1249 Supplemental ventilator care and tracheostomy care payment for Medical Assistance nursing facilities
Title 55—PUBLIC WELFARE DEPARTMENT OF PUBLIC WELFARE [ 55 PA. CODE CHS. 1187 AND 1189 ] Supplemental Ventilator Care and Tracheostomy Care Payment for Medical Assistance Nursing Facilities [44 Pa.B. 3565]
[Saturday, June 14, 2014]The Department of Public Welfare (Department), under the authority of sections 201(2), 206(2), 403(b) and 443.1 of the Public Welfare Code (62 P. S. §§ 201(2), 206(2), 403(b) and 443.1), adds § 1187.117 (relating to supplemental ventilator care and tracheostomy care payments) and amends § 1189.105 (relating to incentive payments) to read as set forth in Annex A. Notice of proposed rulemaking was published at 43 Pa.B. 4855 (August 24, 2013).
Purpose of Final-Form Rulemaking
The purpose of this final-form rulemaking is to change the Department's methods and standards for payment of Medical Assistance (MA) nursing facility services to offer two new categories of supplemental payment to qualified MA nursing facilities.
This final-form rulemaking is needed to address the financial impact that the implementation of the current Resource Utilization Group III (RUG-III) version 5.12 (RUG v. 5.12) resident classification system and the phase-out of the older RUG v. 5.01 has on nursing facilities that care for a significant number of MA ventilator care and tracheostomy care residents.
Background
The Department published a notice at 42 Pa.B. 3824 (June 30, 2012) announcing its intention to implement a new category of supplemental ventilator care payment to qualified MA nonpublic and county nursing facilities that provide medically necessary ventilator care for a significant portion of their MA-recipient resident population. The Department submitted State Plan Amendment (SPA) 12-030 on September 27, 2012, regarding supplemental ventilator care payments to nonpublic and county nursing facilities to the Centers for Medicare and Medicaid Services (CMS). CMS approved the SPA on December 13, 2012, with an effective date of July 1, 2012. On August 24, 2013, the Department published a proposed rulemaking at 43 Pa.B. 4855 regarding the supplemental ventilator care payment for MA nursing facilities.
After soliciting and considering public comments, the Department decided to offer the supplemental payment to qualified MA nonpublic and county nursing facilities that provide medically necessary ventilator care or tracheostomy care for a significant portion of their MA-recipient resident population. Making these additional funds available to promote the growth of ventilator care and tracheostomy care is part of the Department's ongoing efforts to ensure that MA recipients continue to receive access to medically necessary nursing facility services and that those services result in quality care that improves the lives of those who receive them.
The Department intends to submit a SPA to CMS end-dating the supplemental ventilator care payment and adding a supplemental ventilator care and tracheostomy care payment.
Affected Individuals and Organizations
This final-form rulemaking affects nonpublic and county nursing facilities enrolled in the MA Program.
Accomplishments and Benefits
This final-form rulemaking benefits MA nursing facility residents in this Commonwealth by ensuring they continue to have access to medically necessary nursing facility services and that those services result in quality care that improves the lives of those who receive them.
Fiscal Impact
This change resulted in an annual supplemental ventilator care payment of $1.825 million in total funds ($0.848 million in State funds) in Fiscal Year (FY) 2012-2013. The estimated annual supplemental ventilator care payment is $1.825 million in total funds ($0.848 million in State funds) for FY 2013-2014. The estimated supplemental ventilator care and tracheostomy care payments are $3.965 million in total funds ($1.911 million in State funds) for FY 2014-2015.
Paperwork Requirements
There are no new or additional paperwork requirements. The Case-Mix Index (CMI) Report used to determine the number of MA-recipient residents who receive ventilator care or tracheostomy care is an existing report.
Public Comment
The Department received seven letters through the public comment process, which included written comments from nursing facility providers, hospitals and a consulting group. The Independent Regulatory Review Commission (IRRC) also commented on the proposed rulemaking.
Discussion of Comments and Major Changes
Following is a summary of the major comments received within the public comment period following publication of the proposed rulemaking and the Department's response to those comments.
General—Ventilator exception program and peer group 13
One commentator requested further details and a summary of the changes the final-form rulemaking will have on those currently in the ventilator exception program or peer group 13.
Response
The Department contacted the commentator and advised the commentator that the information requested can be found in the Regulatory Analysis Form (RAF) posted on the IRRC web site at http://www.irrc.state.pa.us/.
No one will be adversely affected by the final-form rulemaking. In addition, this final-form rulemaking positively affects MA nonpublic and county nursing facilities that provide ventilator care or tracheostomy care for a significant portion of their MA-recipient resident population by receiving additional reimbursement for providing these medically necessary services.
§§ 1187.117 and 1189.105(c)—Ventilator care and tracheostomy care patients
Three commentators expressed gratitude for the Department recognizing the additional costs incurred by providers who care for ventilator patients. However, six commentators requested that the Department also consider including MA residents who require tracheostomy care in the formula used to calculate the supplemental payment. Several of the commentators stated that there is little to no cost difference between residents on a ventilator and those receiving tracheostomy care because both require the same level of care and monitoring. Some commentators expressed concerns about the unintended negative financial consequences of not including tracheostomy care residents in the formula. These commentators are concerned with the facilities' ability to remain financially viable with the increase of MA recipients resulting in increasing dependency on the level of MA reimbursement. Two commentators stated facilities that can accommodate ventilator and tracheostomy care residents are very limited and should be supported to maintain placement options.
IRRC also requested that the Department consider including trach collar patients at the same reimbursement level as ventilator patients.
Response
After careful consideration, the Department decided to offer the supplemental payment to qualified MA nonpublic and county nursing facilities that provide medically necessary ventilator care or tracheostomy care for a significant portion of their MA-recipient resident population. The supplemental ventilator care payment is effective July 1, 2012, through June 30, 2014, and the supplemental ventilator care and tracheostomy care payment will be effective July 1, 2014, and thereafter. The Department amended §§ 1187.117 and 1189.105(c) by end dating the supplemental ventilator care payments effective June 30, 2014. Sections 1187.117 and 1189.105(c) were also amended to include provisions for a supplemental ventilator care and tracheostomy care payment effective July 1, 2014. In addition, these sections were renumbered accordingly. The supplemental ventilator care and tracheostomy care payment will be calculated on a quarterly basis and paid to nursing facilities caring for a minimum of ten MA-recipient residents who receive medically necessary ventilator care or tracheostomy care, with at least 10% of the facility's MA-recipient resident population receiving medically necessary ventilator care or tracheostomy care. For those nursing facilities meeting both of the threshold criteria on the appropriate picture date, the total supplemental ventilator care and tracheostomy care payment is the nursing facility's supplemental ventilator care and tracheostomy care per diem multiplied by the number of paid MA facility days and therapeutic leave days. If the Department grants a nursing facility a waiver to the 180-day billing requirement, the MA-paid days billed under the waiver and after the authorization date of the waiver will not be included in the calculation of the supplemental ventilator care and tracheostomy care payment and the payment amount will not be retroactively revised. Since this payment is a supplemental payment and not part of the case-mix per diem rates, it is not subject to the budget adjustment factor under § 1187.96 (relating to price- and rate-setting computations).
A nursing facility's supplemental ventilator care and tracheostomy care per diem is calculated as follows: ((number of MA-recipient residents who receive medically necessary ventilator care or tracheostomy care/total MA-recipient residents) × $69) × (the number of MA-recipient residents who receive medically necessary ventilator care or tracheostomy care/total MA-recipient residents).
The maximum supplemental ventilator care and tracheostomy care per diem is $69 for nursing facilities whose percent of MA-recipient residents who received medically necessary ventilator care or tracheostomy care to total MA-recipient residents equals 100%.
In addition, the Department added language to final-form §§ 1187.117(a)(1)(iv) and 1189.105(c)(1)(i)(D) (pro-posed §§ 1187.117(a)(4) and 1189.105(c)(1)(iv)) and final-form § 1187.117(b)(1)(iv) to clarify the total MA-recipient residents listed on the nursing facility's CMI report does not include MA-pending individuals or those individuals found to be eligible after the nursing facility submits a valid CMI report as provided under § 1187.33(a)(5) (relating to resident data and picture date reporting require- ments). Further examples to clarify the term ''two percentage decimal points'' were added to final- form § 1187.117(a)(1)(ii) (proposed § 1187.117(a)(2)), § 1187.117(b)(1)(ii), § 1189.105(c)(1)(i)(B) (proposed § 1189.105(c)(1)(ii)) and § 1189.105(c)(2)(i)(B).
Regulatory Review Act
Under section 5(a) of the Regulatory Review Act (71 P. S. § 745.5(a)), on August 14, 2013, the Department submitted a copy of the notice of proposed rulemaking, published at 43 Pa.B. 4855, to IRRC and the Chairpersons of the House Committee on Human Services and the Senate Committee on Public Health and Welfare for review and comment.
Under section 5(c) of the Regulatory Review Act, IRRC and the House and Senate Committees were provided with copies of the comments received during the public comment period, as well as other documents when requested. In preparing the final-form rulemaking, the Department has considered all comments from IRRC, the House and Senate Committees and the public.
Under section 5.1(j.2) of the Regulatory Review Act (71 P. S. § 745.5a(j.2)), on April 30, 2014, the final-form rulemaking was deemed approved by the House and Senate Committees. Under section 5.1(e) of the Regulatory Review Act, IRRC met on May 1, 2014, and approved the final-form rulemaking.
Findings
The Department finds that:
(a) The public notice of intention to adopt § 1187.117 and amend § 1189.105 by this order has been given under sections 201 and 202 of the act of July 31, 1968 (P. L. 769, No. 240) and regulations promulgated thereunder, 1 Pa. Code §§ 7.1 and 7.2.
(b) The adoption of this final-form rulemaking in the manner provided by this order is necessary and appropriate for the administration and enforcement of the Public Welfare Code.
Order
The Department, acting under sections 201(2), 206(2), 403(b) and 443.1 of the Public Welfare Code, orders that:
(a) The regulations of the Department, 55 Pa. Code Chapters 1187 and 1189, are amended by adding § 1187.117 and amending § 1189.105 to read as set forth in Annex A.
(b) The Secretary of the Department shall submit this order and Annex A to the Offices of General Counsel and Attorney General for approval as to legality and form as required by law.
(c) The Secretary of the Department shall certify and deposit this order and Annex A with the Legislative Reference Bureau as required by law.
(d) Sections 1187.117(a) and 1189.105(c)(1) shall take effect upon publication and apply retroactively from July 1, 2012, through June 30, 2014. Sections 1187.117(c)—(e) and 1189.105(c)(3)—(5) shall take effect upon publication and apply retroactively from July 1, 2012. Sections 1187.117(b) and 1189.105(c)(2) take effect July 1, 2014.
BEVERLY D. MACKERETH,
Secretary(Editor's Note: For the text of the order of the Independent Regulatory Review Commission relating to this document, see 44 Pa.B. 2965 (May 17, 2014).)
Fiscal Note: 14-535. (1) General Fund; (2) Implementing Year 2013-14 is $848,000; (3) 1st Succeeding Year 2014-15 is $1,911,000; 2nd Succeeding Year 2015-16 is $1,911,000; 3rd Succeeding Year 2016-17 is $1,911,000; 4th Succeeding Year 2017-18 is $1,911,000; 5th Succeeding Year 2018-19 is $1,911,000; (4) 2012-13 Program—$765,923,000; 2011-12 Program—$737,356,000; 2010-11 Program—$728,907,000; (7) MA—Long-Term Care; (8) recommends adoption. Funds have been included in the budget to cover this increase.
Annex A TITLE 55. PUBLIC WELFARE PART III. MEDICAL ASSISTANCE MANUAL CHAPTER 1187. NURSING FACILITY SERVICES Subchapter H. PAYMENT CONDITIONS, LIMITATIONS AND ADJUSTMENTS § 1187.117. Supplemental ventilator care and tracheostomy care payments.
(a) Supplemental ventilator care payments.
(1) A supplemental ventilator care payment will be made each calendar quarter, effective July 1, 2012, through June 30, 2014, to nursing facilities subject to the following:
(i) To qualify for the supplemental ventilator care payment, the nursing facility shall satisfy both of the following threshold criteria on the applicable picture date:
(A) The nursing facility shall have a minimum of ten MA-recipient residents who receive medically necessary ventilator care.
(B) The nursing facility shall have a minimum of 10% of their MA-recipient resident population receiving medically necessary ventilator care.
(ii) Under subparagraph (i), the percentage of the nursing facility's MA-recipient residents who require medically necessary ventilator care will be calculated by dividing the total number of MA-recipient residents who receive medically necessary ventilator care by the total number of MA-recipient residents as described in paragraph (2)(i). The result of this calculation will be rounded to two percentage decimal points. (For example, 0.0945 will be rounded to 0.09 (or 9%); 0.1262 will be rounded to 0.13 (or 13%).)
(iii) To qualify as an MA-recipient resident who receives medically necessary ventilator care, the resident shall be listed as an MA resident and have a positive response for the MDS item for ventilator use on the Federally-approved PA-specific MDS assessment listed on the nursing facility's CMI report for the applicable picture date.
(iv) The number of total MA-recipient residents is the number of MA-recipient residents listed on the nursing facility's CMI report for the applicable picture date. MA-pending individuals or those individuals found to be MA eligible after the nursing facility submits a valid CMI report for the picture date as provided under § 1187.33(a)(5) (relating to resident data and picture date reporting requirements) may not be included in the count and may not result in an adjustment of the percent of ventilator dependent MA residents.
(v) The applicable picture dates and the authorization of a quarterly supplemental ventilator care payment are as follows:
Picture Dates Authorization Schedule February 1 September May 1 December August 1 March November 1 June (vi) If a nursing facility fails to submit a valid CMI report for the picture date as provided under § 1187.33(a)(5), the facility cannot qualify for a supplemental ventilator care payment.
(2) A nursing facility's supplemental ventilator care payment is calculated as follows:
(i) The supplemental ventilator care per diem is ((number of MA-recipient residents who receive medically necessary ventilator care/total MA-recipient residents) × $69) × (the number of MA-recipient residents who receive medically necessary ventilator care/total MA-recipient residents).
(ii) The amount of the total supplemental ventilator care payment is the supplemental ventilator care per diem multiplied by the number of paid MA facility and therapeutic leave days.
(b) Supplemental ventilator care and tracheostomy care payment.
(1) A supplemental ventilator care and tracheostomy care payment will be made each calendar quarter, effective July 1, 2014, to nursing facilities subject to the following:
(i) To qualify for the supplemental ventilator care and tracheostomy care payment, the nursing facility shall satisfy both of the following threshold criteria on the applicable picture date:
(A) The nursing facility shall have a minimum of ten MA-recipient residents who receive medically necessary ventilator care or tracheostomy care.
(B) The nursing facility shall have a minimum of 10% of their MA-recipient resident population receiving medically necessary ventilator care or tracheostomy care.
(ii) Under subparagraph (i), the percentage of the nursing facility's MA-recipient residents who require medically necessary ventilator care or tracheostomy care will be calculated by dividing the total number of MA-recipient residents who receive medically necessary ventilator care or tracheostomy care by the total number of MA-recipient residents as described in paragraph (2)(i). The result of this calculation will be rounded to two percentage decimal points. (For example, 0.0945 will be rounded to 0.09 (or 9%); 0.1262 will be rounded to 0.13 (or 13%).)
(iii) To qualify as an MA-recipient resident who receives medically necessary ventilator care or tracheostomy care, the resident shall be listed as an MA resident and have a positive response for the MDS item for ventilator use or tracheostomy care on the Federally-approved PA-specific MDS assessment listed on the nursing facility's CMI report for the applicable picture date.
(iv) The number of total MA-recipient residents is the number of MA-recipient residents listed on the nursing facility's CMI report for the applicable picture date. MA-pending individuals or those individuals found to be MA eligible after the nursing facility submits a valid CMI report for the picture date as provided under § 1187.33(a)(5) may not be included in the count and may not result in an adjustment of the percent of ventilator dependent or tracheostomy care MA residents.
(v) The applicable picture dates and the authorization of a quarterly supplemental ventilator care and tracheostomy care payment are as follows:
Picture Dates Authorization Schedule February 1 September May 1 December August 1 March November 1 June (vi) If a nursing facility fails to submit a valid CMI report for the picture date as provided under § 1187.33(a)(5), the facility cannot qualify for a supplemental ventilator care and tracheostomy care payment.
(2) A nursing facility's supplemental ventilator care and tracheostomy care payment is calculated as follows:
(i) The supplemental ventilator care and tracheostomy care per diem is ((number of MA-recipient residents who receive medically necessary ventilator care or tracheostomy care/total MA-recipient residents) × $69) × (the number of MA-recipient residents who receive medically necessary ventilator care or tracheostomy care/total MA-recipient residents).
(ii) The amount of the total supplemental ventilator care and tracheostomy care payment is the supplemental ventilator care and tracheostomy care per diem multiplied by the number of paid MA facility and therapeutic leave days.
(c) Waiver to 180-day billing requirement. If the Department grants a nursing facility a waiver to the 180-day billing requirement, then the MA-paid days that may be billed under the waiver and after the authorization date of the waiver will not be included in the calculation of the supplemental ventilator care payment under subsection (a) or the supplemental ventilator care and tracheostomy care payment under subsection (b). The Department will not retroactively revise the supplemental payment amount under subsections (a) and (b).
(d) Calculation of qualifying facility's supplemental ventilator care or supplemental ventilator care and tracheostomy care payments. The paid MA facility and therapeutic leave days used to calculate a qualifying facility's supplemental ventilator care or supplemental ventilator care and tracheostomy care payments under subsections (a)(2)(ii) and (b)(2)(ii) will be obtained from the calendar quarter that contains the picture date used in the qualifying criteria as described in subsections (a) and (b).
(e) Quarterly payments. The supplemental ventilator care or supplemental ventilator care and tracheostomy care payments will be made quarterly in each month listed in subsections (a) and (b).
CHAPTER 1189. COUNTY NURSING FACILITY SERVICES Subchapter E. PAYMENT CONDITIONS, LIMITATIONS AND ADJUSTMENTS § 1189.105. Incentive payments.
(a) Disproportionate share incentive payment.
(1) A disproportionate share incentive payment will be made based on MA paid days of care times the per diem incentive to facilities meeting the following criteria for a 12-month facility cost reporting period:
(i) The county nursing facility shall have an annual overall occupancy rate of at least 90% of the total available bed days.
(ii) The county nursing facility shall have an MA occupancy rate of at least 80%. The MA occupancy rate is calculated by dividing the MA days of care paid by the Department by the total actual days of care.
(2) The disproportionate share incentive payments will be based on the following:
Overall MA Per Diem Occupancy Occupancy (y) Incentive Group A 90% >= 90% y $3.32 Group B 90% 88% <= y <90% $2.25 Group C 90% 86% <= y <88% $1.34 Group D 90% 84% <= y <86% $0.81 Group E 90% 82% <= y <84% $0.41 Group F 90% 80% <= y <82% $0.29 (3) The disproportionate share incentive payments as described in paragraph (2) will be inflated forward using the first quarter issue CMS Nursing Home Without Capital Market Basket Index to the end point of the rate setting year for which the payments are made.
(4) These payments will be made annually within 120 days after the submission of an acceptable cost report provided that payment will not be made before 210 days of the close of the county nursing facility fiscal year.
(5) For the period July 1, 2005, to June 30, 2009, the disproportionate share incentive payment to qualified county nursing facilities shall be increased to equal two times the disproportionate share per diem incentive calculated in accordance with paragraph (3).
(i) For the period commencing July 1, 2005, through June 30, 2006, the increased incentive applies to cost reports filed for the fiscal period ending December 31, 2005.
(ii) For the period commencing July 1, 2006, through June 30, 2007, the increased incentive applies to cost reports filed for the fiscal period ending December 31, 2006.
(iii) For the period commencing July 1, 2007, through June 30, 2008, the increased incentive applies to cost reports filed for the fiscal period ending December 31, 2007.
(iv) For the period commencing July 1, 2008, through June 30, 2009, the increased incentive applies to cost reports filed for the fiscal period ending December 31, 2008.
(b) Pay for performance incentive payment. The Department will establish pay for performance measures that will qualify a county nursing facility for additional incentive payments in accordance with the formula and qualifying criteria in the Commonwealth's approved State Plan. For pay for performance payment periods beginning on or after July 1, 2010, in determining whether a county nursing facility qualifies for a quarterly pay for performance incentive, the facility's MA CMI for a picture date will equal the arithmetic mean of the individual CMIs for MA residents identified in the facility's CMI report for the picture date. An MA resident's CMI will be calculated using the RUG-III version 5.12 44 group values in Chapter 1187, Appendix A (relating to resource utilization group index scores for case-mix adjustment in the nursing facility reimbursement system) and the most recent classifiable assessment of any type for the resident.
(c) Supplemental ventilator care and tracheostomy care payments.
(1) Supplemental ventilator care payments.
(i) A supplemental ventilator care payment will be made each calendar quarter, effective July 1, 2012, through June 30, 2014, to county nursing facilities subject to the following:
(A) To qualify for the supplemental ventilator care payment, the county nursing facility shall satisfy both of the following threshold criteria on the applicable picture date:
(I) The county nursing facility shall have a minimum of ten MA-recipient residents who receive medically necessary ventilator care.
(II) The county nursing facility shall have a minimum of 10% of its MA-recipient resident population receiving medically necessary ventilator care.
(B) For purposes of subparagraph (i), the percentage of the county nursing facility's MA-recipient residents who require medically necessary ventilator care will be calculated by dividing the total number of MA-recipient residents who receive medically necessary ventilator care by the total number of MA-recipient residents as described in subparagraph (ii)(A). The result of this calculation will be rounded to two percentage decimal points. (For example, 9% not 9.45%; 13% not 12.62%.)
(C) To qualify as an MA-recipient resident who receives medically necessary ventilator care, the resident shall be listed as an MA resident and have a positive response for the MDS item for ventilator use on the Federally-approved PA-specific MDS assessment listed on the county nursing facility's CMI report for the applicable picture date.
(D) The number of total MA-recipient residents is the number of MA-recipient residents listed on the county nursing facility's CMI report for the applicable picture date. MA-pending individuals or those individuals found to be MA eligible after the county nursing facility submits a valid CMI report for the picture date as provided under § 1187.33(a)(5) (relating to resident data and picture date reporting requirements) may not be included in the count and may not result in an adjustment of the percent of ventilator dependent MA residents.
(E) The applicable picture dates and the authorization of a quarterly supplemental ventilator care payment are as follows:
Picture Dates Authorization Schedule February 1 September May 1 December August 1 March November 1 June (F) If a county nursing facility fails to submit a valid CMI report for the picture date as provided under § 1187.33(a)(5), the facility cannot qualify for a supplemental ventilator care payment.
(ii) A county nursing facility's supplemental ventilator care payment is calculated as follows:
(A) The supplemental ventilator care per diem is ((number of MA-recipient residents who receive medically necessary ventilator care/total MA-recipient residents) × $69) × (the number of MA-recipient residents who receive medically necessary ventilator care/total MA-recipient residents).
(B) The amount of the total supplemental ventilator care payment is the supplemental ventilator care per diem multiplied by the number of paid MA facility and therapeutic leave days.
(2) Supplemental ventilator care and tracheostomy care payment.
(i) A supplemental ventilator care and tracheostomy care payment will be made each calendar quarter, effective July 1, 2014, to county nursing facilities subject to the following:
(A) To qualify for the supplemental ventilator care and tracheostomy care payment, the county nursing facility shall satisfy both of the following threshold criteria on the applicable picture date:
(I) The county nursing facility shall have a minimum of ten MA-recipient residents who receive medically necessary ventilator care or tracheostomy care.
(II) The county nursing facility shall have a minimum of 10% of its MA-recipient resident population receiving medically necessary ventilator care or tracheostomy care.
(B) For purposes of subparagraph (i), the percentage of the county nursing facility's MA-recipient residents who require medically necessary ventilator care or tracheostomy care will be calculated by dividing the total number of MA-recipient residents who receive medically necessary ventilator care or tracheostomy care by the total number of MA-recipient residents as described in subparagraph (ii)(A). The result of this calculation will be rounded to two percentage decimal points. (For example, 0.0945 will be rounded to 0.09 (or 9%); 0.1262 will be rounded to 0.13 (or 13%).)
(C) To qualify as an MA-recipient resident who receives medically necessary ventilator care or tracheostomy care, the resident shall be listed as an MA resident and have a positive response for the MDS item for ventilator use or tracheostomy care on the Federally-approved PA-specific MDS assessment listed on the county nursing facility's CMI report for the applicable picture date.
(D) The number of total MA-recipient residents is the number of MA-recipient residents listed on the county nursing facility's CMI report for the applicable picture date. MA-pending individuals or those individuals found to be MA eligible after the county nursing facility submits a valid CMI report for the picture date as provided under § 1187.33(a)(5) may not be included in the count and may not result in an adjustment of the percent of ventilator dependent or tracheostomy care MA residents.
(E) The applicable picture dates and the authorization of a quarterly supplemental ventilator care and tracheostomy care payment are as follows:
Picture Dates Authorization Schedule February 1 September May 1 December August 1 March November 1 June (F) If a county nursing facility fails to submit a valid CMI report for the picture date as provided under § 1187.33(a)(5), the facility cannot qualify for a supplemental ventilator care and tracheostomy care payment.
(ii) A county nursing facility's supplemental ventilator care and tracheostomy care payment is calculated as follows:
(A) The supplemental ventilator care and tracheostomy care per diem is ((number of MA-recipient residents who receive medically necessary ventilator care or tracheostomy care/total MA-recipient residents) × $69) × (the number of MA-recipient residents who receive medically necessary ventilator care or tracheostomy care/total MA-recipient residents).
(B) The amount of the total supplemental ventilator care and tracheostomy care payment is the supplemental ventilator care and tracheostomy care per diem multiplied by the number of paid MA facility and therapeutic leave days.
(3) Waiver to 180-day billing requirement. If the Department grants a county nursing facility a waiver to the 180-day billing requirement, the MA-paid days that may be billed under the waiver and after the authorization date of the waiver will not be included in the calculation of the supplemental ventilator care payment under paragraph (1)(ii) or the supplemental ventilator care and tracheostomy care payment under paragraph (2)(ii). The Department will not retroactively revise the supplemental payment amount under paragraphs (1) and (2).
(4) Calculation of quarterly payments. The paid MA facility and therapeutic leave days used to calculate a qualifying facility's supplemental ventilator care or supplemental ventilator care and tracheostomy care payments under paragraphs (1)(ii) and (2)(ii) will be obtained from the calendar quarter that contains the picture date used in the qualifying criteria as described in paragraphs (1) and (2).
(5) Quarterly payments. The supplemental ventilator care or supplemental ventilator care and tracheostomy care payments will be made quarterly in each month listed in paragraphs (1) and (2).
[Pa.B. Doc. No. 14-1249. Filed for public inspection June 13, 2014, 9:00 a.m.]
