Section 29-6514. REIMBURSEMENT FOR NEW PROVIDERS

 

6514.1New providers shall submit a pro forma cost report based on a budget of estimated first year costs. MAA has the right to review and adjust each nursing facility's pro forma cost report.

 

6514.2The interim per diem rate for each new provider shall be the sum of the routine and support costs per diem, nursing and resident care costs per diem and capital related costs per diem as calculated pursuant to this section. The interim facility specific rate for each new provider shall remain in effect until the new provider's one full year of operational costs has been audited. Each new provider may receive an add-on payment for each resident that qualifies and receives ventilator care pursuant to sections 6509 through 6511.

 

6514.3Each new provider shall be assigned to the appropriate peer group as set forth in subsection 6502.1.

 

6514.4The interim rate for routine and support costs per diem for a new provider assigned to Peer Groups One or Two shall be equal to the day-weighted median cost per diem for routine and support costs for all facilities in Peer Groups One and Two. The interim rate for routine and support costs per diem for a new provider assigned to Peer Group Three shall be equal to the day-weighted median cost per diem for routine and support costs for all facilities in Peer Group Three.

 

6514.5The interim rate for nursing and resident care costs per diem for a new provider assigned to Peer Group One shall be determined by multiplying the day-weighted median cost per diem for nursing and patient care costs for all facilities in Peer Group One by the District-wide Medicaid average case mix index. The interim rate for nursing and resident care costs per diem for a new provider assigned to Peer Group Two shall be determined by multiplying the median cost per diem for nursing and resident care costs for all facilities in Peer Group Two by the District-wide Medicaid average case mix index. The interim rate for nursing and resident care costs per diem for a new provider assigned to Peer Group Three shall be determined by multiplying the day-weighted median cost per diem for nursing and patient care costs for all facilities in Peer Group Three by the District-wide Medicaid average case mix index.

 

6514.6The interim rate for capital-related costs per diem shall be established by dividing the lower of capital-related reported costs as determined by MAA pursuant to subsection 6514.1 or capital costs set forth in a written finding by the State Health Planning and Development Agency in its approval of the certificate of need issued in accordance with D.C. Official Code § 44-401 et seq. if available, by the number of resident days reported in subsection 6514.1 adjusted in accordance with subsection 6512.2.

 

6514.7Following the results of the audited cost report, the new provider's reimbursement rate for routine and support costs per diem shall be the lower of the audited routine and support costs per diem and the related ceiling for each of the respective cost categories. The reimbursement rate for nursing and resident costs per diem shall be the lower of the audited nursing and resident cost per diem and related ceilings adjusted for case mix by the facility Medicaid case mix index for each of the respective cost categories. The capitol cost per diem shall be calculated in accordance with the requirements set forth in section 6514.6. The peer group ceilings shall not be adjusted until the rates are rebased.

 

6514.8After completion of the audit, a new provider shall have the right to appeal the audit adjustments consistent with the requirements set forth in section 6520.

 

6514.9MAA shall collect any overpayment or pay any difference as a result of the difference between the audited final rate and interim rate paid to a new provider.

 

6514.10MAA shall notify, in writing, each new nursing facility of its payment rate calculated in accordance with this section. The rate letter to a new provider shall include the per diem payment rate calculated in accordance with this section. The rate letter shall also include the District-wide Medicaid average case mix index or the facility Medicaid case mix index as appropriate.

 

6514.11Within thirty days of the date of receipt of the rate letter issued pursuant to subsection 6514.10, a new provider that disagrees with the mathematical calculation of the District-wide Medicaid case mix index or if appropriate, the facility Medicaid case mix index may request an administrative review by sending a written request for administrative review to the Fiscal Officer, Audit and Finance, Medical Assistance Administration, Department of Health, 825 North Capitol Street, NE, Suite 5135, Washington, D.C. 20002.

 

6514.12RUGS III classifications or CMI scores are not subject to appeal.

 

6514.13The written request for an administrative review shall include a specific explanation of why the nursing facility believes the calculation is in error, the relief requested and documentation in support of the relief requested.

 

6514.14MAA shall mail a formal response to the nursing facility no later than forty-five (45) days from the date of receipt of the written request for administrative review pursuant to subsection 6514.13.

 

6514.15Decisions made by MAA and communicated in the formal response described in subsection 6514.14 may be appealed, within thirty (30) days of the date of MAA's letter notifying the facility of the decision, to the Office of Administrative Hearings.

 

6514.16Filing an appeal with the Office of Administrative Hearings pursuant to this section shall not stay any action by MAA to recover any overpayment to the nursing facility.

 

source

Final Rulemaking published at 53 DCR 1370 (February 24, 2006).