The purpose of the amendment to Rule 59G-6.010, Florida Administrative Code, is to clarify Process and Structure Measures and remove references to Medicaid Trend Adjustment (MTA) to reflect use of Budget Neutrality Factor ....

 

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 clarify Process and Structure Measures and remove references to Medicaid Trend Adjustment (MTA) to reflect use of Budget Neutrality Factor for both Prospective Payment System (PPS) and Exempt providers. The amendment also includes the Unit Cost Rate Increase effective July 1, 2020.

SUMMARY: The amendment clarifies the payment methodology for nursing home services and specifies the Unit Cost Rate Increase effective July 1, 2020.

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: July 15, 2021, 2:00 p.m. - 2:30 p.m.

PLACE: The Agency is offering both a remote and an in-person option to attend the hearing at the Agency for Health Care Administration, 2727 Mahan Drive, Tallahassee, Florida 32308-5407.

Remote Listeners: Attendees may register for the hearing at: https://attendee.gotowebinar.com/register/6005872675689826064. After registering, a confirmation email will be received containing information about joining the webinar, and opportunities to offer comments and questions will be available.

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 7 days before the workshop/meeting by contacting: [e-mail]. 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: THE PERSON TO BE CONTACTED REGARDING THE PROPOSED RULE IS: [e-mail]. Please note that a preliminary draft of the reference material, if available, will be posted prior to the hearing at http://ahca.myflorida.com/Medicaid/review/index.shtml. Official comments to be entered into the rule record will be received until 5:00 p.m. on July 16, 2021 and may be e-mailed to [e-mail].

 

THE FULL TEXT OF THE PROPOSED RULE IS:

 

59G-6.010 Payment Methodology for Nursing Home Services.

(1) No change.

(2) Definitions.

(a) through (b) No change.

(c) Budget Neutrality Factor ‒ Budget neutrality multipliers shall be incorporated into the Prospective Payment System (PPS) and exempt provider rate setting 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) No change.

(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. Direct care staff does not include nursing administration, Minimum Data Set (MDS) and care plan coordinators, staff development, infection control preventionist, risk managers, and staffing coordinators.  There shall be no costs directly or indirectly allocated to the direct care component from a home office or management company for staff who do not deliver care directly to residents in the nursing facility.

(f) through (q) No change.

(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 MTA is built into the final Prospective Payment System rate through budget neutrality multipliers. The exempt providers’ rates are reduced by the appropriate percentage allocation as compared to all Medicaid nursing facility providers. The Medicaid share of the NFQA is not subject to the MTA.

(r)(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. through 3. No change.

(s)(t) Occupancy Percentage ‒ Component of the Fair Rental Value System (FRVS) Calculation, the Minimum Occupancy, defined in Section 409.908(2)(b)1.g., F.S.

(t)(u) Offense ‒ Full Qquality Aassessment Ppayment not received by the 20th day of the next succeeding calendar month.

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

(v) through (x) No change.

(y) Quality Incentive Payment – A provider is awarded points for process, outcome, structural and credentialing measures using most recently reported data on May 31 of the rate period year. 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 Medication, and Restraint quality metrics. For each rate period, data to calculate these quality metrics is from the Medicare Nursing Home Compare datasets using the most recent four quarter average available on May 31 of the rate period year. Providers are ranked based on the percentage of residents who have, or do not have, a particular condition. Providers whose fourth quarter measure score is who are at or above the 90th percentile for a particular measure will be awarded 3 points, those scoring from the 75th up to 90th percentiles will be awarded 2 points, and those scoring from the 50th up to 75th 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. The quality measure percentiles that are used to award the points will be recalculated during rebase years starting October 2021 and every subsequent 4th year. During non rebase years the quality measure percentiles will be frozen., Data to calculate these quality metrics is from the Medicare Nursing Home Compare datasets using the most recent four quarter average available on May 31 of the rate period year.

2. Outcome Measures – Includes Urinary Tract Infections, Pressure Ulcers, Falls, Incontinence, and Decline in Activities of Daily Living quality metrics. Outcome Measures are scored and percentiles are calculated 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 CMS Facility Staffing Payroll-Based Journal data for the four most recent quarters as of May 31 of the year in which the rate period begins. Structure Measures are scored and percentiles are calculated using the same methodology as Process Measures and Outcome Measures. Structure Measure percentiles are recalculated annually.

4. Credentialing Measures – Includes CMS Overall 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. For each rate period, the CMS 5-Star Rating Measure will be calculated using the most recent overall rating from the Star Ratings dataset from the Nursing Home Compare datasets provided by CMS as of May 31 of the year in which the rate period begins. Facilities that have either a Florida Gold Seal, Joint Commission Accreditation, or the silver or gold American Health Care Association National Quality Award on May 31 of the current 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) No change.

(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 or State of Florida observed holiday, of the year in which the rate period beings. A link to the Cost Report template Web site can be found at http://ahca.myflorida.com/Medicaid/cost_reim/ecr.shtml.

(bb) Rebase Rate Semester – Direct care, indirect care, and operating cost components will be rebased beginning October 1, 2021 and every subsequent 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) through (dd) No change.

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

(ff) No change.

(gg) Unit Cost Rate Increase - Effective July 1, 2020, a unit cost increase was established as an equal percentage for each nursing home. For the period beginning on October 1, 2020, and ending on September 30, 2021, providers are reimbursed the greater of their September 2016 cost-based rate plus the July 1, 2020, unit cost increase or their prospective payment rate plus the July 1, 2020, unit cost increase.

(hh)(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) No change.

(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) + Unit Cost Rate Increase

(b) through (c) No change.

(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) * Budget Neutrality Factor + Medicaid Share of NFQA – MTA) + Unit Cost Rate Increase

1. No change.

(5) NFQA

(a) through (b) No change.

(c) Providers are subject to the following monetary fines pursuant to Section 409.9082(7), F.S., for failure to timely submit the Quality Assessment Payment:

1. No change.

2. For any offense subsequent to a first offense, a fine of $1,000 per day shall be imposed until the total number of resident days is submitted and Quality Assessment Payment is paid in full, but in no event shall the fine exceed the amount of the quality assessment.

3. No change.

(d) through (f) No change.

(6) The Florida Medicaid rate is equal to the Medicare allowed amount for Medicare approved Part B therapy services provided in nursing facilities. Medicare approved Part B therapy services must be excluded as an allowable cost from the Medicaid cost report. .

(7) This rule is in effect for five years from its effective date.

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, 4-15-20,________.

 

NAME OF PERSON ORIGINATING PROPOSED RULE: Zainab Day

NAME OF AGENCY HEAD WHO APPROVED THE PROPOSED RULE: Simone Marstiller

DATE PROPOSED RULE APPROVED BY AGENCY HEAD: June 09, 2021

DATE NOTICE OF PROPOSED RULE DEVELOPMENT PUBLISHED IN FAR: March 19, 2021