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Nursing Facility Rate Setting Unit:

  • Perform desk audits of the Nursing Facility's (NF) annual cost report.
  • Calculate per diem rates for proprietary and voluntary facilities (Class I) and governmental peer facilities (Class II).
  • Establish median and screen limits in the implementation of the per diem rates.
  • Establish NF per diem rates for 340 nursing facilities.
  • Establish governmental peer rates for 20 county facilities.
  • Evaluate and process Level I Appeals.
  • Prepare analysis of fiscal impact in the preparation of the budget initiatives.
  • Represent the Department in the hearings of the Office of Administrative Law (OAL) if required.
  • Develop and interpret policy and regulation regarding nursing facility reimbursement methodology
  • Review state plan amendments for submission to the Federal Health Care Financing Administration. 

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 Special Program Unit:

The Special Care Nursing Facility (SCNF) rate setting processes annual cost reports, and calculates and develops limits in order to establish SCNF (Class III) annual per diem rates for 28 SCNFs.

  • The SCNFs provide services to Ventilator, Traumatic Brain/Injury/Coma, Pediatric, HIV (AIDS), Neurologically Impaired, young Adult/Huntington's Disease, and Behavioral Management patients
  • Of these 28 Special Care facilities, 5 are free standing, 17 share a section of a facility with a NF, and 6 are located in a section of a Hospital.
  • Process cost reports and performs desk audits for twenty-four (24) combined NF/SCNF facilities in order to establish the NF (Class I and Class II) annual per diem rates.
  • A total of 591 Medicaid beneficiaries were cared for in these SCNF's.
  • Process and evaluate Level I Appeals for SCNFs and NF rates for "combined" facilities.
  • Evaluates outstanding audit issues at audit meetings.
  • Represent the Department in the hearings of the Office of Administrative Law (OAL) for combined NF/SCNF facilities and all special care nursing facilities.

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 Fiscal/Regulations Compliance Unit:

  • Draft Public Notices, State regulations, State Plans, related to NF reimbursement.
  • Develop and implement nursing facility reimbursement policy.
  • Prepare correspondence in response to provider and constituent inquiries.
  • Prepare special projects/fiscal analysis related to NF reimbursement.
  • Facilitate and assist the vendor of the rate setting RFP for changes of the reimbursement system.
  • Provide information and assistance to the Office of Management and Budget (OMB) related to yearly budget initiatives and other issues.
  • Calculate Appropriation Act add-ons for High Medicaid occupancy in qualified facilities.
  • Coordinate IGT (Intergovernmental Transfers) data accumulation and summary proposal.
  • Compile the necessary statistics and data for the Provider Assessment calculations.

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 Audit Liaison/Rate Implementation Unit:

  • Recalculate rates to reflect the results of nursing facility audits.
  • Implement NF and SCNF per diem rates and mass adjustments to reflect retroactive per diem rate changes through the Unisys System.
  • Prepare the annual audit plan of the nursing facility rate reimbursement system.
  • Establish Medical Day Care and Respite Care rates. Implement mass adjustments to reflect retroactive rate change through the Unisys system.
  • Calculate interest on per diem and income audit overpayments.
  • Review income audit findings to determine date of overpayments to be used in the calculations of interest assessments.
  • Initiate update of the Office of Auditing Status Report monthly and maintain other files and records pertaining to per diem and income audit statistics.
  • Prepare annual projections of impact of revenues realized by governmental facilities receiving governmental peer rates.

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 Nursing Facility Medians and Limits (All Classes):

  • For additional rate setting information, please visit the website of Myers & Stauffer.
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