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.

SUBJECT AREA TO BE ADDRESSED: Payment Methodology for Nursing Home Services.

RULEMAKING AUTHORITY: 409.919, 409.9082 FS.

LAW IMPLEMENTED: 409.908, 409.9082, 409.913 FS.

A RULE DEVELOPMENT WORKSHOP WILL BE HELD AT THE DATE, TIME AND PLACE SHOWN BELOW:

DATE AND TIME: May 28, 2019 from 2:00 p.m. to 2:30 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 DEVELOPMENT AND A COPY OF THE PRELIMINARY DRAFT, IF AVAILABLE, 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. May 29, 2019 and may be e-mailed to [e-mail]. For general inquiries and questions about the rule, please contact the person specified above.

 

THE PRELIMINARY TEXT OF THE PROPOSED RULE DEVELOPMENT 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) 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.

(b) 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.

(c) 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.

(d) 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.

(e) Floor Reduction – If a provider’s cost is below the floor, the difference between the floor and the provider’s cost component.

(f) 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.

(g) 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.

(h) 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.

(i) 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. 

(j) Medicaid Trend Adjustment (MTA) - The MTA is a percentage reduction that is uniformly applied to all Florida Medicaid 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.

(k) Nursing Facility Quality Assessment (NFQA) – An assessment imposed on each nursing facility provider used to obtain Federal financial participation through the Medicaid program.

(l) 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.

(m)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.

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

(o) 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.

(p) 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.

(q) 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.

(r) 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 begining October 1, 2021.

(s) Reimbursement Ceiling - The upper rate limits for operating, direct care, and indirect care components for nursing facility providers in a peer group for the exempt providers.

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

(3) Reimbursement. Effective October 1, 2018, The AHCA will reimburse for Florida Medicaid nursing facility services rendered by nursing facilities using the PPS methodology in accordance with section 409.908 (2)(b), F.S. Exempt providers will be reimbursed using a cost based methodolgy.

(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]

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

[[(Facility Annualized Days / Average Annualized Days of All Facilities* Quality Points with Lower Limit) / Sum of Total Points Awarded to All Facilities] * Total Quality Budget]

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

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

2. Adjusted Facility Sq Ft, Land Allocation Percentage, Equipment Cost, Depriciation 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 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 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.

3.(c) An offense is defined as one month’s total number of resident days not submitted and quality assessment payment not received by the 20th day of the next succeeding calendar month.

4.(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 medical assistance 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) Sanctions 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 nursing facility services.

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,________.