| (B) The administration and operations cost includes
compensation and benefits for the following staff: laundry and housekeeping
staff, maintenance and transportation staff, administrator and assistant,
other administrative personnel, activity director and assistant, and
central office staff. Administration and operations also include operations
supply costs; building repair and maintenance costs; laundry and housekeeping
supply costs; transportation and vehicle depreciation costs; utilities,
telecommunications, and technology costs; contracted management costs;
insurance costs, excluding liability insurance reimbursed under §355.312
of this subchapter (relating to Reimbursement Setting Methodology--Liability
Insurance Costs).
(C) The fixed capital asset costs, including the cost
categories listed below:
(i) building and building equipment depreciation and
lease expense;
(ii) mortgage interest;
(iii) land improvement depreciation; and
(iv) leasehold improvement amortization.
(e) Reimbursement determination. HHSC calculates methodological
PDPM LTC rates for each rate component as defined below.
(1) Calculation of the nursing rate component. HHSC
determines a per diem cost for the nursing component by calculating
a median of the allowable nursing costs defined in subsection (d)(1)
of this section from the most recently examined cost report database,
weighted by the total nursing facility units of service from the same
cost report database, adjusted for inflation from the cost reporting
period to the prospective rate period as specified in §355.108
of this chapter (relating to Determination of Inflation Indices) and
multiplied by 1.07.
(2) Calculation of the NTA rate component. HHSC determines
a per diem cost for the NTA component by calculating a median of allowable
NTA costs as defined in subsection (d)(2) of this section from the
most recently examined cost report database, weighted by the total
nursing facility units of service from the same cost report database,
adjusted for inflation from the cost reporting period to the prospective
rate period as specified in §355.108 of this chapter and multiplied
by 1.07.
(3) Calculation of CMI-adjusted rate components. HHSC
adjusts the nursing component and the NTA component by the most recent
corresponding CMI established for PDPM Medicare available for the
rate year, as determined by the Medicare Skilled Nursing Facility
(SNF) Prospective Payment System (PPS). The CMI-adjusted rate components
are calculated as follows.
(A) Calculation of the total nursing rate component.
HHSC will calculate CMI-adjusted nursing rate components for each
nursing case-mix classifier by multiplying the result from paragraph
(1) of this subsection by a CMI specific to each nursing case-mix
classifier. There is one CMI per each nursing case-mix classifier.
(B) Calculation of the total NTA rate component. HHSC
will calculate CMI-adjusted NTA rate components for each NTA case-mix
classifier by multiplying the result from paragraph (2) of this subsection
by a CMI specific to each NTA case-mix classifier. There is one CMI
per each NTA case-mix classifier.
(4) Calculation of the BIMS rate component. This rate
component is calculated at 5 percent of the nursing rate component
established for a nursing case-mix classifier associated with the
highest CMI.
(5) Calculation of the non-case mix rate component.
HHSC determines a per diem cost for the non-case mix rate component
by the following.
(A) HHSC calculates a median of allowable dietary costs
defined in subsection (d)(4)(A) of this section from the most recently
examined cost report database, weighted by the total nursing facility
units of service from the same cost report database, adjusted for
inflation from the cost reporting period to the prospective rate period
as specified in §355.108 of this chapter and multiplied by 1.07.
(B) HHSC calculates a median of the allowable administration
and operations costs defined in subsection (d)(4)(B) of this section
from the most recently examined cost report database, weighted by
the total nursing facility units of service from the same cost report
database, adjusted for inflation from the cost reporting period to
the prospective rate period as specified in §355.108 of this
chapter and multiplied by 1.07.
(C) HHSC calculates a median of allowable fixed capital
costs defined in subsection (d)(4)(C) of this section from the most
recently examined cost report database, weighted by the total nursing
facility units of service from the same cost report database, adjusted
for inflation from the cost reporting period to the prospective rate
period as specified in §355.108 of this chapter and multiplied
by 1.07.
(D) HHSC sums the results from subparagraphs (A) -
(C) of this paragraph for the total non-case mix rate component.
(6) Total per diem rate determination. For each of
the PDPM LTC groups and default groups, the recommended total per
diem rate is determined as the sum of the following four rate components:
(A) Nursing rate component;
(B) NTA rate component;
(C) BIMS rate component; and
(D) Non-Case Mix rate component.
(7) HIV/AIDS Add-on. According to the Texas Health
and Safety Code (THSC) §81.103, it is prohibited to input selected
International Classification of Diseases, Tenth Revision (ICD-10)
diagnosis codes for human immunodeficiency virus (HIV) and acquired
immunodeficiency syndrome (AIDS) in the MDS assessment data. PDPM
LTC methodology establishes a special per diem add-on intended to
reimburse nursing facilities for enhanced nursing and NTA costs associated
with providing care to a resident with an HIV/AIDS diagnosis. The
total HIV/AIDS add-on is a sum of the amounts discussed as follows.
(A) The nursing rate component per PDPM LTC group assigned
to a qualifying resident will receive an 18 percent add-on amount.
(B) The NTA rate component amount will receive an add-on
amount, which is calculated as the difference between the resident's
NTA rate component amount based on their assigned NTA case-mix classifier
and the NTA rate component amount associated with the NTA case-mix
classifier with the highest CMI.
(f) Reimbursement for Hospice care in a nursing facility.
Following 26 TAC §266.305 (relating to General Contracting Requirements),
the Medicaid Hospice Program pays the Medicaid hospice provider a
hospice-nursing facility rate that is no less than 95 percent of the
Medicaid nursing facility rate for each individual in a nursing facility
to take into account the room and board furnished by the facility.
(g) Cost finding methodology.
(1) Cost reports. A nursing facility provider must
file a cost report unless:
(A) the provider meets one or more of the conditions
in §355.105(b)(4)(D) of this chapter (relating to General Reporting
and Documentation Requirements, Methods, and Procedures); or
(B) the cost report would represent costs accrued during
a time period immediately preceding a period of decertification if
the decertification period was greater than either 30 calendar days
or one entire calendar month.
(2) Communication. When material pertinent to proposed
reimbursements is made available to the public, the material will
include the number of cost reports eliminated from reimbursement determination
for one of the reasons stated in paragraph (1) of this subsection.
(3) Exclusion of and adjustments to certain reported
expenses. Providers are responsible for eliminating unallowable expenses
from the cost report. HHSC reserves the right to exclude any unallowable
costs from the cost report and to exclude entire cost reports from
the reimbursement determination database if there is reason to doubt
the accuracy or allowability of a significant part of the information
reported.
(A) Cost reports included in the database used for
reimbursement determination.
(i) Individual cost reports will not be included in
the database used for reimbursement determination if:
(I) there is reasonable doubt as to the accuracy or
allowability of a significant part of the information reported; or
(II) an HHSC examiner determines that reported costs
are not verifiable.
(ii) If all cost reports submitted for a specific facility
are disqualified through the application of subparagraph (A)(i)(I)
or (II) of this paragraph, the facility will not be represented in
the reimbursement database for the cost report year in question.
(B) Occupancy adjustments. HHSC adjusts the facility
and administration costs of providers with occupancy rates below a
target occupancy rate. HHSC adjusts the target occupancy rate to the
lower of:
(i) 85 percent; or
Cont'd... |
