| (i) "Days of Service" is the total Medicaid days of
service for a particular RUG for clean claims for services that were
provided during the Calculation Period; and
(ii) "Medicare Rate" is the Medicare skilled nursing
facility payment rate for the RUG in effect on the date of service.
(B) The Minimum Payment Amount is equal to the sum
of all subsidiary amounts calculated in accordance with subparagraph
(A) of this paragraph.
(2) Calculate the Adjustment to the Minimum Payment
Amount. The adjustment to the Minimum Payment Amount is equal to the
sum of all adjustments for each RUG. The adjustment to the Minimum
Payment Amount is determined as follows:
(A) First, determine the amount of the First Payment
to the nursing facility using the formula: First Payment = Days of
Service x MCO Rate, where:
(i) "Days of Service" is the total Medicaid days of
service for a particular RUG for clean claims for services that were
provided during the Calculation Period; and
(ii) "MCO Rate" is the rate paid by the MCO for the
particular RUG.
(B) Second, sum the result in subparagraph (A) of this
paragraph for each RUG.
(C) Third, add or subtract, as necessary, the amount
of payment adjustments to Nursing Facility Unit Rate claims for services
that were provided during the Calculation Period from the result in
subparagraph (B) of this paragraph.
(D) Fourth, determine the amount related to the Nursing
Facility Add-on Services using the formula: Nursing Facility Add-on
Amount = Days of Service x Per Diem, where:
(i) "Days of Service" equals the number used in subparagraph
(A)(i) of this paragraph; and
(ii) "Per Diem" is an estimate, as determined by HHSC,
of the weighted average per diem payment amount for Nursing Facility
Add-on Services provided to Medicaid recipients in Qualified Nursing
Facilities.
(I) For Eligibility Period One, the per diem will equal
$3.48.
(II) For Eligibility Period Two, the per diem will
equal $3.48 plus medical inflation between the mid-point of Eligibility
Period One and the mid-point of Eligibility Period Two, as determined
by HHSC.
(III) For Eligibility Period Two-A, the per diem will
equal $3.48 plus medical inflation between the mid-point of Eligibility
Period One and the mid-point of Eligibility Period Two-A, as determined
by HHSC.
(IV) For Eligibility Period Three, the per diem will
equal $3.48 plus medical inflation between the mid-point of Eligibility
Period One and the mid-point of Eligibility Period Three, as determined
by HHSC.
(E) Fifth, sum the result in subparagraph (D) of this
paragraph for each RUG.
(F) Sixth, determine the adjustment to the Minimum
Payment Amount by adding the result from subparagraph (E) of this
paragraph from the result from subparagraph (C) of this paragraph.
(3) Calculate the Second Payment. To determine the
Second Payment, subtract the adjustment to the Minimum Payment Amount
described in paragraph (2)(F) of this subsection from the Minimum
Payment Amount described in paragraph (1) of this subsection.
(e) Eligibility for Receipt of Minimum Payment Amounts.
(1) A nursing facility is eligible to receive the Minimum
Payment Amounts described in this section if it complies with the
requirements described in this subsection for each Eligibility Period.
(2) Eligibility Period One. A nursing facility is eligible
to receive Minimum Payment Amounts for Eligibility Period One if it
meets the following requirements:
(A) The nursing facility must be a Non-state Government-owned
Nursing Facility with a Medicaid contract effective date of October
1, 2014, or earlier. HHSC will finalize its list of eligible facilities
on November 1, 2014. A facility may only be eligible if its contract
is assigned by DADS to a non-state government entity by October 31,
2014, with an effective date of October 1, 2014, or earlier.
(B) The Non-state Governmental Entity that owns the
nursing facility must have entered into an IGT Responsibility agreement
with HHSC by November 3, 2014. The IGT Responsibility agreement will
cover the estimated IGT Responsibility for the nursing facility for
the Eligibility Period.
(C) The Non-state Governmental Entity that owns the
nursing facility must certify the following facts on a form prescribed
by HHSC and the form must be received by HHSC by November 3, 2014.
(i) That it is a Non-state Government-owned Nursing
Facility where a Non-state Governmental Entity holds the license and
is party to the facility's Medicaid contract.
(ii) That all funds transferred to HHSC via IGT for
use as the state share of payments are Public Funds.
(iii) That no part of any payment made under the Minimum
Payment Amount program under this section will be used to pay a contingent
fee, consulting fee, or legal fee associated with the nursing facility's
receipt of the Minimum Payment Amount funds.
(3) Eligibility Period Two. A nursing facility is eligible
to receive the Minimum Payment Amounts for Eligibility Period Two
if it has met the following requirements:
(A) The nursing facility must be a Non-state Government-owned
Nursing Facility with a Medicaid contract effective date of March
1, 2015, or earlier. HHSC will finalize its list of eligible facilities
on March 1, 2015. A facility may only be eligible if its contract
is assigned by DADS to a non-state government entity by February 28,
2015, with an effective date of March 1, 2015, or earlier.
(B) The Non-state Governmental Entity that owns the
nursing facility must have entered into an IGT Responsibility agreement
with HHSC by February 28, 2015. The IGT Responsibility agreement will
cover the estimated IGT Responsibility for the nursing facility for
the Eligibility Period.
(C) The Non-state Governmental Entity that owns the
nursing facility must certify the following facts on a form prescribed
by HHSC and the form must be received by HHSC by February 28, 2014.
(i) That it is a Non-state Government-owned Nursing
Facility where a Non-state Governmental Entity holds the license and
is party to the facility's Medicaid contract.
(ii) That all funds transferred to HHSC via IGT for
use as the state share of payments are Public Funds.
(iii) That no part of any payment made under the Minimum
Payment Amount program under this section will be used to pay a contingent
fee, consulting fee, or legal fee associated with the nursing facility's
receipt of the Minimum Payment Amount funds.
(D) The Non-state Governmental Entity that owns the
nursing facility must submit to HHSC, upon demand, copies of any contracts
it has with third parties that reference the administration of, or
payments from, the Minimum Payment Amount program.
(4) Eligibility Period Two-A. A nursing facility is
eligible to receive the Minimum Payment Amounts for Eligibility Period
Two-A if it has met the following requirements:
(A) The nursing facility must not be eligible to receive
the Minimum Payment Amounts for Eligibility Period Two.
(B) The nursing facility must be a Non-state Government-owned
Nursing Facility with a Medicaid contract effective date of June 1,
2015, or earlier. HHSC will finalize its list of eligible facilities
on June 1, 2015. A facility may only be eligible if its contract is
assigned by DADS to a non-state government entity by May 31, 2015,
with an effective date of June 1, 2015, or earlier.
(C) The nursing facility must have given DADS written
notice of the change of ownership on or before February 1, 2015, but
have not qualified for Eligibility Period Two because its contract
was not assigned by DADS to a non-state government entity by February
28, 2015.
(D) DADS must have received all required documents
pertaining to the change of ownership (i.e., DADS must have a complete
application for a change of ownership license as described under 40
TAC §19.201(b) (relating to Criteria for Licensing)) by April
15, 2015.
(E) The Non-state Governmental Entity that owns the
nursing facility must have entered into an IGT Responsibility agreement
with HHSC by May 31, 2015. The IGT Responsibility agreement must cover
the estimated IGT Responsibility for the nursing facility for the
Eligibility Period.
(F) The Non-state Governmental Entity that owns the
nursing facility must certify the following facts on a form prescribed
by HHSC and the form must be received by HHSC by May 31, 2015:
(i) that it is a Non-state Government-owned Nursing
Facility where a Non-state Governmental Entity holds the license and
is party to the facility's Medicaid contract;
(ii) that all funds transferred to HHSC via IGT for
use as the state share of payments are Public Funds; and
Cont'd... |
