Updates on Long-Term Living Programs and Nursing Facility Funding
Daniel Sharar
Finance Director
Office of Long-Term Living
Department of Human Services
Leading Age PA Webinar
Leading Age PA Webinar
DHS Updates
DHS Updates
November 16, 2022
November 16, 2022
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$250,000,000 for Long-Term Living Programs
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Must be in operation of July 1, 2022
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Funding cannot be reimbursed by another funding source
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One-time payments to use for COVID-19 related costs
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Report in a form and manner prescribed by DHS
Nursing Facility Allocations
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$131,157,000 – Nursing Facilities – county and nonpublic
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$104,926,000 – MA days – 3rd quarter of 2021
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$26,231,000 – licensed beds as of July 1, 2022
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$4,283,000 – MA ventilator or tracheostomy nursing facilities
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Based on the payment made through Act 56 of 2021 – quarter ending March 31, 2022
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General Appropriations Act
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Community HealthChoices: $5.061B (State), $7.514B (Federal), $348.966M (Lottery), $156.622M
(Tobacco)
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Long-Term Living: $165.981M (State), $144.183M (Federal)
Act 54 of 2022 (Fiscal Code Updates) Provisions that Affect Nursing Facilities and Rates
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Nursing Facility Rates (Section 1602-T)
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BAF reauthorized through 6/30/2026 or new rate methodology (Section 1602-T)
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Minimum payment rate for NF Rates in CHC through 12/31/2025 – no less than the FFS rates
(Section 1602-T)
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NF Assessment Reauthorized through 6/30/2026 (Section 1606-T)
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NFs must devote 70% of their total costs to resident care and related costs (Section 1603-T)
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Reported through MA-11 cost-reports and supplemental cost reporting form (Section 1603-T)
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Penalty goes into new fund for NF quality improvement (Section 1603-T)
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Funding for a 17.5% rate increase starting 1/1/2023 (Section 1730-F.1.)
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Fiscal Code Section 1602-T
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(1) Payments to county and nonpublic nursing facilities enrolled in the medical assistance program as
providers of nursing facility services shall be determined in accordance with the methodologies for
establishing payment rates for county and nonpublic nursing facilities specified in the Department of
Human Services' regulations and the Commonwealth's approved Title XIX State Plan for nursing
facility services in effect after June 30, 2007.
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Continues case mix rate methodology for 2022-23 for nursing facilities in accordance with the Title
XIX approved State Plan and 55 Pa. Code Chapter 1187 (for nonpublic facilities) and 55 Pa. Code
Chapter 1189 (for county facilities).
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Case mix rate methodology applies to FFS rate setting.
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Fiscal Code Section 1730-F.1.
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(vii) Subject to Federal approval, sufficient funds are included to provide a 17.5% annualized rate
increase effective January 1, 2023, that is calculated in accordance with section 443.1 of the Human
Services Code and 55 Pa. Code Chs. 1187 (relating to nursing facility services) and 1189 (relating to
county nursing facility services), including for costs associated with compliance with section 1603-T.
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Authorizes funding for NF services and staffing effective January 1, 2023.
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Increased funding provides additional base-level support to NFs in advance of Department of Health
staffing regulations (For state fiscal year 2023-24, the proposed regulatory change is from 2.7
hours/day minimum direct resident care to 2.87 hours/day).
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NFs are still eligible for quality incentives above and beyond base-level support.
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Fiscal Code Section 1602-T
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(i) Subject to Federal approval of such amendments as may be necessary to the Commonwealth's
approved Title XIX State Plan, the Department of Human Services shall apply a revenue adjustment
neutrality factor to county and nonpublic nursing facility payment rates so that the estimated
Statewide day-weighted average payment rate in effect for that fiscal year is limited to the amount
permitted by the funds appropriated by the General Appropriation Act for the fiscal year. The revenue
adjustment neutrality factor shall remain in effect until the sooner of June 30, 2026, or the date on
which a new rate-setting methodology for medical assistance nursing facility services which replaces
the rate-setting methodology codified in 55 Pa. Code Chs. 1187 (relating to nursing facility services)
and 1189 (relating to county nursing facility services) takes effect.
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Continues the BAF through June 30, 2026 or the date on which a new rate-setting methodology
replaces case mix methodology established in 55 Pa. Code Chapters 1187 (nonpublic nursing facility
services) and 1189 (county nursing facility services).
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Fiscal Code Section 1602-T
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(ii) Subject to Federal approval as may be necessary, the following shall apply to nonpublic and
county nursing facility payment rates, to the extent funds are appropriated for the purpose of rate
increases for increased direct resident care requirements and resident care and related costs:
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(A) Beginning January 1, 2023, the Department of Human Services shall make capitation
payments to medical assistance Community HealthChoices managed care organizations that
include amounts exclusively for the purpose of making payments to nonpublic nursing facilities
and county nursing facilities as provided under clause (B)(I).
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(B) The Department of Human Services shall adopt a minimum payment rate for payments for
services rendered to medical assistance recipients under the Community HealthChoices program,
effective with dates of service of January 1, 2023, through December 31, 2025, as follows:
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(I) Community HealthChoices managed care organizations shall apply no less than the
minimum payment rate to make payments to nonpublic nursing facilities and county nursing
facilities for services rendered to medical assistance recipients under the Community
HealthChoices program.
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(II) The minimum payment rate shall be greater than or equal to the following amounts:
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(a) For nonpublic nursing facilities, the nursing facility case-mix rates calculated in
accordance with 55 Pa. Code Ch. 1187 and the Commonwealth's approved Title XIX
State Plan in effect for the dates of service.
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(b) For county nursing facilities, the county nursing facility rates in accordance with 55
Pa. Code Ch. 1189 and the Commonwealth's approved Title XIX State Plan in effect for
the dates of service.
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Establishes a minimum payment rate for services provided to MA recipients under the CHC program
through December 31, 2025, to the extent funds are appropriated.
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CHC MCOs must apply no less than the minimum payment rate for nursing facility services.
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Minimum payment rate is the FFS case mix (aka CMI rates or final rates) for nonpublic and county
nursing facilities.
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Quarterly CMI adjustments still apply for nonpublic NFs (annual adjustment for county NFs)
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Fiscal Code Section 1606-T
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Notwithstanding Section 815-A of the Act of June 13, 1967 (P.L. 31, No. 21), known as The Human
Services Code, the Assessment authorized in Article VIII-A of The Human Services Code shall be
imposed July 1, 2003, through June 30, 2026.
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Assessment Reauthorized through June 30, 2026
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Changes for State Fiscal 2022-23
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Fee Increases vs. SFY 2021-22 (both tiers increased by $3.76)
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Tier 1: $9.32 (CCRCs, 0-44 residents, MA Days >=90k & Occupancy >77%, county NFs)
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Tier 2: $33.41
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Calculation of Fees
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Q77 and Q78: Historical Quarters (RD Qtrs. Ended 3/31/2021 and 6/30/2021)
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Q79 and Q80: Quarters Ending 12/31/2022 and 3/31/2023
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Appendix 4 of CHC Agreements
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Appendix 4 funding is intended to help ensure quality of and access to NF services.
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Appendix 4 identifies a specific amount that MCOs must use to pay NFs for NF services and
requires the MCOs to demonstrate the funds were used in accordance with this
requirement.
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DHS is not
involved in or providing
any direction on how the funds are distributed.
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The MCOs and NFs negotiate how the Appendix 4 payments are distributed and paid
separately from the negotiated base rate payments from the MCOs.
CMS is now requiring Pennsylvania to transition Appendix 4 Nursing Facility Access to Care
Payments to a new payment methodology by January of 2023
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Transition to State Directed Payment (SDP)
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CMS is now requiring Pennsylvania to transition NF Access to Care Payments by January of
2023 to a new “State Directed Payment” methodology meeting a set of requirements under
42 CFR 438.6(c). Some of the key requirements include:
o
Must be tied to utilization and delivery of services under the managed care contract
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State oversight to ensure additional payments are linked to specific service or benefit
provided to specific participant
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Must use the same methodology for each provider within a class of providers
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Must advance at least one goal in the state’s managed care quality strategy
The
SDP proposed to CMS is a minimum per diem payment rate comprised of the FFS
base rate including an increase effective in 2023 PLUS the payments previously made
through the Appendix 4 Access to Care (NF Assessment funded)
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Nonpublic Nursing Facility State Directed Payment Rate 2023
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Proposed Draft Methodology for Nonpublic Nursing Facility per diem minimum payment rate is the sum of:
1.
Approved State Plan rate per diem as determined in accordance with State Plan Attachment 4.19 D;
hypothetical example $233.00
2.
A Nonpublic NF uniform per diem of $XX.XX per day;
hypothetical example $25.00
3.
Medicaid Allowable Assessment Cost Component calculated by multiplying the NF’s total cost of the
assessment by the NF’s Medicaid occupancy rate. The result is divided by the NF’s CHC days.
hypothetical
example $35.00
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Minimum per diem payment rate for this hypothetical Nonpublic NF is $293.00
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Fiscal Code Section 1603-T
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(1) The county or nonpublic nursing facility shall demonstrate on its submitted MA-11 that 70% of its
total costs, as reported by the facility, are resident care costs or other resident-related costs under 55
Pa. Code § 1187.51(e)(1) and (2) (relating to scope).
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Requires facilities to demonstrate 70% of total costs are resident care costs or other resident related
costs.
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Total Resident Cost of Care = Resident Care + Other Resident Related Costs (unallocated) from
Schedule C of MA-11
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Total Net Operating Costs = Total Expenses from Schedule C of MA-11 + Capital Costs
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Capital Costs = Real Estate Taxes, NF/HAI Assessment, Depreciation, Interest on Capital
Indebtedness, Rent, and Amortization of Capital Costs from Schedule C of MA-11 or supplemental
cost report form (for CCRCs)
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Fiscal Code Section 1603-T
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Percentage of Total Costs Devoted to Resident Care (70% minimum) = Total Resident Cost of Care ÷
Total Net Operating Cost
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Penalties Authorized by 1603-T(b):
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An amount equal to a facility’s difference between its Percentage of Total Costs Devoted to
Resident Care and the 70% Minimum, up to 5%
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Based on a review of MA-11 cost reports for the period ending 12/31/2023 and later.
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Penalties collected support the Nursing Facility Quality Improvement Fund.
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Provision expires December 31, 2025.
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(A) Use the lesser of the following:
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(I) Five.
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(II) The difference under subparagraph (i).
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(B) Multiply the lowest numeral under clause (A) by one hundredth (.01).
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(C) Multiply the product under clause (B) by the county or nonpublic nursing facility's fee-for-service per diem payment rate as of
June 30, 2022.
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(D) Multiply the product under clause (C) by the
total MA resident days of care
on the facility's MA-11.
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Recent updates highlight significant funding allocations for long-term living programs and nursing facilities in Pennsylvania. The Act 54 of 2022 provides $250 million for Long-Term Living Programs with specific allocations to nursing facilities based on various criteria. The FY 2022-23 Budget Enactment details appropriations for Community HealthChoices and Long-Term Living, along with provisions impacting nursing facility rates. Additionally, the Nursing Facility Rates section outlines payment methodologies and rate-setting criteria for county and nonpublic nursing facilities enrolled in the Medical Assistance program.
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Leading Age PA Webinar DHS Updates November 16, 2022 Daniel Sharar Finance Director Office of Long-Term Living Department of Human Services
Act 54 of 2022 Act 54 of 2022 ARPA Funding ARPA Funding $250,000,000 for Long-Term Living Programs Must be in operation of July 1, 2022 Funding cannot be reimbursed by another funding source One-time payments to use for COVID-19 related costs Report in a form and manner prescribed by DHS Nursing Facility Allocations $131,157,000 Nursing Facilities county and nonpublic $104,926,000 MA days 3rd quarter of 2021 $26,231,000 licensed beds as of July 1, 2022 $4,283,000 MA ventilator or tracheostomy nursing facilities Based on the payment made through Act 56 of 2021 quarter ending March 31, 2022 2
FY 2022 FY 2022- -23 Budget Enactment 23 Budget Enactment General Appropriations Act Community HealthChoices: $5.061B (State), $7.514B (Federal), $348.966M (Lottery), $156.622M (Tobacco) Long-Term Living: $165.981M (State), $144.183M (Federal) Act 54 of 2022 (Fiscal Code Updates) Provisions that Affect Nursing Facilities and Rates Nursing Facility Rates (Section 1602-T) BAF reauthorized through 6/30/2026 or new rate methodology (Section 1602-T) Minimum payment rate for NF Rates in CHC through 12/31/2025 no less than the FFS rates (Section 1602-T) NF Assessment Reauthorized through 6/30/2026 (Section 1606-T) NFs must devote 70% of their total costs to resident care and related costs (Section 1603-T) Reported through MA-11 cost-reports and supplemental cost reporting form (Section 1603-T) Penalty goes into new fund for NF quality improvement (Section 1603-T) Funding for a 17.5% rate increase starting 1/1/2023 (Section 1730-F.1.) 3
Nursing Facility Rates Nursing Facility Rates Fiscal Code Section 1602-T (1) Payments to county and nonpublic nursing facilities enrolled in the medical assistance program as providers of nursing facility services shall be determined in accordance with the methodologies for establishing payment rates for county and nonpublic nursing facilities specified in the Department of Human Services' regulations and the Commonwealth's approved Title XIX State Plan for nursing facility services in effect after June 30, 2007. Continues case mix rate methodology for 2022-23 for nursing facilities in accordance with the Title XIX approved State Plan and 55 Pa. Code Chapter 1187 (for nonpublic facilities) and 55 Pa. Code Chapter 1189 (for county facilities). Case mix rate methodology applies to FFS rate setting. 4
Rate Increase Effective 1/1/2023 Rate Increase Effective 1/1/2023 Fiscal Code Section 1730-F.1. (vii) Subject to Federal approval, sufficient funds are included to provide a 17.5% annualized rate increase effective January 1, 2023, that is calculated in accordance with section 443.1 of the Human Services Code and 55 Pa. Code Chs. 1187 (relating to nursing facility services) and 1189 (relating to county nursing facility services), including for costs associated with compliance with section 1603-T. Authorizes funding for NF services and staffing effective January 1, 2023. Increased funding provides additional base-level support to NFs in advance of Department of Health staffing regulations (For state fiscal year 2023-24, the proposed regulatory change is from 2.7 hours/day minimum direct resident care to 2.87 hours/day). NFs are still eligible for quality incentives above and beyond base-level support. 5
Budget Adjustment Factor (BAF) Budget Adjustment Factor (BAF) Fiscal Code Section 1602-T (i) Subject to Federal approval of such amendments as may be necessary to the Commonwealth's approved Title XIX State Plan, the Department of Human Services shall apply a revenue adjustment neutrality factor to county and nonpublic nursing facility payment rates so that the estimated Statewide day-weighted average payment rate in effect for that fiscal year is limited to the amount permitted by the funds appropriated by the General Appropriation Act for the fiscal year. The revenue adjustment neutrality factor shall remain in effect until the sooner of June 30, 2026, or the date on which a new rate-setting methodology for medical assistance nursing facility services which replaces the rate-setting methodology codified in 55 Pa. Code Chs. 1187 (relating to nursing facility services) and 1189 (relating to county nursing facility services) takes effect. Continues the BAF through June 30, 2026 or the date on which a new rate-setting methodology replaces case mix methodology established in 55 Pa. Code Chapters 1187 (nonpublic nursing facility services) and 1189 (county nursing facility services). 6
Minimum Payment Rate Minimum Payment Rate Fiscal Code Section 1602-T (ii) Subject to Federal approval as may be necessary, the following shall apply to nonpublic and county nursing facility payment rates, to the extent funds are appropriated for the purpose of rate increases for increased direct resident care requirements and resident care and related costs: (A) Beginning January 1, 2023, the Department of Human Services shall make capitation payments to medical assistance Community HealthChoices managed care organizations that include amounts exclusively for the purpose of making payments to nonpublic nursing facilities and county nursing facilities as provided under clause (B)(I). (B) The Department of Human Services shall adopt a minimum payment rate for payments for services rendered to medical assistance recipients under the Community HealthChoices program, effective with dates of service of January 1, 2023, through December 31, 2025, as follows: (I) Community HealthChoices managed care organizations shall apply no less than the minimum payment rate to make payments to nonpublic nursing facilities and county nursing facilities for services rendered to medical assistance recipients under the Community HealthChoices program. (II) The minimum payment rate shall be greater than or equal to the following amounts: 7
Minimum Payment Rate (contd.) Minimum Payment Rate (contd.) (a) For nonpublic nursing facilities, the nursing facility case-mix rates calculated in accordance with 55 Pa. Code Ch. 1187 and the Commonwealth's approved Title XIX State Plan in effect for the dates of service. (b) For county nursing facilities, the county nursing facility rates in accordance with 55 Pa. Code Ch. 1189 and the Commonwealth's approved Title XIX State Plan in effect for the dates of service. Establishes a minimum payment rate for services provided to MA recipients under the CHC program through December 31, 2025, to the extent funds are appropriated. CHC MCOs must apply no less than the minimum payment rate for nursing facility services. Minimum payment rate is the FFS case mix (aka CMI rates or final rates) for nonpublic and county nursing facilities. Quarterly CMI adjustments still apply for nonpublic NFs (annual adjustment for county NFs) 8
NF Assessment NF Assessment Fiscal Code Section 1606-T Notwithstanding Section 815-A of the Act of June 13, 1967 (P.L. 31, No. 21), known as The Human Services Code, the Assessment authorized in Article VIII-A of The Human Services Code shall be imposed July 1, 2003, through June 30, 2026. Assessment Reauthorized through June 30, 2026 Changes for State Fiscal 2022-23 Fee Increases vs. SFY 2021-22 (both tiers increased by $3.76) Tier 1: $9.32 (CCRCs, 0-44 residents, MA Days >=90k & Occupancy >77%, county NFs) Tier 2: $33.41 Calculation of Fees Q77 and Q78: Historical Quarters (RD Qtrs. Ended 3/31/2021 and 6/30/2021) Q79 and Q80: Quarters Ending 12/31/2022 and 3/31/2023 9
NF Assessment and Appendix 4 Current NF Assessment and Appendix 4 Current Process Process \ Appendix 4 of CHC Agreements Appendix 4 funding is intended to help ensure quality of and access to NF services. Appendix 4 identifies a specific amount that MCOs must use to pay NFs for NF services and requires the MCOs to demonstrate the funds were used in accordance with this requirement. DHS is not involved in or providing any direction on how the funds are distributed. The MCOs and NFs negotiate how the Appendix 4 payments are distributed and paid separately from the negotiated base rate payments from the MCOs. CMS is now requiring Pennsylvania to transition Appendix 4 Nursing Facility Access to Care Payments to a new payment methodology by January of 2023 10
Phase Out of Nonpublic NF Access to Care Phase Out of Nonpublic NF Access to Care Program Program Transition to State Directed Payment (SDP) CMS is now requiring Pennsylvania to transition NF Access to Care Payments by January of 2023 to a new State Directed Payment methodology meeting a set of requirements under 42 CFR 438.6(c). Some of the key requirements include: o Must be tied to utilization and delivery of services under the managed care contract o State oversight to ensure additional payments are linked to specific service or benefit provided to specific participant o Must use the same methodology for each provider within a class of providers o Must advance at least one goal in the state s managed care quality strategy The SDP proposed to CMS is a minimum per diem payment rate comprised of the FFS base rate including an increase effective in 2023 PLUS the payments previously made through the Appendix 4 Access to Care (NF Assessment funded) 11
State Directed Payment Example State Directed Payment Example Nonpublic Nursing Facility State Directed Payment Rate 2023 Proposed Draft Methodology for Nonpublic Nursing Facility per diem minimum payment rate is the sum of: 1. Approved State Plan rate per diem as determined in accordance with State Plan Attachment 4.19 D; hypothetical example $233.00 2. A Nonpublic NF uniform per diem of $XX.XX per day; hypothetical example $25.00 3. Medicaid Allowable Assessment Cost Component calculated by multiplying the NF s total cost of the assessment by the NF s Medicaid occupancy rate. The result is divided by the NF s CHC days. hypothetical example $35.00 Minimum per diem payment rate for this hypothetical Nonpublic NF is $293.00 Upon CMS approval, this per diem rate will be the minimum the CHC-MCOs must pay for nursing facility services for CHC participants. Higher rates may be negotiated. 12
Timeline Timeline DRAFT for FY 2022 DRAFT for FY 2022- -23 23 Target Date Action CMS approval of CHC-MCO 2022 agreements and rates. May 2022 1 2 DHS and NF Associations agree on 2022-23 NF assessment model. July 2022 DHS makes first monthly payment related to FY 2022-23 (July program month capitation payments including Nonpublic NF Access To Care paid to CHC-MCOs for NFs). August 2022 3 DHS submits SDP Minimum Payment Rate Preprint to CMS October 2022 4 Targeted CMS approval of CHC-MCO 2023 agreements, rates, and SDP Minimum Payment Rate Preprint. Dec 2022/ Jan 2023 5 DHS makes final monthly payment related to FY 2022-23 Nonpublic NF Access to Care under Appendix 4 of CHC Agreement. January 2023 6 Nonpublic NFs receive Appendix 4 distribution for December program month February 2023 7 Nonpublic NFs are paid no less than SDP Minimum Payment Rate for dates of service beginning January 1, 2023. February 2023 8 NF Assessments Due (Q77-Q78) February 2023 9 NF Assessments Due (Q79-Q80) June 2023 10 10
Resident Care and Related Costs Resident Care and Related Costs Fiscal Code Section 1603-T (1) The county or nonpublic nursing facility shall demonstrate on its submitted MA-11 that 70% of its total costs, as reported by the facility, are resident care costs or other resident-related costs under 55 Pa. Code 1187.51(e)(1) and (2) (relating to scope). Requires facilities to demonstrate 70% of total costs are resident care costs or other resident related costs. Total Resident Cost of Care = Resident Care + Other Resident Related Costs (unallocated) from Schedule C of MA-11 Total Net Operating Costs = Total Expenses from Schedule C of MA-11 + Capital Costs Capital Costs = Real Estate Taxes, NF/HAI Assessment, Depreciation, Interest on Capital Indebtedness, Rent, and Amortization of Capital Costs from Schedule C of MA-11 or supplemental cost report form (for CCRCs) 14
Resident Care and Related Costs Resident Care and Related Costs Fiscal Code Section 1603-T Percentage of Total Costs Devoted to Resident Care (70% minimum) = Total Resident Cost of Care Total Net Operating Cost Penalties Authorized by 1603-T(b): An amount equal to a facility s difference between its Percentage of Total Costs Devoted to Resident Care and the 70% Minimum, up to 5% Based on a review of MA-11 cost reports for the period ending 12/31/2023 and later. Penalties collected support the Nursing Facility Quality Improvement Fund. Provision expires December 31, 2025. (A) Use the lesser of the following: (I) Five. (II) The difference under subparagraph (i). (B) Multiply the lowest numeral under clause (A) by one hundredth (.01). (C) Multiply the product under clause (B) by the county or nonpublic nursing facility's fee-for-service per diem payment rate as of June 30, 2022. (D) Multiply the product under clause (C) by the total MA resident days of care on the facility's MA-11. 15
