Section 405 IAC 1-14.7-5 - New provider reimbursementAuthority: 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. 5.
(a) This section describes the treatment of nursing facility providers that have not previously been certified to participate in the Medicaid nursing facility program.(b) Rate requests to establish an initial rate for a new provider rate shall be filed by submitting an initial rate request to the office on or before the thirtieth day after notification of the enrollment date.(c) Initial rates shall be effective on the: (2) date a service is established; whichever is later.(d) Initial rates shall be set at the sum of the following: (1) The statewide average nursing facility quality add-on of the preceding July 1.(2) Assessment add-on, as determined in subsection (g).(3) NEMT add-on, as determined in section 7 of this rule.(4) Legacy system medians at the preceding July 1 for each of the following components: (A) Direct care component, as follows: (i) Until the provider has one (1) full reporting quarter of MDS assessment information, the direct care component shall be multiplied by the statewide average Medicaid CMI used as determined for the previous July 1 rate effective date.(ii) Once a provider has one (1) full reporting quarter of MDS assessment information, the direct care component shall be multiplied by the facility's own facility average Medicaid CMI and updated each rate effective date thereafter.(C) Indirect care component.(D) Administrative component.(E) Eighty percent (80%) of the capital component.(e) A provider shall remain under the initial rate calculation process until the first annual rebase period in which the provider has a desk or field audited cost report of six (6) months or more in length available for use in the rebase.(f) The initial monthly quality assessment value owed to the office shall be determined based on six (6) months of patient days from the required monthly nursing facility census data collection form provider filings. The initial monthly quality assessment value owed to the office shall remain in effect until the first annual rebase period in which the provider has a desk or field audited cost report of six (6) months or more in length available for use in the rebase. A retroactive settlement of the initial quality assessment total for unpaid periods shall occur after the provider's assessment value is determined by the office and the fiscal intermediary has established the monthly assessment receivable.(g) The assessment add-on is twelve dollars and twenty cents ($12.20) a patient day unless exempt from the assessment add-on, as noted in section 11 of this rule. Once the office collects six (6) months of patient days from the required monthly nursing facility census data collection forms, the office shall establish the provider specific assessment add-on and implement on the next rate effective date.(h) Providers are eligible to participate in the special care unit and ventilator programs and receive additional reimbursement if the qualifications in sections 2 and 7 of this rule are met.Office of the Secretary of Family and Social Services; 405 IAC 1-14.7-5; filed 8/20/2024, 9:11 a.m.: 20240918-IR-405240088FRA