603745 Medicaid Reimbursement for ICF/MR

DEPARTMENT OF HEALTH CARE FINANCE

NOTICE OF EMERGENCY AND PROPOSED RULEMAKING

The Director of the Department of Health Care Finance (DHCF), pursuant to the authority set forth in An Act to enable the District of Columbia to receive federal financial assistance under Title XIX of the Social Security Act for a medical assistance program, and for other purposes, approved December 27, 1967 (81 Stat. 774; D.C. Official Code § 1-307.02) and section 6 (6) of the Department of Health Care Finance Establishment Act of 2007, effective February 27, 2008 (D.C. Law 17-109; D.C. Official Code § 7-771.05(6)), hereby gives notice of the adoption, on an emergency basis, of an amendment to repeal sections 968 through 982 of Title 29, “Public Welfare,” of the District of Columbia Municipal Regulations (DCMR) and to add a new Chapter 41, to be entitled “Medicaid Reimbursement for Intermediate Care Facilities for Persons with Mental Retardation (ICF/MR),” to Title 29. The effect of these rules is to change the prospective payment reimbursement methodology for services provided to a Medicaid beneficiary residing in an ICF/MR.

Under the proposed rules, the per diem reimbursement rates for each ICF/MR shall include payment for: (1) residential services provided to each beneficiary based upon the beneficiary’s level of need and class of facility; (2) active treatment services; and (3) plant and capital. In addition to the per diem rate, each facility may receive a supplemental payment for quality of care improvements pursuant to the requirements set forth in the Stevie Sellows Intermediate Care Facility for the Mentally Retarded Quality Improvement Act of 2005, effective March 8, 2006 (D.C. Law 16-68; D.C. Official Code § 47-1270 et seq.). These rules also authorize a temporary rate adjustment if DHCF determines that a facility is financially distressed and in imminent peril of closing.

The current Medicaid reimbursement system for ICFs/MR was implemented beginning in fiscal year 1997 and, with the exception of one-to-one services, has not been updated since that time. The proposed rules move away from a less flexible and less efficient cost-based rate setting methodology that is based on provider costs to a more flexible methodology based on the needs of the recipient. The new methodology will ensure that the reimbursement rates paid to ICFs/MR are reasonable and adequate to meet the costs that must be incurred by efficiently and economically operated facilities in conformity with District and federal laws, rules and quality and safety standards, and are at a level that will maintain and attract new providers. The Medicaid program estimates an aggregate increase which includes federal and District dollars of approximately five million eight hundred forty one thousand dollars ($5,841,000) in fiscal year 2011 as a result of the revised methodology.

This emergency rulemaking is necessitated by the immediate need to create new levels of need that better align with the needs of individuals with developmental disabilities. The new levels of need are linked to a new reimbursement structure that will offer providers payments that will allow them to better support these individuals. Emergency action is necessary for the immediate preservation of the health, safety, and welfare of persons who are in need of services provided in an ICF/MR.

The corresponding amendment to the District of Columbia State Plan for Medical Assistance (State Plan) was approved by the Council of the District of Columbia on July 31, 2009. (See PR 18-389, entitled New Medicaid Reimbursement Methodology for Intermediate Care Facilities for the Intellectually and Developmentally Disabled State Plan Amendment Approval Resolution of 2009.) The State Plan has been submitted to the U.S. Department of Health and Human Services, Centers for Medicare and Medicaid Services (CMS) for approval. These proposed rules shall become effective for services rendered on or after December 1, 2010, if the corresponding State Plan amendment has been approved by CMS with an effective date of December 1, 2010, or the effective date established by CMS in its approval of the corresponding State Plan amendment, whichever is later. If approved, DHCF will publish a notice which sets forth the effective date of the rules.

The emergency rulemaking was adopted on October 20, 2010, and shall become effective for services rendered on or after December 1, 2010. The emergency rules will remain in effect for one hundred and twenty (120) days or until January 16, 2011, unless superseded by publication of a Notice of Final Rulemaking in the D.C. Register. The Director also gives notice of the intent to take final rulemaking action to adopt this proposed rule not less than thirty (30) days from the date of publication of this notice in the D.C. Register.

Title 29, PUBLIC WELFARE, of the District of Columbia Municipal Regulations is amended as follows:

Chapter 9, MEDICAID PROGRAM, is amended by deleting Sections 968 through 982 in their entirety.

A new Chapter 41 is added to read as follows:

CHAPTER 41 MEDICAID REIMBURSEMENT FOR INTERMEDIATE CARE FACILITIES FOR PERSONS WITH MENTAL RETARDATION

4100 GENERAL PROVISIONS

4100.1 The purpose of this Chapter is to establish principles of reimbursement for intermediate care facilities for persons with mental retardation (ICFs/MR) participating in the District of Columbia Medicaid program.

4100.2 Medicaid reimbursement to ICFs/MR for services provided beginning on or after December 1, 2010, shall be on a prospective payment system consistent with the requirements set forth in this Chapter.

4100.3 The Department of Health Care Finance (DHCF) used the following principles to determine the payment rates:

(a) Payment rates based on the class of a facility as described in § 4102.2 and each beneficiary’s level of need (LON) should be differentiated;

(b) Reimbursement for active treatment services for each beneficiary should be included, as appropriate;

(c) Payment rates should be uniform and District-wide for the same class of facility and for beneficiaries with the same level of need; and

(d) A day of care should be used as the unit of service.

4100.4 The per diem reimbursement rate to each ICF/MR shall include payment for the following services:

(a) Residential services provided to each beneficiary based on level of need;

(b) Active treatment services; and

4100.5 In addition to the per diem reimbursement rate set forth in § 4100.4, each ICF/MR may receive a supplemental payment for quality of care improvements pursuant to §§ 4106 through 4109 and a temporary rate adjustment subject to the requirements set forth in § 4105.

4101 LEVEL OF NEED

4101.1 Reimbursement rates shall be differentiated based on the beneficiary’s level of need (LON) as described in this section.

4101.2 The LON shall be specific to the beneficiary and are as follows:

(a) Level 1 – base: standard level of care;

(b) Level 2 – limited: level of care to accommodate individuals with functional impairment as described in § 4101.4;

(c) Level 3 – extensive and behavioral acuity: level of care to accommodate individuals with significant behavioral challenges as described in § 4101.5;

(d) Level 3 – extensive and medical acuity: level of care to accommodate individuals with significant medical challenges as described in § 4101.6;

(e) Level 4 – pervasive: level of care to accommodate individuals with dangerous behaviors and/or conditions that require one-to-one (1:1) supervision less than twenty-four (24) hours per day as described in § 4101.7; and

(f) Levels 5 – pervasive plus: level of care to accommodate individuals with dangerous behaviors and/or conditions that require one-to-one (1:1) supervision twenty-four (24) hours per day and individuals in need of extensive skilled nursing service as described in §§ 4101.8 and 4101.9.

4101.3 For purposes of reimbursement, a beneficiary shall be assumed to be at Level 1 (base), unless DHCF approves a higher level based upon supporting documentation. The facility may apply for one (1) of the enhanced levels of need above Level 1 if the facility provides services to a beneficiary with more intensive needs.

4101.4 A beneficiary may qualify for Level 2 (limited) when he or she has at least three (3) of the following characteristics:

(a) Is dependent on others for physical functioning and requires full staff involvement to meet needs associated with activities of daily living (ADL);

(b) Has severe deficits in gross and fine motor functioning;

(c) Requires full staff involvement for transfers and bed mobility, such as when a manual and/or mechanical lift is required;

(d) Is non-ambulatory, such as when the beneficiary is wheelchair-dependent for locomotion;

(e) Has total dependence for ADLs involving personal hygiene, such as showering, washing and drying his or her face, hands, and perineum, brushing teeth, and dressing;

(f) Has dependence for elimination, such as when assistance of one (1) or two (2) persons is required to transfer the beneficiary on and off the commode or when total care of one (1) person is required after each incontinent episode for clothing adjustment and cleansing; or

(g) Requires extensive assistance for nutritional intake, for example the beneficiary requires continual staff help, a feeding protocol to address chewing or swallowing problems is necessary, or a mechanically altered diet is required.

4101.5 A beneficiary may qualify for Level 3 (extensive and behavioral acuity) when he or she is dually diagnosed and meets all of the following requirements:

(a) Exhibits assaultive, self-abusive, or aggressive behaviors;

(b) Requires a written behavior plan which is based on on-going written data and targets the identified behaviors; and

(c) Requires intensive staff intervention and additional staff resources to manage the behaviors set forth in § 4101.5(a).

4101.6 A beneficiary may qualify for Level 3 (extensive and medical acuity) when he or she meets all of the following requirements:

(a) Is medically fragile;

(b) Has clearly documented multiple medical concerns; and

4101.7 A beneficiary may qualify for Level 4 (pervasive) when he or she requires one-to-

one (1:1) services not to exceed eighty-two (82) hours per week and meets at least

one (1) of the following requirements:

(a) Exhibits elopement which places him or her at risk;

(b) Exhibits behavior that is life-threatening to the individual or others;

(d) Is a sexual predator; or

(e) Has another intense behavioral problem that has been deemed to require one-to-one (1:1) services.

4101.8 A beneficiary may qualify for Level 5 (pervasive plus) when he or she requires one-to-one (1:1) services not less than one hundred thirty-eight (138) hours per week and meets at least one (1) of the following requirements:

(a) Exhibits elopement which places him or her at risk;

(b) Exhibits behavior that is life-threatening to the individual or others;

(d) Is a sexual predator; or

(e) Has another intense behavioral problem that has been deemed to require one-to-one (1:1) services.

4101.9 A beneficiary may qualify for Level 5 (pervasive plus skilled nursing) if the individual meets at least one (1) of the following requirements:

(a) Is at risk for cardio-pulmonary failure;

(b) Requires monitoring and care of circulatory functions at least once every hour;

(d) Requires constant monitoring and care of neurological functions;

(e) Requires monitoring and care of skeletal functions that require turning and re-positioning at least every hour as ordered by a physician;

(f) Requires wound care as ordered by a physician four (4) or more times per day;

(g) Requires constant observation of urine, blood, or bodily orifices for bleeding tendencies; or

(h) Has another intense medical condition that requires monitoring or care at least once every hour.

4101.10 In order to qualify for a LON other than Level 1 (base), each beneficiary shall be assessed using a standardized assessment tool identified by DHCF.

4101.11 The ICF/MR provider shall be responsible for compiling information required by DHCF and sufficient for DHCF or its designee to conduct the assessment and determine the level of need.

4101.12 In order to qualify for Level 2 (limited) LON, an ICR/MR shall submit the following documents to DHCF:

(a) A concise statement that sets forth the presenting problem(s);

(b) An up to date Health Management Care Plan or similar document as required by the Department on Disability Services, Developmental Disabilities Administration;

(c) An up to date Health Passport or similar document as required by the Department on Disability Services, Developmental Disabilities Administration;

(d) A current Individual Service Plan (ISP);

(e) A nursing assessment completed within thirty (30) days before the request;

(f) A current physician’s order;

(g) If necessary, a discharge summary from a hospital or nursing home stay(s), documentation from routine medical services and follow up care, and documentation from medical services provided by specialist(s);

(h) Documentation related to specialized medical service requirements, such as specialty assessments for physical therapy, occupational therapy, and speech and language therapy; and

(i) Any other documentation not listed above to justify the need for added services.

4101.13 In order to qualify for Level 3 (medical acuity) LON or Level 5 (pervasive plus skilled nursing) LON, an ICF/MR shall submit the following documents to DHCF:

(a) A concise statement that sets forth the presenting problem(s);

(b) An up to date Health Management Care Plan or similar document as required by the Department on Disability Services, Developmental Disabilities Administration;

(c) An up to date Health Passport or similar document as required by the Department on Disability Services, Developmental Disabilities Administration;

(d) A current ISP;

(e) A current history and physical examination;

(f) A nursing assessment completed within (30) days before the request;

(g) A current physician’s order;

(h) A discharge summary from a hospital or nursing home stay, documentation from routine medical follow up, and services provided by a specialist;

(i) Documentation related to specialized medical service requirements, such as specialty assessments for physical therapy, occupational therapy, and speech and language therapy; and

(j) Any other documentation not listed above to justify the need for added services.

4101.14 In order to qualify for Level 3 (behavioral acuity) LON, Level 4 (pervasive) LON, or Level 5 (pervasive plus) LON, an ICF/MR shall submit the following documents to DHCF:

(a) A concise statement that sets forth the presenting problem(s);

(b) An up to date Health Management Care Plan or similar document as required by the Department on Disability Services, Developmental Disabilities Administration;

(c) An up to date Health Passport or similar documents as required by the Department on Disability Services, Developmental Disabilities Administration;

(d) A current ISP;

(e) A psychiatric evaluation completed within thirty (30) days before the request;

(f) A psychological evaluation completed within thirty (30) days before the request;

(g) Medication monitoring reports for ninety (90) days before the request:

(h) Current written behavior support plan;

(i) Behavior data for thirty (30) days before the request;

(j) Nursing assessment completed within thirty (30) days before the request;

(k) A current physician’s order; and

(l) Any other documentation not listed above to justify the need for added services.

4101.15 Unless otherwise indicated, supporting documentation submitted pursuant to §§ 4101.12 through 4101.14 shall not be older than ninety (90) days and shall reflect the beneficiary’s current status.

4101.16 The number of one- to- one (1:1) hours shall be determined by an assessment tool developed by DHCF. Under Level 4 (pervasive), a staff member assigned to supervise the individual shall accompany the individual the entire time the individual is awake and shall have no other duties while assigned to the individual. Under Levels 5, Pervasive and Pervasive plus Skilled Nursing, a staff member assigned to supervise the individual shall accompany the individual the entire time the individual is awake and sleep and shall have no other duties while assigned to the individual.

4101.17 Each ICF/MR shall have a skilled health care professional on duty twenty-four (24) hours a day for services provided to individuals with Levels 5 LON.

4101.18 For LON renewals, each ICF/MR shall be responsible for compiling the beneficiary’s information in the format required by DHCF and ensuring the submission of supporting documentation to DHCF at least six (6) weeks before expiration of the current authorization. DHCF shall not retroactively adjust the reimbursement rate for late renewal submissions.

4101.19 In the event of an emergency, including hospital or nursing home discharges that require a higher LON than currently provided to the beneficiary, the ICF/MR shall contact DHCF immediately to schedule a conference call for a temporary LON assignment if DHCF determines that such a temporary change is needed.

4101.20 The temporary assignment of a LON shall not exceed sixty (60) days. The ICF/MR shall collect the data and other required documentation in support of the LON and schedule an assessment prior to the expiration of the sixty (60) day period.

4101.21 The LON of each beneficiary newly admitted to an ICF/MR shall be determined within six (6) weeks of admission if all required documentation has been provided by the ICF/MR.

4101.22 Each beneficiary shall be issued a written notice in accordance with District and federal law and rules for the initial determination of the LON and any subsequent change to the LON. At a minimum, the notice shall include the following information:

(a) The beneficiary’s LON; and

(b) The procedures and timeframes for requesting an administrative review or appeal with the Office of Administrative Hearings if the beneficiary disagrees with the LON determination.

4102 RESIDENTIAL SERVICES

4102.1 The payment rates for residential services were developed utilizing a representative sample determined by DHCF to include providers of different sizes serving beneficiaries with different levels of need and fiscal year 2007 cost data.

4102.2 For the purposes of rate-setting, DHCF shall divide ICF/MR facilities into two (2) classes based on the size of the facility. The reimbursement rates shall be different for each class of ICF/MR facilities, which are as follows:

(a) Class I - A facility with five (5) or fewer Medicaid beneficiaries either residing in the facility as of the first day of the month or with a bed allocated for them under the reserved bed policy; and

(b) Class II - A facility with six (6) or more Medicaid beneficiaries either residing in the facility as of the first day of the month or with a bed allocated for them under the reserved bed policy.

4102.3 The residential component of the rate shall be based on a model that includes the following eight (8) cost centers:

(a) The direct service cost center shall include expenditures for:

(1) Nursing;

(2) Personal care;

(3) Qualified Mental Retardation Professional (QMRP); and

(4) Health-related clerical staff.

(b) The non-personnel operations cost center shall include expenditures for:

(1) Food;

(2) Laundry;

(3) Housekeeping;

(4) License and fees;

(5) Utilities; and

(6) Other non-personnel operating costs.

(1) Clerical staff;

(2) Payroll taxes;

(3) Salaries and consulting fees to non-direct care staff;

(4) Insurance;

(5) Travel and entertainment;

(6) Transportation of staff when not accompanying an individual served by the facility;

(7) Beneficiary medical record maintenance;

(8) Training costs;

(9) Office expenses; and

(10) Other administrative costs.

(d) The program support cost center shall include expenditures for:

(1) Program materials;

(2) Incident management;

(3) Quality assurance;

(4) Program management;

(5) Program development; and

(6) Other program support.

(e) The professional support and consultation cost center shall include expenditures for:

(1) Dietary and nutrition;

(2) Professional services;

(3) Utilization and medical record reviews; and

(4) Other professional support and consultation.

(f) The health-care related cost center shall include expenditures for:

(1) Pharmacy;

(2) Medical supplies;

(3) Lab and X-ray;

(4) Oxygen;

(5) Therapy;

(6) Physician services;

(7) Behavioral and psychiatric services and consultation; and

(8) Miscellaneous medical costs.

(g) The transportation cost center shall include expenditures for:

(1) Transportation of an individual served by the facility;

(2) Transportation of staff when accompanying an individual served by the facility; and

(3) Transportation of staff when not accompanying an individual if the transportation is directly related to a medical service for an individual served by the facility.

(h) The plant and capital cost center shall include expenditures for:

(1) Plant maintenance;

(2) Rent;

(3) Equipment rental;

(4) Depreciation and amortization;

(5) Interest on capital debt;

(6) Real estate taxes;

(7) Property insurance; and

(8) Miscellaneous plant and capital costs.

4102.4 The direct service cost center shall be calculated based on the direct care staff to beneficiary ratio.

4102.5 The residential services per diem reimbursement rates for beneficiaries with Level 1 LON are as follows:

COST CENTER	CLASS 1	CLASS II
Direct Service	$ 239.34	$ 176.68
Non-Personnel Operations	12.38	9.14
Administration	40.15	29.63
Program Support	6.86	5.06
Professional Support and Consultation	10.22	7.54
Health Care Related	13.72	10.12
Transportation	10.42	7.69
TOTAL PER DIEM RATE	$ 333.09	$ 245.86

4102.6 The residential services per diem reimbursement rates for beneficiaries with Level 2 Limited LON are as follows:

COST CENTER	CLASS 1	CLASS II
Direct Service	$ 302.47	$ 239.78
Non-Personnel Operations	15.65	12.41
Administration	50.73	40.22
Program Support	8.67	6.87
Professional Support and Consultation	12.91	10.24
Health Care Related	17.33	13.74
Transportation	13.17	10.44
TOTAL PER DIEM RATE	$ 420.93	$ 333.70

4102.7 The residential services per diem reimbursement rates for beneficiaries with Level 3-Extensive (Behavioral Acuity) LON are as follows:

COST CENTER	CLASS 1	CLASS II
Direct Service	$ 314.52	$ 280.43
Non-Personnel Operations	16.27	14.51
Administration	52.75	47.04
Program Support	9.01	8.03
Professional Support and Consultation	13.43	11.97
Health Care Related	18.02	16.07
Transportation	13.69	12.21
TOTAL PER DIEM RATE	$ 437.69	$ 390.26

4102.8 The residential services per diem reimbursement rates for beneficiaries with Level 3 –Extensive (Medical Acuity) LON are as follows:

COST CENTER	CLASS 1	CLASS II
Direct Service	$ 340.78	$ 306.59
Non-Personnel Operations	17.63	15.86
Administration	57.16	51.42
Program Support	9.76	8.78
Professional Support and Consultation	14.55	13.09
Health Care Related	19.53	17.57
Transportation	14.84	13.35
TOTAL PER DIEM RATE	$ 474.25	$ 426.66

4102.9 The residential services per diem reimbursement rates for beneficiaries with Level 4 – Pervasive LON are as follows:

COST CENTER	CLASS 1	CLASS II
Direct Service	$ 419.24	$ 385.85
Non-Personnel Operations	21.69	19.96
Administration	70.32	64.72
Program Support	12.01	11.05
Professional Support and Consultation	17.90	16.47
Health Care Related	24.02	22.11
Transportation	18.25	16.80
TOTAL PER DIEM RATE	$ 583.43	$ 536.96

4102.10 The residential services per diem reimbursement rates for beneficiaries with Level 5 –Pervasive Plus LON are as follows:

COST CENTER	CLASS 1	CLASS II
Direct Service	$ 514.61	$ 510.76
Non-Personnel Operations	26.63	26.43
Administration	86.32	85.67
Program Support	14.74	14.63
Professional Support and Consultation	21.97	21.81
Health Care Related	29.49	29.27
Transportation	22.40	22.23
TOTAL PER DIEM RATE	$ 716.16	$ 710.80

4102.11 The residential services per diem reimbursement rates for beneficiaries with Level 5 –Pervasive Plus Skilled Nursing LON are as follows:

COST CENTER	CLASS 1	CLASS II
Direct Service	$ 548.40	$ 502.38
Non-Personnel Operations	28.35	25.99
Administration	91.92	84.26
Program Support	15.70	14.39
Professional Support and Consultation	23.40	21.45
Health Care Related	31.40	28.79
Transportation	23.86	21.87
TOTAL PER DIEM RATE	$ 763.03	$ 699.13

4102.12 Effective October 1, 2011, and annually thereafter, the residential services per diem rates set forth in sections 4102.5 through 4102.11 shall be adjusted for inflation in accordance with the Centers for Medicare and Medicaid Services (CMS) Skilled Nursing Facility Market Basket Index or other similar index if the CMS Skilled Nursing Facility Market Basket Index is discontinued.

4102.13 DHCF shall notify each facility, no later than forty-five (45) days after publication by CMS of the inflation factor referenced in section 4102.12.

4103 ACTIVE TREATMENT SERVICES

4103.1 Each beneficiary shall receive a continuous active treatment program consistent with the requirements set forth in 42 CFR § 483.440.

4103.2 The active treatment program shall include aggressive, consistent implementation of a program of specialized and generic training, treatment, health services and other related services that is directed towards:

(a) The acquisition of the behaviors necessary for the beneficiary to function with as much self-determination and independence as possible; and

(b) The prevention or deceleration of regression or loss of current optimal functional status.

4103.3 Active treatment services may vary depending on the need of the beneficiary. Each beneficiary shall receive all services that are required to implement the active treatment program described in each beneficiary’s ISP.

4103.4 The decision on the type of the active treatment program each beneficiary will attend shall be determined by the interdisciplinary team and described in the ISP. The decision shall not be based on the reimbursement rate paid by DHCF to the active treatment provider.

4103.5 Reimbursement rates for active treatment providers set forth below shall be as

follows:

PROVIDERS	PER DIEM RATE
Art and Drama Therapy Institute	$ 136.10
St. John’s Day Treatment Program	$ 145.53
United Cerebral Palsy of DC and VA	$ 136.00
United Cerebral Palsy of Washington	$ 136.00
National Children’s Center	$ 101.60
PSI Associates (CMRDT#2)	$ 100.92
Brookland Senior Day Care	$ 129.16
Psychiatric Center Chartered, Inc.	$ 99.58
Vocational Corporation of America	$ 87.45
Crescent Cities	$ 72.91
Helping Hands Adult Day Care	$ 92.38
Metro Homes Treatment Center	$ 118.44
Associated Community Services	$ 116.91
Wholistic Habilitative Services	$ 128.79
Vocational Corporation ATP	$ 90.52
Helping Hands Adult Day Services	$ 92.81
St. Coletta	$ 68.30
Progressive Habilitative Services at 8^th St.	$ 121.51
Progressive Habilitative Services at Chillum Place	$ 111.47
DC ARC	$ 65.44
Capital Hill SEP	$ 78.96
Deaf Reach	$ 76.51
Life Skills	$ 75.00

4103.6 The per diem reimbursement rate for providers of in-home active treatment services shall be $ 94.80.

4103.7 The per diem reimbursement rate for providers of active treatment services, excluding supported employment, that are enrolled in the Medicaid program on or after October 1, 2010, shall be $ 94.80.

4103.8 The per diem reimbursement rate for providers of supported employment active treatment services that are enrolled in the Medicaid program on or after October 1, 2010, shall be $ 169.50.

4103.9 Effective October 1, 2011, and annually thereafter, the active treatment services per diem rates set forth in §§ 4103.5 through 4103.8 shall be adjusted for inflation in accordance with the CMS Skilled Nursing Facility Market Basket Index or other similar index if the CMS Skilled Nursing Facility Market Basket Index is discontinued.

4104 PLANT AND CAPITAL

4104.1 The per diem reimbursement rate for plant and capital for each ICF/MR shall be

developed pursuant to the requirements set forth in this section.

4104.2 Each ICF/MR enrolled in the Medicaid program on or after October 1, 2010, shall

be reimbursed pursuant to the new methodology for plant and capital set forth in

sections 4104.6 through 4104.10.

4104.3 Each ICF/MR enrolled in the Medicaid program prior to October 1, 2010, shall be

transitioned to the new methodology for plant and capital as set forth in section

4104.5 beginning October 1, 2010, through October 1, 2015.

4104.4 The previous methodology for plant and capital shall consist of the capital

costs calculated pursuant to the facility’s 1993 audited cost report or costs from

the facility’s initial cost reported period, whichever is later and adjusted for inflation in accordance with the CMS Skilled Nursing Facility Market Basket Index. If the provider is reimbursed an interim rate for capitol costs under the previous methodology the interim rate shall be used until the rate has been audited and finalized.

4104.5 The plant and capital per diem for each ICF/MR enrolled in the Medicaid program prior to October 1, 2010, shall be calculated as follows:

(a) Beginning October 1, 2010, through September 30, 2011, the facility’s plant and capital shall be eighty percent (80%) of the facility’s capital per diem in accordance with the previous methodology for plant and capital as described in section 4104.4 plus twenty percent (20%) of the new methodology calculated pursuant to sections 4104.6 through 4104.10.

(b) For the District’s FY 2012, the facility’s plant and capital per diem shall be sixty percent (60%) of the facility’s capital per diem in accordance with the previous methodology as described in section 4104.4 plus forty percent (40%) of the new methodology calculated pursuant to sections 4104.6 through 4104.10.

(c) For the District’s FY 2013, the facility’s plant and capital per diem shall be forty percent (40%) of the facility’s capital per diem in accordance with the previous methodology as described in section 4104.4 plus sixty percent (60%) of the new methodology calculated pursuant to sections 4104.6 through 4104.10.

(d) For the District’s FY 2014, the facility’s plant and capital per diem shall be twenty percent (20%) of the facility’s capital per diem in accordance with the previous methodology as described in section 4104.4 plus eighty percent (80%) of the new methodology calculated pursuant to sections 4104.6 through 4104.10.

(e) For the District’s FY 2015 and each fiscal year thereafter, the facility’s plant and capital per diem shall be one hundred percent (100%) of the new methodology calculated pursuant to sections 4104.6 through 4104.10.

4104.6 The per diem reimbursement for plant and capital under the new methodology shall be the sum of the following:

(a) Facility capital per diem;

(b) Facility maintenance per diem; and

4104.7 The facility’s capital per diem shall be equal to the facility’s rental value per month divided by the number of patient days for the facility for the preceding year as reported in the facility’s cost report.

4104.8 The facility’s rental value per month shall be calculated as follows:

(a) Establish the facility’s current value. The current value shall be based upon the assessed value of the property as determined by the D.C. Office of Tax and Revenue for the 2009 tax year.

(b) The amount established in section 4104.8(a) shall be adjusted for depreciation. The depreciation rate shall be two and fifty-six hundredth percent (2.56%).

(c) The facility’s current value adjusted for depreciation shall be multiplied by the rental rate value of sixteen and half percent (16.5%).

(d) The amount established in section 4104.8(c) shall be divided by twelve (12) to obtain the facility’s rental value per month.

4104.9 A facility maintenance allowance of three thousand dollars ($3,000.00) per facility shall be established per facility per year for each facility. The facility maintenance per diem shall equal three thousand dollars ($3,000.00) divided by the number of patient days for the facility for the preceding year as reported in the facility’s cost report.

4104.10 A facility’s equipment per diem allowance of two hundred fifty dollars ($250.00) per bed per year shall be established for each facility. The equipment per diem shall be established as follows:

(a) Multiply the number of licensed beds in the facility by two hundred fifty dollars ($250.00);

(b) The amount established in section 4104.10(a) shall be depreciated over five (5) years using straight-line depreciation; and

(c) The amount established in section 4104.10(b) shall be divided by the number of patient days for the facility for the preceding year as reported in the facility’s cost report to obtain the facility’s equipment per diem.

4105 TEMPORARY RATE ADJUSTMENT

4105.1 Each ICF/MR may receive a temporary rate adjustment subject to the requirements set forth in this section.

4105.2 The temporary rate adjustment shall be a negotiated rate and shall be awarded only after consideration of the ICF/MR historical payment levels and need.

4105.3 To qualify for a temporary rate adjustment each provider shall meet at least one (1) of the following requirements:

(a) The number of beneficiaries residing in a facility is less than four (4); or

(b) The provider is financially distressed as described in § 4105.4.

4105.4 A provider shall be considered financially distressed if any of the following

conditions have been met:

(a) Thirty-five percent (35%) or more of the facility’s vendor accounts are overdue by more than one hundred twenty (120) days following submission of an accurate and acceptably filed claim;

(b) Required employee pension and health insurance contributions are more than sixty (60) days overdue;

(c) The facility continues to maintain an unfavorable ratio of working capital assets to liability for more than one (1) year;

(d) The facility continues to incur significant operating losses or maintain minimal equity or reserves for more than one (1) fiscal year; or

(e) Any other compelling circumstances determined by the District.

4105.5 Each provider shall submit an application to DHCF which shall include the amount of the proposed temporary rate adjustment, a financial review prepared by the provider, documentation of the facility’s income and expenses for the preceding twelve (12) months and specific steps taken by the facility to reduce costs or increase occupancy if the number of beneficiaries residing in the facility is less than four (4).

4105.6 DHCF may request additional financial documentation in support of the request for a temporary rate adjustment from the individual facility as well as the corporate entity, if applicable.

4105.7 DHCF shall have the right to conduct its own independent financial review of the

facility prior to making a decision whether to approve a temporary rate adjustment.

4105.8 DHCF may consider the following criteria when evaluating whether a facility is

financially distressed:

(a) The frequency of advances from District government agencies, if applicable;

(b) Unfavorable ratio of working capital assets to liabilities;

(d) Significant increases in accounts payable, unpaid local taxes, fees or payroll related costs;

(e) Minimal or decreasing equity or reserves;

(f) High levels or significant increases in debt or borrowing costs; and

(g) Significant operating losses for two (2) or more years.

4105.9 If DHCF determines that the facility is in imminent peril of closing, DHCF may

approve a temporary rate adjustment not to exceed ninety (90) days.

4105.10 If the facility requests a temporary rate adjustment in excess of ninety (90) days, the Facility shall demonstrate that:

(a) The facility has taken all reasonable steps to reduce costs, increase revenue or increase occupancy;

(b) Despite taking the reasonable steps listed above, the facility continues to lose money and is predicted to continue losing money for at least the next month; and

(c) The amount of the approved temporary rate adjustment shall allow the facility to pay expenses and continue to support the needs of the individuals residing in the facility, without unduly enriching the owners of the facility.

4105.11 DHCF shall approve any extension of the temporary rate adjustment in excess of ninety (90) days. Extensions of the temporary rate adjustment shall be limited to three (3) additional thirty (30) day periods.

4105.12 After approval of a temporary rate adjustment, the provider shall develop and submit a plan of correction to DHCF for approval.

4105.13 The plan of correction shall:

(a) Articulate significant risks facing the provider including an assessment of the risks and management’s plan for mitigating the risks;

(b) List measurable goals to be attained by the provider;

(d) Identify the individual manager or stakeholder responsible for each goal.

4105.14 DHCF’s decision to extend the temporary rate adjustment beyond ninety (90) days shall be based on the provider attaining the goals and milestones set forth in the plan of correction and its overall compliance with the Plan.

4105.15 DHCF may seek alternative placements for beneficiaries in the financially distressed facility.

4106 SUPPLEMENTAL PAYMENT FOR QUALITY OF CARE IMPROVEMENTS

4106.1 Consistent with the requirements set forth in the Stevie Sellows Intermediate Care Facility for the Mentally Retarded Quality Improvement Act of 2005, effective March 8, 2006 (D.C. Law 16-68; D.C. Official Code § 47-1270 et seq.), each ICF/MR that meets the criteria set forth in §§ 4106 through 4109 may receive a supplemental payment for quality of care improvements.

4106.2 The supplemental payment shall be developed based on the cost of salary increases, benefit increases, and training provided to employees other than managers, administrators, and contract employees. The amount and availability of the supplemental payment are contingent upon the availability of funding from DHCF.

4106.3 To qualify for a supplemental payment, an ICF/MR shall, by June 30^th of the prior fiscal year, submit to DHCF all of the following:

(a) Proof of a legally binding written agreement with its employees, excluding managers, administrators and contract employees which meets the requirements set forth in § 4107 to fund quality of care improvements through measurable efforts to do one (1) or both of the following:

(1) Retain staff by increasing staff salaries and/or benefits; and

(2) Develop and improve staff skills by increasing staff training and educational opportunities.

(b) Proof of an enforcement mechanism of the written commitment to fund quality of care improvements, such as arbitration, that is:

(1) Expeditious;

(2) Uses a neutral decision maker;

(3) Economical for the employee; and

(4) Available to the employees or their representatives.

(c) Proof that the facility has provided written notice of the terms of the commitment and the availability of the enforcement mechanism to the relevant employees or their recognized representatives consistent with the requirements set forth in § 4108;

(d) Documentation verifying the costs of salaries, benefits and training for purposes of determining the facility’s supplemental payment; and

(e) Any other information requested by DHCF.

4106.4 For the initial year of implementation, DHCF shall issue a transmittal to all providers which shall include a listing of all information, including any documents that are required to be submitted to DHCF and the timeframes for submission.

4106.5 An annual salary cost amount shall be established for salary increases for employees other than managers, administrators and contract employees. The annual value of the salary amount shall be determined by multiplying the difference between the increased hourly wage committed and/or paid by the provider and the base year hourly wage, by the estimated annual number of employee hours to be worked by these employees for the period of the year during which the salary increase is in effect. For purposes of this calculation, in the first year of implementation base year wages shall be the wage amounts in place as of September 30, 2008. Thereafter, the base year to be used in the computation shall be determined by DHCF. Wage increases implemented by the provider other than increases mandated by a legislative increase to the minimum wage after the initial year of implementation shall be counted for purposes of determining the annual salary amount.

4106.6 An annual benefit amount shall be established for increases in employee benefits for employees other than managers, administrators and contract employees. Benefits eligible for inclusion in the benefit cost amount shall include the following:

(a) Employer contributions to deferred compensation plans which meet the requirements set forth in § 4109.1;

(b) Employer contributions to an employee retirement plan or pension plans which meet the requirements set forth in § 4109.2;

(c) Employer costs of health, disability and life insurance programs paid or incurred by the provider if the benefits of the policy are payable to the employee or his beneficiary; and

(d) Employer costs of vacation allowance, sick leave or other paid leave.

4106.7 The annual value of the benefit amount shall be determined by multiplying the difference between the increased per employee cost to be incurred by the provider for increases in benefits and the base year per employee benefit cost, by the estimated number of employees, excluding managers, administrators and contract employees who shall receive the benefit. For purposes of this calculation in the first year of implementation the base year benefit amount shall be the benefits amounts in place as of September 30, 2008. Thereafter, the base year to be used in the computation shall be determined by DHCF.

4106.8 A training cost amount shall be established for training employees other than managers, administrators and contract employees. The training cost amount shall be the actual cost incurred by the provider. To qualify for inclusion, the training cost shall meet all of the following requirements:

(a) Be related to patient care;

(b) Be related to improving the skills, competency and qualifications of employees in providing care; and

4106.9 The supplemental payment amount to be made to an ICF/MR that meets the criteria set forth in §§ 4106.5 through 4106.8 shall be determined as follows:

(a) The sum of the annual salary, benefit and training amounts as set forth in §§ 4106.5 through 4106.8 shall be divided by the estimated annual number of employee hours, excluding managers, administrators and contract employees;

(b) A gross supplemental payment amount shall be established, which is the lesser of the amount determined in § 4106.9(a) or two dollars and fifty cents ($2.50), multiplied by the estimated annual number of hours for employees other than managers, administrators and contract employees;

(c) Subject to the limitations set forth in § 4106.9(d), the supplemental payment amount to be made to an eligible provider is established by multiplying the gross supplemental payment amount determined in § 4106.9(b) by the facility’s ratio of Medicaid days to total days; and

(d) If the total amount of payments to be made to all eligible providers exceeds the amount appropriated for such payments, the payments to all eligible providers shall be proportionately reduced.

4106.10 DHCF shall issue a Notice of Eligibility and Proposed Reimbursement to each

provider within sixty (60) days of receipt of all required information. The written

notice shall contain at a minimum all of the following information:

(a) A determination indicating whether the provider is eligible or ineligible to receive the supplemental payment;

(b) If a provider is determined to be ineligible to receive the supplemental payment, a written statement explaining why the facility is ineligible;

(d) The annual number of employee hours, excluding managers, administrators and contract employees; and

(e) Language describing the procedures and timeframes for requesting an

administrative review with DHCF.

4106.11 A provider who disagrees with the Notice of Eligibility and Proposed Reimbursement may request an administrative review by submitting a written request for an administrative review to DHCF within thirty (30) days after the date of the Notice of Eligibility and Proposed Reimbursement.

4106.12 The written request for an administrative review shall include:

(a) The reason(s) for the request, including an identification of the specific item(s) to be reviewed; and

(b) Supporting documentation.

4106.13 No later than ninety (90) days of receipt of all requests for administrative review

DHCF shall issue a Final Notice of Eligibility and Reimbursement to each provider that has applied for the supplemental payment. The notice shall contain at a minimum the following information:

(a) A final determination indicating whether the provider is eligible to receive the supplemental payment. If ineligible, the notice shall contain a written statement explaining why the provider is ineligible;

(b) The total amount of the supplemental payment, including the annual salary, benefit and training cost amounts;

(d) The timeframe for payment of the supplemental payment; and

(e) Language describing the procedures and timeframes for requesting an appeal with the Office of Administrative Hearings.

4106.14 A provider who disagrees with the Final Notice of Eligibility and Reimbursement

may file an appeal with the Office of Administrative Hearings within forty-five (45) days of the date of the Final Notice of Eligibility and Reimbursement.

4106.15 Any adjustments to the supplemental payment as a result of a decision rendered by the Office of Administrative Hearings shall be offset against payments the following fiscal year.

4106.16 DHCF reserves the right to inspect relevant payroll and personnel records of each

facility receiving funds pursuant to this section to ensure that quality of care improvements have been implemented. DHCF reserves the right to conduct audits or reviews to ensure that the salary, benefit or training increases were paid in the

manner specified in the written commitment and ensure that the full distribution

of funds received from DHCF was made to covered employees.

4106.17 Each ICF/MR shall maintain records , including but not limited to employee time sheets, employee files and payroll records that substantiate compliance with the requirements governing the supplemental payment for three (3) years following the end of the supplemental payment period in which funding under the Quality Improvement Fund Program was received.

4106.18 DHCF shall terminate the quality improvement funding for an ICF/MR if it determines the binding written commitment described in § 4107 has expired and does not otherwise remain enforceable. Any overpayment to the provider shall be promptly returned. DHCF may offset the amount owed against other amounts owed to the facility if the funds are not returned.

4106.19 If a facility underestimates the salary and benefits amounts in its request for a supplemental payment for quality of care improvements, DHCF shall not provide additional funds for the difference between the amount requested and the actual costs incurred by the facility for salary and benefits increases for covered employees.

4106.20 If, subsequent to the approval of the supplemental payment for quality of care improvements, a facility is unable to fully distribute, in accordance with the request approved by DHCF, the amount of funds received, for example due to changes in the facility’s workforce, the facility shall return the undistributed funds to DHCF within thirty (30) days following receipt of the funds. DHCF may offset the amount owed against other amounts owed to the facility if the funds are not returned.

4106.21 If, subsequent to the approval of the supplemental payment for quality of care improvements, a facility closes or otherwise ceases to be an ICF/MR enrolled in the D.C. Medicaid program, the facility shall return to DHCF the prorated amount of the payment based on the effective date of the closure or change in status.

4106.22 Each fiscal year DHCF shall list on its web-portal the name of each applicant for the supplemental payment and the name of each ICF/MR that received a supplemental payment.

4107 WRITTEN AGREEMENT AND COMMITMENT

4107.1 The written agreement set forth in §4106.3(a) shall meet all of the following requirements:

(a) Specify the employee classification(s) that are covered by the written commitment;

(b) Specify the incremental amount or the percentage increase of the base salary and benefits, and the training costs that covered employees in each employee classification are to receive under the terms of the written commitment during the fiscal year, or any part of the fiscal year;

(d) Provide that any salary, benefit, or training increase specified in the written commitment supersedes any oral or written statements previously provided to covered employees regarding salaries, benefits, or training;

(e) Provide that the salary, benefit, or training increases apply to both existing and newly hired covered employees;

(f) Specify the enforcement mechanism available to covered employees and ensure a neutral decision maker;

(g) Provide that the timelines for resolving a dispute conclude no later than sixty (60) days from receipt of a written challenge of non-compliance, or adhere to the timelines contained in the rules or policies of a professional dispute resolution service;

(h) Provide that the facility will not recover funds paid to the covered employees by compensation offset, or otherwise, in the event DHCF initiates a recoupment of funds and related penalties;

(i) Provide that a covered employee’s enforcement or attempted enforcement of the written commitment shall not constitute a basis for disciplinary or adverse action against that covered employee;

(j) Provide that the method of enforcement of the written commitment does not preclude a covered employee from filing a complaint concerning the written commitment with a federal, state, or other governmental administrative agency statutorily charged with protecting the rights of employees;

(k) Provide that the enforcement mechanism is economical and low-cost to the employee;

(l) Specify the conditions and processes for amending the written commitment; and

(m) Specify the conditions and processes for terminating the written commitment.

4107.2 An ICF/MR may condition its written commitment to increase salaries, benefits, or training of covered employees upon approval by DHCF or receipt of funding of the supplemental payment.

4107.3 An ICF/MR shall immediately notify DHCF of the termination or any amendment to the written commitment.

4108 WRITTEN NOTICE REQUIREMENTS

4108.1 A facility shall provide written notice to the covered employee or the covered employee’s authorized representative of the specific terms of the written commitment by one of the following means:

(a) Broad distribution to the covered employees and the covered employees’ authorized representative, if applicable, by including the written notice in employee handbooks, manuals, mailbox distribution, staff mailing to home addresses, handouts, or stuffers in pay envelopes;

(b) Distribution to a recognized collective bargaining representative who is the legal representative of the covered employees consistent with federal or state law; or

(c) Distribution to individual covered employees and have those employees acknowledge receipt of the written notice by signature.

4108.2 If the terms of the written commitment are modified, a new written notice describing the modifications shall be distributed to the covered employees in accordance with the requirements of this section.

4109 DEFERRED COMPENSATION AND RETIREMENT PLANS

4109.1 Employer contributions to deferred compensation plans may be considered as an eligible expense for purposes of determining the supplemental payment for quality of care improvements if there is a written agreement between the provider and participating employees. A written plan shall be established and maintained by the provider and communicated to all eligible employees. The written plan shall meet all of the following requirements:

(a) Prescribe the method for calculating all contributions to the fund;

(b) Be funded with contributions made systematically to a funding agency outside the provider’s ownership or control, such as a trustee, an insurance company, or a custodial bank account;

(d) Designate the requirements for vested benefits;

(e) Provide the basis for the computation of the amounts of benefits to be paid;

(f) Be expected to continue despite normal fluctuations in the provider’s economic experience; and

(g) Use all fund contributions and earnings for the sole benefit of the participating employees.

4109.2 Employer contributions to an employee retirement fund or pension plan may be considered as an eligible expense for purposes of determining the supplemental payment for quality of care improvements if all of the following conditions have been met:

(a) The pension plan shall meet all the requirements of a deferred compensation plan, as enumerated in §4109.1;

(b) All employees’ pension fund rights shall be non-forfeitable after such time as they vest under the plan;

(d) Contributions representing the employee’s share cannot revert to the provider, but the employer-paid contributions can revert to the provider in the event an employee does not vest.

4110 RESIDENT TRANSFER AND DISCHARGE

4110.1 Each ICF/MR that is planning a non-emergency voluntary or involuntary transfer or discharge of a beneficiary shall provide the following:

(a) Written notice to DHCF at least sixty (60) days prior to the transfer and discharge. The written notice shall include the name of each beneficiary, the beneficiary’s Medicaid identification number, the number of individuals being transferred or discharged, the address of the current placement and provider identification number, the name and address of the facility where the individual is transferring or being discharged and the reason for the transfer or discharge. If the beneficiary is enrolling in a Home and Community Based Waiver, then a copy of the relevant waiver documents shall be included with the written notification;

(b) Comprehensive relocation assistance and counseling to each beneficiary that is transferred or discharged; and

(c) A written summary which identifies the beneficiary’s needs and the required services to be provided in the new placement.

4110.2 In addition to the requirements set forth in § 4110.1, each ICF/MR shall also

comply with District and federal laws and rules governing transfers and discharges.

4111 REBASING

4111.1 No later than October 1, 2012, and every three (3) years thereafter, the reimbursement rates for residential services and plant and capital shall be updated.

4112 COST REPORTING

4112.1 Each participating facility shall report direct service, active treatment and plant and capital costs on an annual basis to DHCF no later than six (6) months after the District’s fiscal year.

4112.2 The data described in § 4112.1 shall be reported on a cost report template designed by DHCF. The cost report shall be properly completed in accordance with program instructions.

4112.3 The cost report instructions shall include, but not be limited to, guidelines and

standards for determining and reporting allowable costs.

4112.4 A cost report that is not completed as required in § 4112.2 shall be considered an

incomplete filing and the facility shall be so notified.

4112.5 Providers that fail to submit a completed cost report within twelve (12) months of the end of the District’s fiscal year shall be considered in violation of the Medicaid provider agreement and may be subject to termination from the Medicaid program.

4113 FISCAL ACCOUNTABILITY

4113.1 Each facility shall spend at least eighty percent (80%) of the facility’s beneficiary service revenue on direct service and active treatment services.

4113.2 Each facility whose direct service costs and active treatment costs are less than seventy-five percent (75%) of the beneficiary service revenues shall be required to pay DHCF the difference between their beneficiary service costs and eighty (80%) of the facility’s beneficiary service revenues.

4113.3 Each facility whose direct service costs and active treatment costs are less than eighty (80%) but greater than or equal to seventy-five (75%) of the beneficiary service revenues shall be required to repay DHCF seventy-five (75%) of the difference between their beneficiary service costs and eighty (80%) of the facility’s beneficiary service revenues.

4113.4 If a provider fails to submit a cost report consistent with the instructions, guidelines and procedures issued by DHCF, the provider shall be assumed to have direct service costs and active treatment costs equal to sixty-five (65%) of the beneficiary service revenues and shall repay DHCF consistent with the requirements set forth in § 4113.2.

4114 RATE LETTERS AND APPEALS

4114.1 The reimbursement rates for a provider entering the Medicaid Program after October 1, 2010, shall be set in a timely manner and no later than fourteen (14) business days after a Medicaid provider number has been issued and receipt of all required documentation.

4114.2 Prior to initial implementation and each fiscal year thereafter, DHCF shall issue each ICF/MR a rate letter.

4114.3 The rate letter shall include all of the following information:

(a) A listing of each beneficiary and their LON;

(b) The residential rate component for each beneficiary;

(d) The plant and capital rate component for each beneficiary; and

(e) Procedures and timeframes for requesting an administrative review and appeal before the Office of Administrative Hearings.

4114.4 Provider appeals shall be limited to:

(a) Plant and Capitol component rate;

(b) Calculation of the active treatment component; and

4199 DEFINITIONS

4199.1 For purposes of this chapter, the following terms shall have the meanings ascribed:

Active treatment services - A program of specialized and generic training, treatment, health services and related services designed toward the acquisition of the behaviors necessary for the beneficiary to function with as much self-determination and independence as possible, and the prevention or deceleration of regression or loss of current optimal functional status. These services shall be provided consistent with the federal standard.

Acuity - The level of care required for an individual in an ICF/MR. Customers with a high acuity level require more care; those with lower acuity levels require less care.

Administrator - An employee that administers or implements facility policies or

procedures other than through services directly related to resident treatment and care, food service or maintenance of the facility.

Allowable costs - Actual costs, after appropriate adjustments, incurred by an ICF/MR, which are reimbursable under the Medicaid Program.

Base year - The standardized year on which rates for all facilities are calculated to derive a prospective reimbursement rate.

Beneficiary service revenue - The sum of the direct service component of the

residential services rate and the active treatment rate, multiplied by the number

of allowable units paid for services provided during the reporting period.

Covered employee - An existing or newly hired employee, other than a manager or

administrator who is covered by the written committee as described in section 4107;

is paid by the facility; performs services on behalf of the facility and is not a

government employee or employee working at the facility through a registry or a

temporary.

Deferred compensation - Remuneration currently earned by an employee but is not received until a subsequent period, usually after retirement.

Depreciation - The systematic distribution of the cost or other basis of depreciable assets, less salvage value, over the estimated useful life of the assets.

Direct service costs - Costs incurred by a provider that are attributable to the operation of providing services to beneficiaries.

Facility - An intermediate care facility for the mentally retarded.

Facility maintenance - Operations and maintenance of the facility that includes day to day activities necessary for building and its systems and equipment to perform their intended function.

Individual support plan (ISP) - The successor to the Individual Habilitation Plan as defined in the court-approved Joy Evans Exit Plan.

Interdisciplinary team - A group of persons with special training and experience in the diagnosis and habilitation of mentally retarded persons which has the responsibility of performing a comprehensive evaluation of each beneficiary and participating in the development, implementation and monitoring of the beneficiary’s individual habilitation plan. The “core team” shall include the beneficiary and beneficiary’s representative, the case manager, and relevant clinical staff.

Manager - An employee who is responsible for formulating and administering facility policies; and customarily and regularly directs the work of two or more

of the facility except for nursing staff or staff that provides indirect services such as

dietary and housekeeping; or has the authority to hire and fire other employees of

the facility; or has sole charge of the facility; or has at least twenty percent (20%)

ownership interest in the facility.

Medically fragile - A weakened medical state in which an individual is susceptible to disruptions in one’s physical, emotional, and functional well-being.

Owner - A person who is a sole proprietor, partner, or corporate stockholder-employee owning any of the outstanding stock of the contracted provider.

Patient day - Care of one patient during the day of service. The day of admission is counted as a day of care but the discharge is not counted as a day of care.

Pension plan - A type of deferred compensation plan which is established and maintained by the employer to provide systematic payment of definitely determinable benefits to its employees over a period of years, or for life, after retirement. Such a plan may include disability, withdrawal, option for lump-sum payment, or insurance or survivorship benefits incidental and directly related to the pension benefits.

Per diem rate - The rate per day established by DHCF.

Program - The District of Columbia Medicaid Program as administered by the Department of Health Care Finance.

Quality of care improvements - The same definition as set forth in D.C. Official Code § 47-1270.

Comments on the proposed rule shall be submitted, in writing, to Julie Hudman, Ph.D., Director, Department of Health Care Finance, 825 North Capitol Street, N.E., 6^th Floor, Washington, D.C. 20002, within thirty (30) days from the date of publication of this notice in the D.C. Register. Copies of the proposed rule may be obtained from the same address.

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603745 Medicaid Reimbursement for ICF/MR

DEPARTMENT OF HEALTH CARE FINANCE

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