Section 51.74. Approval of a cost-based rate for nontransportation HCBS

To establish a cost-based rate, the Department will:

(1) Utilize cost data submitted by providers on the standardized cost report developed by the Department.

(2) Review each cost report to ensure the cost report is completed in accordance with § 51.73 (relating to cost report requirements).

(3) Adjust current cost report information based on any changes in the service definitions in the approved applicable waiver, including approved waiver amendments, from the prior cost reporting period.

(4) Identify provider cost reports which are an outlier in comparison to other cost reports submitted. An outlier occurs when the cost report information is at least one standard deviation outside the average unit cost.

(5) Review the outlier information by identifying the average of the unit costs and determining how far above or below the standard deviation they fall.

(6) From July 1, 2011, through June 30, 2012, unit costs flagged as outliers that are determined to be within 5% of the provider’s prior year rate for an HCBS will be used to determine the cost-based rate.

(7) From July 1, 2011, through June 30, 2012, the Department will review unit costs flagged as outliers that are not within 5% of the provider’s prior year rate for an HCBS and these costs will undergo further review as follows:

(i) If the outlier unit costs are justified by the review, the outlier rate will be accepted.

(ii) If the outlier unit costs are not justified by the review, the outlier rate will be adjusted to be within the standard deviation.

(8) Prior to the effective date of rates, the Department will publish the methodology for calculating unit costs that includes the outlier review process and rate assignment process as a notice in the Pennsylvania Bulletin.

(9) The Department may apply a cost of living adjustment during the rate development and assignment process.

(10) A rate adjustment factor may be applied during the rate development and assignment process.

(11) Prior to rates being established each fiscal year, the outlier analyses, cost of living adjustment and a rate adjustment factor are calculated and may be applied to all cost-based rates.

(12) The Department will publish changes in the rate-setting methodology, including the cost report review, outlier analyses, vacancy factor, rate adjustment factor and rate assignment process, as a notice in the Pennsylvania Bulletin.

(13) The cost-based rate for the residential habilitation service includes necessary household goods and furniture provided for the participant.

(14) A vacancy factor shall be applied to finalize a provider’s residential rate.

(15) A provider may request additional staffing costs above what is included in the approved cost report rate for current staffing if there is a new participant entering the program that has above average staffing needs.

(16) If a provider did not submit a cost report, the lowest rate calculated Statewide will be assigned for the HCBS offered in the SSD. If there was a new provider that started HCBS and did not have historical experience, the area average rate will be assigned.

The provisions of this § 51.74(9) and (15) effective July 1, 2012, 43 Pa.B. 588. Immediately preceding text appears at serial pages (361312) to (361313).

Notation

Cross References

This section cited in 55 Pa. Code § 51.48 (relating to provider in the Adult Autism Waiver); and 55 Pa. Code 51.71 (relating to definitions).