1953 Payments to nursing facilities; final rates for State Fiscal Year 2004-2005

DEPARTMENT OF
PUBLIC WELFARE

Payments to Nursing Facilities; Final Rates for State Fiscal Year 2004-2005

[35 Pa.B. 5872]

   The Department of Public Welfare (Department) intends to make changes in the payment rates for Medical Assistance (MA) nursing facility providers for the State Fiscal Year (FY) 2004-2005. The Department received 12 comment letters regarding the proposed FY 2004-2005 rate notice and considered those comments in the development of the final rates.

   Under the Department's case-mix payment methodology, the Department establishes a new case-mix per diem payment rate for each MA nursing facility provider once for each fiscal year. Each provider's annual case-mix per diem rate is comprised of four cost components: (i) resident care; (ii) other resident related; (iii) administrative; and (iv) capital. For each quarter of the fiscal year, the Department adjusts the resident care cost component of each provider's rate by multiplying the resident care cost component by the provider's MA Case Mix Index for the appropriate picture date as follows: July 1 rate--February 1 picture date; October 1 rate--May 1 picture date; January 1 rate--August 1 picture date; and April 1 rate--November 1 picture date. See 55 Pa. Code § 1187.96 (relating to price and rate setting computations). The Department pays the provider for nursing facility services provided to MA recipients during that quarter using the provider's adjusted quarterly per diem rate.

   The Department has calculated new annual case-mix per diem payment rates for FY 2004-2005 for MA nursing facility providers. The methodology that the Department used to set the final rates is contained in 55 Pa. Code Chapter 1187, Subchapter G (relating to rate setting) as amended at 35 Pa.B. 4612 (August 13, 2005) and the Commonwealth's approved Title XIX State Plan.

   The final FY 2004-2005 annual per diem rates are available on the Office of Medical Assistance Programs' (OMAP) website at www.dpw.state.pa.us/omap. The final FY 2004-2005 annual per diem rates are also available at local county assistance offices throughout this Commonwealth or by contacting Tom Jayson, Policy Unit, Bureau of Long Term Care Programs, [phone].

   The Department has also calculated adjusted quarterly rates for the July, October, January and April quarters of FY 2004-2005 for each MA nursing facility provider. These adjusted quarterly rates are also available on the OMAP's website, at local county assistance offices and from Tom Jayson.

   The database that the Department used to calculate the rates is available on the OMAP's website. Since some of the audited cost reports in the database relate to fiscal periods beginning prior to January 1, 2001, the Department revised the audited costs in the database as specified in 55 Pa. Code § 1187.91(1)(iv)(D) (relating to database) to disregard certain audit adjustments disallowing minor movable property or linen costs. The criteria that the Department used to make these revisions are available on the OMAP's website or by contacting Tom Jayson.

Appeals

   An MA nursing facility provider that has not submitted a signed Certification and Settlement Agreement for Year 10 (July 1, 2004--June 30, 2005) may file an administrative appeal if it believes that the Department made any errors or the provider otherwise disagrees with its Year 10 rates. A provider's appeal must be sent, in writing, to the Department's Bureau of Hearings and Appeals, P. O. Box 2675, Harrisburg, PA 17105, and received by the Bureau of Hearings and Appeals (Bureau) within 33 days of the date of the Department's letter notifying the provider of its final rates. The filing of an appeal constitutes the exclusive way by which a provider can present the Department with a demand that a final rate be modified, reversed, rescinded or otherwise altered, or with a demand that the Department increase the amount of reimbursement paid to the provider under that rate. If a provider chooses to appeal, the provider will be afforded the opportunity for a de novo hearing before the Bureau. The provider's rates may be changed as a result of the final adjudication of the appeal. Providers should refer to 67 Pa.C.S. Chapter 11 (relating to Medical Assistance hearings and appeals) and to the Department's standing practice order, set forth at 33 Pa.B. 3053 (June 28, 2003), for more detail regarding their appeal rights and the requirements related to their written appeals.

Fiscal Impact

   This change in payment rates, effective July 1, 2004, and the quarterly case-mix adjustments are estimated to cost the Department $196.366 million ($90.191 million in State funds) in FY 2004-2005.

Public Comment

   Interested persons are invited to submit written comments regarding this notice to Gail Weidman, Chief, Program Analysis and Review Section, Department of Public Welfare, P. O. Box 2675, Harrisburg, PA 17105. Persons with a disability who require an auxiliary aid or service may submit comments using the AT&T Relay Services at [phone] (TDD users) or [phone] (voice users).

ESTELLE B. RICHMAN,   
Secretary

   Fiscal Note: 14-NOT-444. (1) General Fund; (2) Implementing Year 2004-05 is $90.191 million; (3) 1st Succeeding Year 2005-06 is $96.939 million; 2nd Succeeding Year 2006-07 is $96.939 million; 3rd Succeeding Year 2007-08 is $96.939 million; 4th Succeeding Year 2008-09 is $96.939 million; 5th Succeeding Year 2009-10 is $96.939 million; (4) 2004-05 Program--$983.936 million; 2003-04Program--$836.317 million; 2000-01 Program--$777.084 million; (7) Medical Assistance--Long-Term Care; (8) recommends adoption. Funds have been included in the Department's budget to cover this increase.

[Pa.B. Doc. No. 05-1953. Filed for public inspection October 21, 2005, 9:00 a.m.]