405 Ind. Admin. Code 1-14.7-2

Current through December 4, 2024

Section 405 IAC 1-14.7-2 - Definitions

Authority: IC 12-15-1-10; IC 12-15-21-3

Affected: IC 4-21.5-3; IC 12-13-7-3; IC 12-15

Sec. 2.

(a) The definitions in this section apply throughout this rule.

(b) "Administrative component" means the portion of the Medicaid rate that reimburses providers for allowable administrative services and supplies, including prorated employee benefits based on salaries and wages. Allowable administrative services and supplies are the patient related costs necessary for the operation of a nursing facility, but cannot be directly associated with a specific member.

(c) As set forth in section 6(e) of this rule, "allowable per patient day cost" means a ratio between allowable variable cost and patient days using each provider's actual occupancy from the most recently completed desk reviewed or field audited cost report, plus a ratio between allowable fixed costs and patient days using the greater of the minimum occupancy requirements, or each provider's actual occupancy rate from the most recently completed desk reviewed or field audited cost report. As set forth in section 6(d) of this rule, the term means a ratio between allowable cost and patient days using each provider's actual occupancy from the most recently completed desk review or field audited cost report using the greater of the minimum occupancy requirements, or each provider's actual occupancy rate from the most recently completed desk reviewed or field audited cost report.

(d) "Bed days available" means the number of licensed beds reported during the cost reporting period multiplied by the number of calendar days in that period. If the number of licensed beds changed during a reporting period, the:

(1) number of licensed beds reported on the cost report as of the calendar day immediately after the end of the cost report period shall be used in the calculation of the rate and the related bed days available;

(2) provider may request in writing, with the cost report submission, for the weighted average of the number of beds licensed during the cost report period to be used in the calculation of the rate and the related bed days available; or

(3) provider may request the office to calculate bed days available under section 6 of this rule.

(e) "Biannual" means a six (6) month period beginning January 1 and July 1.

(f) "Capital component" means the portion of the Medicaid rate that reimburses providers for the use of allowable capital related items. Allowable capital related items are the patient related costs associated with a nursing facility's physical assets and related ownership costs.

(g) "Case mix index" or "CMI" means a numerical value score that describes the relative resource use for each resident in the groups of the resident classification system prescribed by the office, as described in the MDS and Case Mix Index Supportive Documentation Manual, and based on an assessment of each resident. The facility CMI is based on the resident CMI, calculated on a facility average, time-weighted basis for the following:

(1) Medicaid residents.

(2) Each resident of the facility.

(h) "Children's nursing facility" means a nursing facility that, as of January 1, 2009, has:

(1) fifteen percent (15%) or more residents less than twenty-one (21) years of age; and

(2) received written approval from the office to be designated as a children's nursing facility.

(i) "Cost report" refers to a presentation of financial data, including appropriate supplemental data and accompanying notes, derived from accounting records and intended to communicate the provider's economic resources or obligations at a point in time, or changes to that data at that time, in compliance with the reporting requirements of this rule.

(j) "Delinquent MDS resident assessment" means an assessment that is inactive or expired due to exceeding maximum thresholds set by the office for filing and inclusion in the time-weighted CMI calculation. This determination is made as described for required filing in the MDS and Case Mix Index Supportive Documentation Manual.

(k) "Desk review" means a review and application of the regulations to a provider submitted cost report, including accompanying notes and supplemental information within the scope, as defined by the office.

(l) "Direct care component" means the portion of the Medicaid rate that reimburses providers for allowable direct patient care services and supplies, including prorated employee benefits based on salaries and wages. Allowable direct patient care services and supplies are patient related costs associated with direct hands-on care or related support of a member.

(m) "Employee benefits" means total allowable employee benefits costs from the most recently desk reviewed or field audited cost report, excluding owners' benefits as described in the IMPRM, unless specified otherwise.

(n) "Field audit" means a review and application of the regulations to a provider submitted cost report, including accompanying notes and supplemental information within the scope, as defined by the office.

(o) "Fixed costs" means the portion of each rate component based on the minimum occupancy requirements.

(p) "Forms prescribed by the office" means either of the following:

(1) Cost report forms provided by the office.

(2) Substitute forms that have received prior written approval by the office.

(q) "Generally accepted accounting principles" or "GAAP" means those accounting principles as established by the Financial Accounting Standards Board.

(r) "IDOH" means the Indiana department of health.

(s) "Indiana Medicaid provider reimbursement manual" or "IMPRM" means the policy document supporting the reporting requirements, allowable cost classifications, and calculation of the Medicaid rate.

(t) "Indirect care component" means the portion of the Medicaid rate that reimburses providers for allowable indirect patient care services and supplies, including prorated employee benefits based on salaries and wages. Allowable indirect patient care services and supplies are patient related costs necessary in the care of a member, but not directly based on providing hands-on care.

(u) "Inflation factor" means inflating costs using the CMS Nursing Home without Capital Market Basket Index, as published by IHS Markit, using the period prescribed by the office.

(v) "Legacy system" means the historic system used to calculate the Medicaid nursing facility per patient day rate under section 6 of this rule.

(w) "Medicaid patient days" means total Medicaid days from the most recently desk reviewed or field audited cost report.

(x) "Minimum data set" or "MDS" means a core set of screening and assessment elements, including common definitions and coding categories, that forms the foundation of the comprehensive assessment for residents of long term care facilities certified to participate in Medicaid. The Indiana system uses the MDS 3.0 or later revisions as approved by CMS, as detailed in the MDS and Case Mix Index Supportive Documentation Manual.

(y) "MDS and Case Mix Index Supportive Documentation Manual" means the policy document supporting the following:

(1) The MDS assessment instrument.

(2) MDS assessment processing.

(3) MDS supportive documentation requirements.

(4) The resident classification system.

(5) The CMI calculation.

(z) "MDS review" means a formal official verification and methodical examination and review of resident assessment data and its supporting documentation by the office or their designee.

(aa) "Nonemergency medical transportation" or "NEMT" means medical transportation to a covered service whenever needs are not immediate, such as to and from a doctor's office, a hospital, or other medical offices for covered care. NEMT services provided by ambulance providers are neither the financial responsibility of nursing facility providers and included in the nursing facility Medicaid per diem, nor covered under this definition.

(bb) "Nursing facility census data collection form" means the form designated by the office for providers to file their monthly census information.

(cc) "Ordinary patient related costs" means costs of allowable per diem services and supplies necessary in the delivery of patient care by similar providers in this state. Services or supplies Medicaid covers outside the per diem rate are not ordinary patient related costs.

(dd) "Patient/member care" means those Medicaid program services delivered to a Medicaid enrolled member by a provider.

(ee) "Patient days" means total patient days, inclusive of paid leave days, from the most recently desk reviewed or field audited cost report.

(ff) "Prospective system" means the methodology used to calculate the Indiana Medicaid reimbursement per patient day rate under section 6 of this rule.

(gg) "Quality program manual" means the policy document supporting the calculation of the total quality score.

(hh) "Rate year" means the period beginning July 1 and ending June 30.

(ii) "RSMeans Construction Cost Index" means the simple average of construction costs for Indiana cities listed in the Construction Cost Indexes with RSMeans Data, as published by Gordian.

(jj) "Reasonable allowable costs" means the price a prudent, cost-conscious buyer pays a willing seller for goods or services in an arms length transaction, not to exceed the limitations set forth in this rule or other policy documents.

(kk) "Rebase" means the process of reestablishing rate component medians, percentiles, prices, and reimbursement rates by incorporating the most recently completed desk or field audited qualifying Medicaid cost reports.

(ll) "Rental rate" means a simple average of the United States Treasury bond ten (10) year amortization, constant maturity rate plus three percent (3%), in effect on the first day of the month the index is published for each of the twelve (12) months immediately preceding the rate effective date, as determined in section 6 of this rule.

(mm) "Resident classification system" means the classification system used to classify residents into groups to determine CMI values and reimbursement levels, as supported by the MDS and Case Mix Index Supportive Documentation Manual.

(nn) "Special care unit (SCU) for Alzheimer's disease or dementia" means the nursing facility that meets all the following requirements:

(1) Has a locked, secure, segregated unit, or provides a special program or unit for residents with Alzheimer's disease, related disorders, or dementia.

(2) The facility advertises, markets, or promotes the health facility as providing Alzheimer's care services or dementia care services, or both.

(3) The nursing facility has a designated director for the Alzheimer's and dementia special care unit, who satisfies the following conditions:

(A) Became the director of the SCU prior to August 21, 2004, has earned a degree from an educational institution in a health care, mental health, or social service profession, or is a licensed health facility administrator.

(B) Has at least one (1) year work experience with dementia or Alzheimer's residents, or both, in the past five (5) years.

(C) Completed at least twelve (12) hours of dementia-specific training within three (3) months of initial employment, and has continued to obtain six (6) hours annually of dementia-specific training thereafter to:

(i) meet the needs or preferences, or both, of cognitively impaired residents; and

(ii) gain understanding of the current standards of care for residents with dementia.

(D) Performs the following duties:

(i) Oversees the operations of the unit.

(ii) Ensures personnel assigned to the unit receive required in-service training.

(iii) Ensures the care provided to Alzheimer's and dementia care unit residents is consistent with in-service training, current Alzheimer's and dementia care practices, and regulatory standards.

(oo) "Therapy component" means the portion of each facility's direct costs for providing therapy services, including prorated employee benefits based on total salaries and wages, rendered to Medicaid residents not reimbursed by other payors.

(pp) "Total quality score" means the sum of the quality points awarded to each nursing facility for the quality measures as described by the quality program manual.

(qq) "Unsupported MDS resident assessment" means an assessment missing one (1) or more data items required to classify a resident through the resident classification system under the MDS and Case Mix Index Supportive Documentation Manual.

(rr) "Ventilator program" means a nursing facility that meets all the following requirements:

(1) The nursing facility uses an active, ongoing interdisciplinary approach to resident care, including participation as needed by a:

(A) physician;

(B) practitioner;

(C) pulmonologist;

(D) registered nurse;

(E) pharmacist;

(F) dietitian;

(G) speech therapist;

(H) respiratory therapist;

(I) physical or occupational therapist;

(J) resident; and

(K) resident's representative.

The interdisciplinary approach includes a physician who is board certified in pulmonary disease or critical care, as recognized by either the American Board of Medical Specialties or American Osteopathic Associations, as applicable.

(2) The nursing facility has a licensed respiratory care practitioner, as defined by 844 IAC 11, onsite twenty-four (24) hours a day, seven (7) days a week.

(3) The nursing facility has ventilator back-up provisions, including:

(A) internal or external battery back-up systems, or both, to provide at least eight (8) hours of power;

(B) enough emergency oxygen delivery devices (e.g., compressed gas or battery operated concentrators);

(C) at least one (1) battery operated suction device available for every nine (9) residents on a mechanical ventilator or with a tracheostomy;

(D) at least one (1) resident ready back-up ventilator available in the facility at all times;

(E) an audible, redundant external alarm system connected to emergency power or battery back-up, or both, located outside the room of each ventilator-dependent resident, for the purpose of alerting staff of resident ventilator disconnection or ventilator failure; and

(F) ventilator equipment, and preferably physiologic monitoring equipment, connected to back-up generator power through clearly marked wall outlets.

(4) The nursing facility has a plan specific for ventilator-dependent residents, which specifically addresses total power failures, such as the loss of power and generator, as well as other emergency circumstances.

(5) The nursing facility has a written training program, including an annual demonstration of competencies, for nursing and respiratory therapy staff, including nurse aides, registered nurses, and licensed practical nurses, providing direct care services for ventilator-dependent residents.

405 IAC 1-14.7-2

Office of the Secretary of Family and Social Services; 405 IAC 1-14.7-2; filed 8/20/2024, 9:11 a.m.: 20240918-IR-405240088FRA