1179 Payment for nursing facility services provided by nonpublic and county nursing facilities; change in methods and standards of setting payment rates?
Payment for Nursing Facility Services Provided by Nonpublic and County Nursing Facilities; Change in Methods and Standards of Setting Payment Rates Purpose
[40 Pa.B. 3627]
[Saturday, June 26, 2010]This announcement is to provide notice that the Department of Public Welfare (Department) is proposing to adopt regulations and amend the Commonwealth's Title XIX State Plan to change its methods and standards for payment of Medical Assistance (MA) nursing facility services provided by nonpublic and county nursing facilities beginning Fiscal Year (FY) 2010-2011.
Background
Currently the MA Program pays for nursing facility services provided to MA eligible recipients by participating nonpublic nursing facilities at per diem rates that are computed using the case-mix payment system set forth in the Department's regulations at 55 Pa. Code Chapter 1187, Subchapter G (relating to rate setting). A new case-mix payment rate is established for each nonpublic nursing facility once each FY. The rates take effect July 1, the start of the State FY, and remain in effect until the close of the FY on June 30.
Each nonpublic nursing facility's case-mix per diem rate consists of four rate components, one for each of the three net operating cost centers (''resident care'' costs; ''other resident related'' costs; ''administrative'' costs) and a fourth component for the ''capital'' cost center. To determine the rate components of each of the three net operating cost centers, the Department groups nonpublic and county nursing facilities into peer groups based on bed size and geographical location.1 For each peer group, the Department calculates a ''peer group price'' for each of the three net operating cost centers and uses the peer group prices to set the amounts of the respective rate components for the individual nursing facilities. Prior to setting the peer group price for each nursing facility's resident care rate component, the Department neutralizes each nursing facility's resident care costs using the facility's Total Facility Case Mix Index (CMI), which is the average total acuity of all of the facility's residents on the applicable February 1st picture date. See § 1187.96(a)(5) (relating to price- and rate-setting computations).
Once the Department calculates the resident care peer group price for the rate year, the Department computes each facility's resident care rate component, and then adjusts that component every quarter during the rate year by the average acuity of the facility's MA residents using the facility's MA CMI for the ''picture date'' designated for the rate quarter. See § 1187.96(a)(5). The Department pays each nonpublic nursing facility for nursing facility services provided to MA recipients during the quarter using the facility's adjusted quarterly case-mix payment rate calculated for the respective calendar quarter.
The Department makes payments to county nursing facilities for services provided to MA recipients as specified in the Department's regulations at 55 Pa. Code Chapter 1189 (relating to county nursing facility services), and the Commonwealth's approved State Plan. Among other things, Chapter 1189 authorizes the Department to make pay-for-performance (P4P) payments to county nursing facilities in accordance with the Commonwealth's State Plan. In September 2009, the Department submitted a State Plan Amendment, which if approved by the Federal Centers for Medicare and Medicaid Services (CMS), will continue to allow for quarterly P4P payments in FY 2009-2010 and FY 2010-2011 to those county nursing facilities that have an MA CMI for a picture date which is higher than their MA CMI for the prior picture date.
To calculate a nursing facility's Total Facility and quarterly MA CMIs, the Department first determines a CMI score for each nursing resident present in the facility on the relevant picture date. To determine a resident's CMI score, the Department extracts data from the most recent comprehensive assessment of the resident, which was transmitted by the nursing facility using the Federally Approved Pennsylvania Specific MDS version 2.0.2 Then, using the Resource Utilization Group III (RUG III) version 5.01 44 grouper classification system, the Department classifies the resident into one of the 44 groups and assigns a CMI score.
Proposed Changes
1. RUG-III v. 5.12-44 Grouper.
This Commonwealth is currently only one of two states still using the older RUG-III v. 5.01-44 Grouper for rate-setting. CMS has announced that it will implement the MDS 3.0 effective October 1, 2010. MDS 3.0 does not contain all the elements necessary for resident classification with RUG-III v. 5.01-44 Grouper and CMS has stated it will no longer support this Grouper System once MDS 3.0 is implemented. In anticipation of the CMS move to the new MDS 3.0, the Department is proposing to change the Grouper used in determining nursing facility residents' CMI scores to the RUG-III v. 5.12-44 Grouper effective July 1, 2010. This change will apply to residents of both nonpublic and county nursing facilities.
2. Use of the most recent resident assessment.
As noted previously, the Department currently uses data from the most recent comprehensive assessment on file for a nursing facility resident in determining that resident's RUG category and CMI score. Under both MDS 2.0 and MDS 3.0, nursing facilities are required to conduct and electronically submit assessments other than ''comprehensive assessments'' for their residents. These assessments also contain all the MDS data elements needed to calculate the residents' RUG category and CMI score. These assessments may be completed after the latest comprehensive assessment and, therefore, provide more current information on the residents' condition and care needs.
Rather than continuing to use older assessment data to determine residents' RUG category and CMI score, the Department intends to amend the State Plan and its regulations to require use of the most recent assessment of any type for each resident, whether or not the assessment is comprehensive effective July 1, 2010. This change will apply to residents of both nonpublic and county nursing facilities. It will enable the Department to make acuity adjustments that are based upon the most up-to-date resident data without any additional administrative burdens or costs to either nursing facilities or the Department.3
3. Phase-in of RUG-III v. 5.12 44 Grouper and use of the latest resident assessment in Nonpublic Nursing Facility Rate Setting.
The Department recognizes that the change in Grouper and use of the most recent resident assessment may cause a reduction in per diem rates for some nonpublic nursing facilities. To mitigate any adverse impact of this change on nonpublic nursing facilities, the Department is proposing to amend 55 Pa. Code § 1187.96 to authorize a 3-year phase-in for the transition to the RUG-III v. 5.12 44 Grouper and the use of the latest resident assessment. The phase-in will only affect the resident care component of a facility's case-mix per diem rate. For the phase-in period beginning July 1, 2010, and ending June 30, 2013, the resident care rate used to establish a nursing facility's case-mix per diem rate will be a blended resident care rate. A nursing facility's blended resident care rate will consist of a portion of a 5.01 resident care rate and a portion of a 5.12 resident care rate.
The Department does not intend to apply the phase-in provisions to new nonpublic nursing facilities since the phase-in period is being proposed as a transition from one system to another or to county nursing facilities, since MA CMI scores are only used for the limited purpose of determining whether county nursing facilities qualify for P4P payments.
Fiscal Impact
No fiscal impact is anticipated as a result of these changes.
Public Comment
Interested persons are invited to submit written comments regarding these proposed changes to the Department of Public Welfare, Office of Long-Term Living, Attention: Judith Patrick, Department of Public Welfare/Department of Aging, Office of Long-Term Living, Policy and Strategic Planning, 555 Walnut Street, Forum Place, 5th Floor, Harrisburg, PA 17101-1919. Comments received within 30 days will be reviewed and considered for any subsequent revision of the notice.
Persons with a disability who require an auxiliary aid or service may submit comments using the Pennsylvania AT&T Relay Service at (800) 654-5984 (TDD users) or (800) 654-5988 (voice users).
HARRIET DICHTER,
SecretaryFiscal Note: 14-NOT-643. No fiscal impact; (8) recommends adoption.
[Pa.B. Doc. No. 10-1179. Filed for public inspection June 25, 2010, 9:00 a.m.] _______
1 Although the Department established a separate payment methodology for county nursing facilities in 2006, the Department has continued to use county nursing facility audited costs in determining the peer group prices for nonpublic nursing facilities. Consistent with Act 44 of 2008, the Department is seeking to amend the State Plan and Chapter 1187 (relating to nursing facility services) to phase out the use of county costs over a 3-year period ending June 30, 2012. See 39 Pa.B. 4179 (July 18, 2009).
2 The MDS, or Minimum Data Set, is as Federally-mandated standardized assessment of a resident's clinical and functional status that all nursing facilities participating in the MA Program must complete and submit for each of their nursing facility residents at prescribed periods during the resident's stay at the facility. (See 42 CFR 483.20 (relating to resident assessment).)
3 In addition, the MA Change Tracking form is currently used to determine MA for MA case-mix status. CMS has indicated that this tracking form cannot be processed by the planned national MDS 3.0 submission system. It is anticipated that when MDS 3.0 is implemented, MA status will be determined from a Section S (a state specific section) item added to each MDS 3.0 assessment and will be collected from the latest assessment as a replacement for the MA Change Tracking form.
