| (1) Determine the sum of recipient care costs from
the direct care staff cost center in subsection (a) of this section
in all nursing facilities included in the Texas Nursing Facility Cost
Report database used to determine the nursing facility rates in effect
on January 1, 2000 (hereinafter referred to as the initial database).
(2) Adjust the sum from paragraph (1) of this subsection
as specified in §355.108 of this title (relating to Determination
of Inflation Indices) to inflate the costs to the prospective rate
year.
(3) Divide the result from paragraph (2) of this subsection
by the sum of recipient days of service in all facilities in the initial
database and multiply the result by 1.07. The result is the average
direct care staff base rate component for all facilities.
(4) For rates effective September 1, 2009 and thereafter,
to calculate the direct care staff per diem base rate component for
all facilities for each of the RUG-III case mix groups and for the
default groups, divide each RUG-III index from §355.307(b)(3)(C)
of this title (relating to Reimbursement Setting Methodology) by 0.9908,
which is the weighted average Texas Index for Level of Effort (TILE)
case mix index associated with the initial database, and then multiply
each of the resulting quotients by the average direct care staff base
rate component from paragraph (3) of this subsection.
(5) The direct care staff per diem base rates will
remain constant except for adjustments for inflation from paragraph
(2) of this subsection. HHSC may also recommend adjustments to the
rates in accordance with §355.109 of this title (relating to
Adjusting Reimbursement When New Legislation, Regulations, or Economic
Factors Affect Costs).
(l) Determine each participating facility's total direct
care staff rate. Each participating facility's total direct care staff
rate will be equal to the direct care staff base rate from subsection
(k) of this section plus any add-on payments associated with enhanced
staffing levels selected by and awarded to the facility during open
enrollment. HHSC will determine a per diem add-on payment for each
enhanced staffing level taking into consideration the most recently
available, reliable data relating to LVN equivalent compensation levels.
(m) Staffing requirements for participating facilities.
Each participating facility will be required to maintain adjusted
LVN-equivalent minutes equal to those determined in subsection (j)
of this section. Each participating facility's adjusted LVN-equivalent
minutes maintained during the reporting period will be determined
as follows.
(1) Determine unadjusted LVN-equivalent minutes maintained.
Upon receipt of the staffing and spending information described in
subsection (f) of this section, HHSC will determine the unadjusted
LVN-equivalent minutes maintained by each facility during the reporting
period.
(2) Determine adjusted LVN-equivalent minutes maintained.
Compare the unadjusted LVN-equivalent minutes maintained by the facility
during the reporting period from paragraph (1) of this subsection
to the LVN-equivalent minutes required of the facility as determined
in subsection (j) of this section. The adjusted LVN-equivalent minutes
are determined as follows:
(A) If the number of unadjusted LVN-equivalent minutes
maintained by the facility during the reporting period is greater
than or equal to the number of LVN-equivalent minutes required for
the facility or less than the minimum LVN-equivalent minutes required
for participation as determined in subsection (j)(1) of this section;
the facility's adjusted LVN-equivalent minutes maintained is equal
to its unadjusted LVN-equivalent minutes; or
(B) If the number of unadjusted LVN-equivalent minutes
maintained by the facility during the reporting period is less than
the number of LVN-equivalent minutes required of the facility, but
greater than or equal to the minimum LVN-equivalent minutes required
for participation as determined in subsection (j)(1) of this section,
the following steps are performed.
(i) Determine what the facility's accrued Medicaid
fee-for-service direct care revenue for the reporting period would
have been if their staffing requirement had been set at a level consistent
with the highest LVN-equivalent minutes that the facility actually
maintained, as defined in subsection (j) of this section.
(ii) Determine the facility's adjusted accrued direct
care revenue by multiplying the accrued direct care revenue from clause
(i) of this subparagraph by 0.85.
(iii) Determine the facility's accrued allowable Medicaid
fee-for-service direct care staff expenses for the rate year.
(iv) Determine the facility's direct care spending
surplus for the reporting period by subtracting the facility's adjusted
accrued direct care revenue from clause (ii) of this subparagraph
from the facility's accrued allowable direct care expenses from clause
(iii) of this subparagraph.
(v) If the facility's direct care spending surplus
from clause (iv) of this subparagraph is less than or equal to zero,
the facility's adjusted LVN-equivalent minutes maintained is equal
to the unadjusted LVN-equivalent minutes maintained as calculated
in paragraph (1) of this subsection.
(vi) If the facility's direct care spending surplus
from clause (iv) of this subparagraph is greater than zero, the adjusted
LVN-equivalent minutes maintained by the facility during the reporting
period is set equal to the facility's direct care spending surplus
from clause (iv) of this subparagraph divided by the per diem enhancement
add-on as determined in subsection (l) of this section plus the unadjusted
LVN-equivalent minutes maintained by the facility during the reporting
period from paragraph (1) of this subsection according to the following
formula: (Direct Care Spending Surplus/Per Diem Enhancement Add-on
for One LVN-equivalent Minute) + Unadjusted LVN-equivalent Minutes.
(C) For adjusted LVN-equivalent minutes calculated
on or after March 1, 2004, requirements relating to the minimum LVN-equivalent
minutes required for participation in subparagraphs (A) and (B) of
this paragraph do not apply.
(n) Staffing accountability. Participating facilities
will be responsible for maintaining the staffing levels determined
in subsection (j) of this section. HHSC will determine the adjusted
LVN-equivalent minutes maintained by each facility during the reporting
period by the method described in subsection (m) of this section.
HHSC or its designee will recoup all direct care staff revenues associated
with unmet staffing goals from participating facilities that fail
to meet their staffing requirements during the reporting period.
(o) Spending requirements for participants. Participating
facilities are subject to a direct care staff spending requirement
with recoupment calculated as follows:
(1) At the end of the rate year, a spending floor will
be calculated by multiplying accrued Medicaid fee-for-service direct
care staff revenues (net of revenues recouped by HHSC or its designee
due to the failure of the facility to meet a staffing requirement
as per subsection (n) of this section) by 0.85.
(2) Accrued allowable Medicaid direct care staff fee-for-service
expenses for the rate year will be compared to the spending floor
from paragraph (1) of this subsection. HHSC or its designee will recoup
the difference between the spending floor and accrued allowable Medicaid
direct care staff fee-for-service expenses from facilities whose Medicaid
direct care staff spending is less than their spending floor.
(3) At no time will a participating facility's direct
care rates after spending recoupment be less than the direct care
base rates.
(p) Dietary and Fixed Capital Mitigation. Recoupment
of funds described in subsection (o) of this section may be mitigated
by high dietary and/or fixed capital expenses as follows.
(1) Calculate dietary cost deficit. At the end of the
facility's rate year, accrued Medicaid dietary per diem revenues will
be compared to accrued, allowable Medicaid dietary per diem costs.
If costs are greater than revenues, the dietary per diem cost deficit
will be equal to the difference between accrued, allowable Medicaid
dietary per diem costs and accrued Medicaid dietary per diem revenues.
If costs are less than revenues, the dietary cost deficit will be
equal to zero.
(2) Calculate dietary revenue surplus. At the end of
the facility's rate, accrued Medicaid dietary per diem revenues will
be compared to accrued, allowable Medicaid dietary per diem costs.
If revenues are greater than costs, the dietary per diem revenue surplus
will be equal to the difference between accrued Medicaid dietary per
diem revenues and accrued, allowable Medicaid dietary per diem costs.
If revenues are less than costs, the dietary revenue surplus will
be equal to zero.
Cont'd... |
