| (4) New facilities. A new facility's enrollment will
be determined in accordance with subsection (e) of this section.
(j) Determination of staffing requirements for participants.
Facilities choosing to participate in the enhanced direct care staff
rate agree to maintain certain direct care staffing levels above the
minimum staffing levels described in paragraph (1) of this subsection.
In order to permit facilities the flexibility to substitute RN, LVN
and aide (Medication Aide and nurse aide) staff resources and, at
the same time, comply with an overall nursing staff requirement, total
nursing staff requirements are expressed in terms of LVN equivalent
minutes. Conversion factors to convert RN and aide minutes into LVN
equivalent minutes are based upon most recently available, reliable
relative compensation levels for the different staff types.
(1) Minimum staffing levels. HHSC determines, for each
participating facility, minimum LVN equivalent staffing levels as
follows.
(A) Determine minimum required LVN equivalent minutes
per resident day of service for various types of residents using time
study data, cost report information, and other appropriate data sources.
(i) Determine LVN equivalent minutes associated with
Medicare residents based on the data sources from this subparagraph
adjusted for estimated acuity differences between Medicare and Medicaid
residents.
(ii) Determine minimum required LVN equivalent minutes
per resident day of service associated with each Resource Utilization
Group (RUG-III) case mix group and additional minimum required minutes
for Medicaid residents reimbursed under the RUG-III system who also
qualify for supplemental reimbursement for ventilator care or pediatric
tracheostomy care as described in §355.307 of this title (relating
to Reimbursement Setting Methodology) based on the data sources from
this subparagraph adjusted for acuity differences between Medicare
and Medicaid residents and other factors.
(B) Based on most recently available, reliable utilization
data, determine for each facility the total days of service by RUG-III
group, days of service provided to Medicaid residents qualifying for
Medicaid supplemental reimbursement for ventilator or tracheostomy
care, total days of service for Medicare Part A residents in Medicaid-contracted
beds, and total days of service for all other residents in Medicaid-contracted
beds.
(C) Multiply the minimum required LVN equivalent minutes
for each RUG-III group and supplemental reimbursement group from subparagraph
(A) of this paragraph by the facility's Medicaid days of service in
each RUG-III group and supplemental reimbursement group from subparagraph
(B) of this paragraph and sum the products.
(D) Multiply the minimum required LVN equivalent minutes
for Medicare residents by the facility's Medicare Part A days of service
in Medicaid-contracted beds.
(E) Divide the sum from subparagraph (C) of this paragraph
by the facility's total Medicaid days of service, with a day of service
for a Medicaid RUG-III recipient who also qualifies for a supplemental
reimbursement counted as one day of service, compare this result to
the minimum required LVN-equivalent minutes for a RUG-III PD1 and
multiply the lower of the two figures by the facility's other resident
days of service in Medicaid-contracted beds.
(F) Sum the results of subparagraphs (C), (D) and (E)
of this paragraph, divide the sum by the facility's total days of
service in Medicaid-contracted beds, with a day of service for a Medicaid
recipient who also qualifies for a supplemental reimbursement counted
as one day of service. The results of these calculations are the minimum
LVN equivalent minutes per resident day a participating facility must
provide.
(G) In cases where the minimum required LVN-equivalent
minutes per resident day of service associated with a RUG-III case
mix group or supplemental reimbursement group change during the reporting
period, the minimum required LVN-equivalent minutes for the RUG-III
case mix group or supplemental reimbursement group for the reporting
period will be equal to the weighted average LVN-equivalent minutes
in effect during the reporting period for that group calculated as
follows:
(i) Multiply the first minimum required LVN equivalent
minutes per resident day of service associated with the RUG-III case
mix group or supplemental reimbursement group in effect during the
reporting period by the most recently available, reliable Medicaid
days of service utilization data for the time period the first minimum
required LVN equivalent minutes were in effect.
(ii) Multiply the second minimum required LVN equivalent
minutes per resident day of service associated with the RUG-III case
mix group or supplemental reimbursement group in effect during the
reporting period by the most recently available, reliable Medicaid
days of service utilization data for the time period the second minimum
required LVN equivalent minutes were in effect.
(iii) Sum the products from clauses (i) and (ii) of
this subparagraph.
(iv) Divide the sum from clause (iii) of this subparagraph
by the sum of the most recently available, reliable Medicaid days
of service utilization data for the entire reporting period used in
clauses (i) and (ii) of this subparagraph.
(2) Enhanced staffing levels. Facilities desiring to
participate in the enhanced direct care staff rate are required to
staff above the minimum requirements from paragraph (1) of this subsection.
These facilities may request LVN-equivalent staffing enhancements
from an array of LVN-equivalent enhanced staffing options and associated
add-on payments during open enrollment under subsection (d) of this
section.
(3) Granting of staffing enhancements. HHSC divides
all requested enhancements, after applying any enrollment limitations
from subsection (i) of this section, into two groups: pre-existing
enhancements that facilities request to carry over from the prior
year and newly-requested enhancements. Newly-requested enhancements
may be enhancements requested by facilities that were nonparticipants
in the prior year or by facilities that were participants in the prior
year desiring to be granted additional enhancements. Using the process
described herein, HHSC first determines the distribution of carry-over
enhancements. If HHSC determines that funds are not available to carry
over some or all pre-existing enhancements, facilities will be notified
as per subsection (ee) of this section. If funds are available after
the distribution of carry-over enhancements, HHSC then determines
the distribution of newly requested enhancements. HHSC may not distribute
newly requested enhancements to facilities owing funds identified
for recoupment from subsections (n) and/or (o) of this section.
(A) HHSC determines projected Medicaid units of service
for facilities requesting each enhancement option, and multiplies
this number by the rate add-on associated with that enhancement option
as determined in subsection (l) of this section.
(B) HHSC compares the sum of the products from subparagraph
(A) of this paragraph to available funds.
(i) If the product is less than or equal to available
funds, all requested enhancements are granted.
(ii) If the product is greater than available funds,
enhancements are granted beginning with the lowest level of enhancement
and granting each successive level of enhancement until requested
enhancements are granted within available funds. Based upon an examination
of existing staffing levels and staffing needs, HHSC may grant certain
enhancement options priority for distribution.
(4) Notification of granting of enhancements. Participating
facilities are notified, in a manner determined by HHSC, as to the
disposition of their request for staffing enhancements.
(5) In cases where more than one enhanced staffing
level is in effect during the reporting period, the staffing requirement
will be based on the weighted average enhanced staffing level in effect
during the reporting period calculated as follows:
(A) Multiply the first enhanced staffing level in effect
during the reporting period by the most recently available, reliable
Medicaid days of service utilization data for the time period the
first enhanced staffing level was in effect.
(B) Multiply the second enhanced staffing level in
effect during the reporting period by the most recently available,
reliable Medicaid days of service utilization data for the time period
the second enhanced staffing level was in effect.
(C) Sum the products from subparagraphs (A) and (B)
of this paragraph.
(D) Divide the sum from subparagraph (C) of this paragraph
by the sum of the most recently available, reliable Medicaid days
of service utilization data for the entire reporting period used in
subparagraphs (A) and (B) of this paragraph.
(k) Determination of direct care staff base rate.
Cont'd... |
