| (a) Case mix classes. The Texas Health and Human Services
Commission (HHSC) reimbursement rates for nursing facilities (NFs)
vary according to the assessed characteristics of the recipient. Rates
are determined for 34 case mix classes of service, plus a 35th, temporary
classification assigned by default when assessment data are incomplete
or in error and a 36th classification assigned by default when an
assessment is missing.
(b) Reimbursement determination. HHSC applies the general
principles of cost determination as specified in §355.101 of
this title (relating to Introduction).
(1) Rate Components. Under the case mix methodology,
reimbursements are comprised of five cost-related components: the
direct care staff component; the other recipient care component; the
dietary component; the general/administration component; and the fixed
capital asset component. The direct care staff component is calculated
as specified in §355.308 of this title (relating to Direct Care
Staff Rate Component).
(A) The dietary rate component is constant across all
case mix classes and is calculated at the median cost (weighted by
Medicaid days of service in the rate base) in the array of projected
allowable per diem costs for all contracted nursing facilities included
in the rate base, multiplied by 1.07.
(B) The general/administration rate component is constant
across all case mix classes and is calculated at the median cost (weighted
by Medicaid days of service in the rate base) in the array of projected
allowable per diem costs for all contracted nursing facilities included
in the rate base, multiplied by 1.07.
(C) The fixed capital asset component is constant across
all case mix classes and is calculated as follows:
(i) Determine the 80th percentile in the array of allowable
appraised property values per licensed bed, including land and improvements.
Appraised values for this purpose are determined as follows:
(I) For proprietary facilities, tax exempt facilities
provided an appraisal from their local property taxing authority,
and tax exempt facilities not provided an appraisal from their local
property taxing authority because of an "exempt" status whose independent
appraisal is in the first year of its five-year interval as described
in §355.306(g)(2)(B)(ii) of this title (relating to Cost Finding
Methodology), allowable appraised values are determined as described
in §355.306(g) of this title (relating to Cost Finding Methodology).
(II) For tax exempt facilities not provided an appraisal
from their local property taxing authority because of an "exempt"
status whose independent appraisal is not in the first year of its
five-year interval as described in §355.306(g)(2)(B)(ii) of this
title (relating to Cost Finding Methodology), allowable appraised
values are determined by indexing the facility's allowable appraised
value as determined in §355.306(g) of this title (relating to
Cost Finding Methodology) to the median increase in appraised values
among contracted facilities in the state as a whole from the reporting
period coinciding with the first year of the facility's five-year
interval to the reporting period upon which reimbursements are to
be based.
(III) Those facilities that do not report an allowable
appraised value as described in §355.306(g) of this title (relating
to Cost Finding Methodology) are not included in the array for purposes
of calculating the use fee.
(ii) Project the 80th percentile of appraised property
values per bed by one-half the forecasted increase in the personal
consumption expenditures (PCE) chain-type price index from the cost
reporting year to the rate year.
(iii) Calculate an annual use fee per bed as the projected
80th percentile of appraised property values per bed times an annual
use rate of 14%.
(iv) Calculate a per diem use fee per bed by dividing
the annual use fee per bed by annual days of service per bed at the
higher of 85% occupancy, or the statewide average occupancy rate during
the cost reporting period.
(v) The use fee is limited to the lesser of the fee
as calculated in clauses (i) - (iv) of this subparagraph, or the fee
as calculated by inflating the fee from the previous rate period by
the forecasted rate of change in the PCE chain-type price index.
(2) Case mix classification system. All Medicaid recipients
are classified according to the Resource Utilization Group (RUG-III)
34 group classification system, Version 5.20, index maximizing, as
established by the state and the Centers for Medicare and Medicaid
Services (CMS). Each of the case-mix groups, including the default
groups, is assigned CMS standard nursing time measurements for Registered
Nurses (RNs), Licensed Vocational Nurses (LVNs) and aides (Medication
Aides and Certified Nurse Aides). These measurements indicate the
amount of staff time required on average to deliver care to residents
in that group.
(3) Per diem rate methodology. Staff determine per
diem rate recommendations for each of the RUG-III groups and for the
default groups according to the following procedures:
(A) For each RUG-III group, calculate a total LVN-equivalent
minute statistic by converting the CMS standard nursing time measurements
for RNs, LVNs and aides into Texas-specific LVN-equivalent minutes
as per §355.308(j) of this title (relating to Direct Care Staff
Rate Component) and summing the converted figures.
(B) Weight the total LVN-equivalent minute statistics
from subparagraph (A) of this paragraph for each RUG-III group except
the default groups as follows and determine the statewide weighted
average total adjusted minutes:
(i) For rates effective September 1, 2008, the total
LVN-equivalent minute statistics for each RUG-III group will be weighted
by the estimated statewide recipient days of service by case mix group
during the period beginning the first day of December 2007 and ending
the last day of February 2008.
(ii) For rates effective September 1, 2009, the total
LVN-equivalent minute statistics for each RUG-III group will be weighted
by the estimated statewide recipient days of service by case mix group
during the period beginning the first day of September 2008 and ending
the last day of February 2009.
(iii) For rates effective September 1, 2011 and thereafter,
for the other recipient care rate component, the total LVN-equivalent
minute statistics for each RUG-III group will be weighted by the estimated
statewide recipient days of service by case mix group during the cost
reporting period covered by the rate base. For the direct care rate
component, the total LVN-equivalent minute statistics for each RUG-III
group will be weighted by the estimated statewide recipient days of
service by case mix group during the period beginning the first day
of September, 2008 and ending the last day of February, 2009.
(C) Determine the standardized statewide case mix index
for each of the RUG-III groups by dividing each of the total LVN-equivalent
minute statistics described under subparagraph (A) of this paragraph
by the statewide weighted average total adjusted minutes described
under subparagraph (B) of this paragraph.
(D) The other recipient care rate component varies
according to case mix class of service and is calculated as follows.
Adjust the raw sum of other recipient care costs in all nursing facilities
included in the rate base in order to account for disallowed costs
and inflation, as specified in §355.306 of this title (relating
to Cost Finding Methodology). Then divide the adjusted total by the
sum of recipient days of service in all facilities in the current
rate base. Multiply the resulting weighted, average per diem cost
of other recipient care by 1.07. The result is the average other recipient
care rate component. To calculate the other recipient care per diem
rate component for each of the RUG-III case mix groups and for the
default groups, multiply each of the standardized statewide case mix
indexes from subparagraph (C) of this paragraph by the average other
recipient care rate component.
(E) Total case mix per diem rates vary according to
case mix class of service and according to participant status in Direct
Care Staff Rate enhancements described in §355.308 of this title
(relating to Direct Care Staff Rate Component).
(i) For each participating facility, for each of the
RUG-III case mix groups and for the default groups, the recommended
total per diem rate is the sum of the following five rate components:
(I) the dietary rate component from paragraph (1)(A)
of this subsection;
(II) the general/administration rate component from
paragraph (1)(B) of this subsection;
(III) the fixed capital asset use fee component from
paragraph (1)(C) of this subsection;
(IV) the case mix group's other recipient care per
diem rate component by case mix group from subparagraph (D) of this
paragraph; and
Cont'd... |
