to calculate the rate for a future rate period.

(l) High Medicaid Utilization and High Direct Patient Care Add-On - Providers who meet the minimum Medicaid utilization and staffing criteria outlined in section 409.908(2)(b)6, F.S. and have a prospective payment per diem rate that is lower than their per diem rate effective September 1, 2016, shall receive the lesser of a $20 per diem increase or a per diem increase sufficient to set their rate equal to their September 1, 2016 rate.

(m) Indirect Care Cost Component - All other allowable Medicaid patient care costs, that are not listed in the operating or direct care components, are adjusted for inflation and shall be included in the indirect patient care component.

(n) Land Allocation Percentage - Component of the FRVS Calculation defined in section 409.908(2)(b)1.g., F.S.

(o) Medians - The mid-points of the inflated per diems for direct care, indirect care, and operating cost components of all providers in a peer group. Beginning October 1, 2018 separate medians shall be calculated for operating, direct, and indirect cost components based on the most recent cost reports received for the September 2016 rate setting by the rate setting acceptance cut-off date, per section 409.908(2)(b)1.b., F.S. Beginning October 1, 2021 medians shall be calculated based on the most recently finalized, audited cost report.

(p) Medicaid Adjustment Rate (MAR) – An add-on to the direct care and indirect care cost components of exempt providers with greater than 50 percent Medicaid utilization.

(q) Medicaid Bad Debt – amounts considered to be uncollectible from accounts and notes receivable which are created or acquired in providing services per CMS publication 15-1 chapter 3 section 302.1. 

(r) Medicaid Trend Adjustment (MTA) - The MTA is a percentage reduction that is uniformly applied to all Florida Medicaid nursing facility providers each rate period which equals all recurring and nonrecurring budget reductions on an annualized basis. The exempt providers’ rates are reduced by the appropriate percentage allocation as compared to all Medicaid nursing facility providers.

(s) Nursing Facility Quality Assessment (NFQA) – An assessment imposed on each nursing facility provider used to obtain Federal financial participation through the Medicaid program and partially fund the quality incentive payment program for nursing facilities that exceed quality benchmarks. The per diem Florida Medicaid share of the NFQA is calculated as follows:

1. Total patient days minus Medicare days is equal to total non-Medicare days.

2. The product of total non-Medicare days, NFQA rate and Florida Medicaid days as a percentage of total days  is equal to the total NFQA Florida Medicaid share.

3. Total NFQA Florida Medicaid share divided by Florida Medicaid days is equal to the per diem Florida Medicaid Share of the NFQA.

(t) Offense - one month’s total number of resident days not submitted and full quality assessment payment not received by the 20th day of the next succeeding calendar month.

(u) Operating Cost Component - The operating cost component shall include the Medicaid allowable costs for medical records, plant operation, housekeeping, administration, Medicaid bad debt, and laundry and linen adjusted for inflation.

(v)Pass-Through Payments - Real estate and personal property taxes and property insurance shall be reimbursed as pass-through payments calculated as the total cost, as reported in the most recent cost report received by the rate setting acceptance cutoff date, divided by the total patient days.

(w) Peer Group – Providers are divided into two peer groups defined in section 409.908(2)(b)1.a., F.S.

(x) Price - The standardized rate for each peer group that is calculated for the direct care, indirect care and operating cost components as the median times the price percentage as defined in section 409.908(2)(b)1.b., F.S.

(y) Quality Incentive Payment – A provider is awarded points for process, outcome, structural and credentialing measures. To qualify for a quality incentive payment, a provider must meet the minimum threshold defined in section 409.908(2)(b)1.f., F.S. The Quality Incentive budget is defined in section 409.908(2)(b)1.e., F.S.

1. Process Measures - Includes Flu Vaccine, Antipsychotic, and Restraint quality metrics. Providers are ranked based on the percentage of residents who have, or do not have, a particular condition. Providers who are at or above the 90th percentile for a particular measure will be awarded 3 points, those scoring from the 75th through the 89th percentiles will be awarded 2 points, and those scoring from the 50th through the 74th percentiles will receive 1 point. Providers who score below the 50th percentile and achieve a 20 percent improvement from the previous year will receive 0.5 points. Data to calculate these quality metrics is from the Medicare Nursing Home Compare datasets.

2. Outcome Measures – Includes Urinary Tract Infections, Pressure Ulcers, Falls, Incontinence, and Decline in Activities of Daily Living quality metrics. Outcome Measures are scored using the same methodology as Process Measures. Data to calculate these metrics is from the Medicare Nursing Home Compare datasets.

3. Structure Measures – Includes Direct Care Staffing from the Medicaid cost report received by the rate setting cutoff date and Social Work and Activity Staff as reported on CMS 671 Reports. Structure Measures are scored using the same methodology as Process Measures and Outcome Measures.

4. Credentialing Measures – Includes CMS 5-Star, Florida Gold Seal, Joint Commission Accreditation, and American Health Care Association National Quality Award. Facilities assigned a rating of 3, 4, or 5 stars in the CMS 5- Star program will receive 1, 3, or 5 points, respectively. CMS 5-Star rating is found on the Medicare Nursing Home Compare datasets. Facilities that have either a Florida Gold Seal, Joint Commission Accreditation, or the silver or gold America Health Care Association National Quality Award on May 31 of the subsequent year will be awarded 5 points. Recipients of the Florida Gold Seal Award can be viewed on Florida Health Finder website, recipients of the Joint Commission Accreditation can be viewed on the Joint Commission website, and recipients of the American Health Care Association National Quality Award can be viewed on the American Health Care Association website. 

(z) Rate Period – October 1 - September 30.

(aa) Rate Setting Acceptance Cost Report Cutoff Date – The cost report cutoff date is April 30, or the next business day if April 30 falls on a weekend, of the year in which the rate period beings.

(bb) Rebase Rate Semester – Direct care, indirect care, and operating cost components will be rebased every fourth year by using the most recently finalized, audited cost report available by the rate setting acceptance cut-off date beginning October 1, 2021.

(cc) Reimbursement Ceiling - The upper rate limits, calculated based on all Medicaid Nursing Facility  providers, for operating, direct care, and indirect care components applicable to exempt nursing facility providers in a peer group.

(dd) Reimbursement Targets – Provider specific per diem limitations, for the operating and indirect care cost components for exempt providers.

(ee) RSMeans Data -The industry-standard materials, labor, and equipment cost information database used by contractors and other professionals to accurately estimate project costs.

(ff) Subsequent Offense - any offense within a period of five years preceding the most recent quality assessment due date.

(gg)Ventilator Supplemental Payment - Effective October 1, 2019, claims and encounter data with diagnosis code Z99.11, dependence on respirator (ventilator) status, with dates of service in the prior calendar year will be used to calculate the ventilator supplemental payment. The sum of claims and encounters with  diagnosis code Z99.11 for the facility will be divided by annualized Medicaid days from the most recently submitted cost report received by the Rate Setting Acceptance Cost Report Cutoff Date, then multiplied by $200.00. The result will be added to the rate setting per diem.

(3) Reimbursement. Effective each October 1 the AHCA will reimburse for Florida Medicaid nursing facility services rendered by nursing facilities using the Prospective Payment System (PPS) methodology in accordance with section 409.908 (2)(b), F.S. Exempt providers will be reimbursed using a cost based methodology.

(4) Reimbursement Methodology.

(a) PPS Calculation. The calculation is as follows:

(Operating Price + Direct Care Price - Floor Reduction + Indirect Care Price - Floor Reduction + FRVS Rate + Pass Through Payments) * Budget Neutrality Factor + Quality Incentive Payment + Medicaid Share of NFQA + Ventilator Supplemental Payment + High Medicaid Utilization and High Direct Patient Care Add-On

(b) Quality Incentive Payment Calculation. The calculation is as follows:

Facility Annualized Medicaid Days / Average Annualized Medicaid Days of All Facilities* Quality Points with Lower Limit / Sum of Total Points Awarded to All Facilities * Total Quality Budget/Facility Annualized Medicaid Days

(c) FRVS Calculation. The calculation is as follows:

Building = 2018 RSMeans Cost Per Sq Ft * Adjusted Facility Sq Ft * Zip Code Location Factor

Land = Building * Land Allocation Percentage

Undepreciated Value = Building + Land + Equipment

Depreciation = (Building + Equipment) * Depreciation Factor * Facility Adjusted Age

FRVS Rate = (Undepreciated Value – Depreciation) * Fair Rental Rate / (Occupancy Percentage * 365.25)

1. 2018 RSMeans Cost Per Sq Ft and Zip Code Location Factor are defined in the latest Gordian Building Construction Costs publication with RSMeans Data available on March 31 of the year in which the rate period begins.

2. Adjusted Facility Sq Ft, Land Allocation Percentage, Equipment Cost, Depreciation Factor, and Fair Rental Rate are defined in section 409.908(2)(b)1.g., F.S.

3. Facility Adjusted Age is calculated using FRVS survey data.

(d) Exempt Calculation. The calculation is as follows:

Operating Cost Component + Direct Care Cost Component + Indirect Care Cost Component + MAR + FRVS Rate + Pass Through Payments + Medicaid Share of NFQA – MTA

(5) NFQA

(a) Participating nursing facilities homes shall use the Nursing Facility Quality Assessment form (only accepted electronically), AHCA Form 5000-3549, Revised October 2013, incorporated by reference, for the submission of its monthly quality assessment. This form can be accessed at http://ahca.myflorida.com/QAF/index.shtml.

(b)(3) Each facility shall report monthly to the Agency for Health Care Administration (AHCA) its total number of resident days and remit an amount equal to the assessment rate times the reported number of days. Facilities are required to submit their full quality assessment payment no later than 20 days from the next succeeding calendar month.

(c)(4) Providers are subject to the following monetary fines pursuant to section 409.9082(7), Florida Statutes (F.S.), for failure to timely submit the facility total number of resident days and  pay the full amount of the a quality assessment:

1.(a) For a facility’s first offense, a fine of $500 per day shall be imposed until the total number of resident days is submitted and quality assessment is paid in full, but in no event shall the fine exceed the amount of the quality assessment.

2.(b) For any offense subsequent to a first offense, a fine of $1,000 per day shall be imposed until total number of resident days is submitted and the quality assessment is paid in full, but in no event shall the fine exceed the amount of the quality assessment. A subsequent offense is defined as any offense within a period of five years preceding the most recent quality assessment due date.

(c) An offense is defined as one month’s quality assessment payment not received by the 20th day of the next succeeding calendar month.

3.(d) In the event that a provider fails to report their total number of resident days as defined in section 409.9082(1)(c), F.S., by the 20th day of the next succeeding calendar month, the fines in paragraphs (a)-(c), apply and the maximum amount of the fines shall be equal to their last submitted quality assessment amount but in no event shall the total fine exceed the amount of the quality assessment.                    

(d)(5) In addition to the aforementioned fines, providers are also subject to the non-monetary remedies enumerated in section 409.9082(7), F.S. Imposition of the non-monetary remedies by AHCA will be as follows:

1.(a) For a third subsequent offense, AHCA will withhold any Medicaid reimbursement payments until the assessment is recovered.

2.(b) For a fourth or greater subsequent offense, AHCA will seek suspension or revocation of the facility’s license.

(e)(6) Fines  for failure to timely submit a quality assessment are non-allowable costs for reimbursement purposes and shall not be included in the provider’s Medicaid per diem rate.

(f)(7) The facility may amend any previously submitted quality assessment data, but in no event may an amendment occur more than twelve months after the due date of the assessment. The deadline for submitting an amended assessment shall not relieve the facility from their obligation to pay any amount previously underpaid and shall not waive AHCA’s right to recoup any underpaid assessments.

(6)(8) The Florida Medicaid rate is equal to the Medicare allowed amount for Medicare approved Part B therapy services provided in nursing facilities ty.

Rulemaking Authority 409.919, 409.9082 FS. Law Implemented 409.908, 409.9082, 409.913 FS. History–New 7-1-85, Amended 10-1-85, Formerly 10C-7.482, Amended 7-1-86, 1-1-88, 3-26-90, 9-30-90, 12-17-90, 9-15-91, 3-26-92, 10-22-92, 4-13-93, 6-27-93, Formerly 10C-7.0482, Amended 4-10-94, 9-22-94, 5-22-95, 11-27-95, 11-6-97, 2-14-99, 10-17-99, 1-11-00, 4-24-00, 9-20-00, 11-20-01, 2-20-02, 7-14-02, 1-8-03, 6-11-03, 12-3-03, 2-16-04, 7-21-04, 10-12-04, 4-19-06, 7-1-06, 8-26-07, 2-12-08, 9-22-08, 3-3-10, 2-23-11, 5-3-12, 2-13-14, 1-19-15, 5-3-15, 7-17-16, 8-6-17, 3-25-18,________.

 

NAME OF PERSON ORIGINATING PROPOSED RULE: Rebekah Falk

NAME OF AGENCY HEAD WHO APPROVED THE PROPOSED RULE: Mary C. Mayhew

DATE PROPOSED RULE APPROVED BY AGENCY HEAD: November 05, 2019

DATE NOTICE OF PROPOSED RULE DEVELOPMENT PUBLISHED IN FAR: May 10, 2019