SubPart 86-7 - Assisted Living Program

Effective Date: 
Monday, December 20, 1993
Doc Status: 
Complete
Statutory Authority: 
Public Health Law 3614(6) and Social Services Law 461-(l)(5)

Section 86-7.1 - Definitions

Section 86-7.1 Definitions. As used in this Subpart, the following words shall have following meanings:

(a) "Assisted living program" shall mean an entity as defined in paragraph (a) of subdivision (1) of section 461-1 of the social services law.

(b) "Services" shall mean all services for which full payment to an assisted living program is included in the rate of payment which shall consist of the following: nursing services, personal care services, home health aide services, physical therapy, occupational therapy, speech therapy, medical supplies and equipment not requiring prior approval, personal emergency response services and adult day health care in a program approved by the commissioner and which the assisted living program shall provide directly, or arrange for the provision of, through contract(s) with a social services district, a long term home health care program or a certified home health agency, or other qualified providers.

(c) "Patient classification groups" shall mean patient categories contained in the classification system, Resources Utilization Groups-II (RUG-II), which identifies the relative resource consumption required by different types of residential health care facility (RHCF) patients as specified in Appendix 13-A of this Title.

(d) "Regions" shall mean the sixteen regions within the State into which residential health care facilities are grouped, by county, as identified in Appendix 13-A of this Title.

(e) "Rate of payment" shall mean the capitated per diem rate of reimbursement established pursuant to this Subpart for governmental agencies for services provided directly by an assisted living program or provided through contract(s) with eligible providers.

(f) "Per Diem" shall mean the unit of measure denoting services rendered to one patient between the census taking hour on two successive days. In computing per diems, the day of admission shall be counted but not the day of discharge. When a patient is admitted and discharged on the same day, this period shall be counted as one per diem.

(g) "Roll factor" shall mean the cumulative result of multiplying one year's trend (inflation) factor times one or more other year's trend factor which is used to inflate costs from a base period to a rate period.
 

Effective Date: 
Monday, December 20, 1993
Doc Status: 
Complete

Section 86-7.2 - Computation of the rate of payment

86-7.2 Computation of the rate of payment.

(a) For each region, a rate of payment shall be established for each of the sixteen patient classification groups. The rate of payment shall be established for the calendar year 1992. For each subsequent calendar year, the 1992 rate of payment shall be increased by a roll factor as determined pursuant to section 86-7.3.

(b)(1) For purposes of this Subpart, the rate of payment shall be related to an average residential health care facility rate consisting of two components:

(i) Direct component;

(ii) Other than direct component.

(2) Direct component of the rate of payment:

(i) The direct component of the rate of payment shall be composed of costs incurred in providing care directly to patients as set forth in section 86-2.10(c)(1).

(ii) The direct component for each patient classification group shall be equal to the statewide mean direct case mix neutral cost, as determined in section 86-2.10(c)(3), times the case mix index for the patient classification group divided by a regional direct input price adjustment factor for the patient classification group as identified in subparagraph (iii) of this paragraph and trended to 1992 by the applicable weighted average regional roll factor as determined pursuant to section 86-7.3. The case mix index for each patient classification group shall be as identified in Appendix 13-A of this Title, however, the case mix index for reduced physical functioning A shall be .4414 as identified in section 86-2.10(c)(3)(iii)(i).

(iii) The Regional Direct Input Price Adjustment Factor (RDIPAF) shall adjust for differences in wage and fringe benefit costs between and among the regions caused by differences in the wage scale of each level of employee. Within each region, a RDIPAF shall be calculated for each patient classification group.

The RDIPAF shall be based upon the following factors:

(a) Sixteen regions within the state as identified in Appendix 13-A.

(b) Case mix predicted staffing for registered professional nurses, licensed practical nurses and aides, orderlies and assistants for each patient classification group.

(c) The proportion of residential health care facility salaries and fringe benefit costs for the direct care cost centers identified in section 86-2.10(c)(1) to the total costs of the direct care cost centers.

(d) A regional average dollar per hour and proportion of regional direct salaries and fringe benefits to total direct costs as identified in clause (c) of this subparagraph based upon either 1983 or 1987 residential health care facility financial and statistical data in accordance with section 86-2.10(m)(l)(iv).

(3) Other than direct component of the rate of payment:

(i) The other than direct component shall be equal to the mean indirect price per day set forth in section 86-2.10(d)(4) for the freestanding, low intensity, less than 300 beds peer group divided by the regional indirect input price adjustment factor for the patient classification group as identified in subparagraph (ii) of this paragraph and trended to 1992 by the applicable weighted average regional roll factor as determined pursuant to section 86-7.3 plus a 1992 regional weighted average per diem for other than direct and indirect components of the RHCF rate as set forth in sections 86-2.10 (f), (g) and (r), computed using the first January 1, 1992 rate promulgated following the thirty day period established for correcting errors in the initial January 1, 1992 rate issued at least sixty days prior to January 1, 1992.

(ii) The Regional Indirect Input Price Adjustment Factor (RIIPAF) shall adjust for differences in wage and fringe benefit costs between and among the wage equalization factor regions caused by differences in the wage scale of each level of employee. Within each region, a RIIPAF shall be calculated for each patient classification group. The RIIPAF shall be based upon the following factors:

(a) Sixteen regions within the state, as identified in Appendix 13-A.

(b) Case mix predicted staffing for registered professional nurses, licensed practical nurses and aides, orderlies and assistants for each patient classification group.

(c) The proportion of regional RHCF salaries and fringe benefit costs for the indirect cost centers identified in section 86-2.10(d)(1) to the total costs of the indirect care cost centers.

(d) A regional average dollar per hour and proportion of regional indirect salaries and fringe benefits to total indirect costs as identified in clause (c) of this subparagraph based upon either 1983 or 1987 residential health care facility financial and statistical data in accordance with section 86-2.10(m)(l)(iv). (c) For calendar year 1992, for each patient classification group in each region, the direct and other than direct components shall be summed and multiplied by fifty percent. For subsequent calendar years, the 1992 rate of payment shall be increased by the applicable roll factor determined pursuant to section 86-7.3(b).
 

Effective Date: 
Monday, December 20, 1993
Doc Status: 
Complete

Section 86-7.3 - Adjustments to rate of payment

86-7.3 Adjustments to rate of payment.

(a) For the calendar year 1992, for each region, the direct component as identified in section 86-7.2(b)(2) and the mean indirect price per day divided by the regional indirect input price adjustment factor for the patient classification group as identified in section 86-7.2(b)(3) shall be trended to 1992 by a roll factor to project allowable cost increases for the rate period. The trend factors used in the calculation of the roll factor shall be determined in a manner consistent with the methodology set forth in section 86-2.12. A weighted average roll factor shall be calculated for each region. Relative weights shall be assigned to each trend factor group within the region and shall be based upon the aggregate operating portion of RHCF rates as defined in section 86-2.10(a)(7) using the initial July 1, 1992 RHCF rate certified by the commissioner pursuant to section 2807(3) of the Public Health Law times the 1990 RHCFs' patient days. The weighted average roll factor for each region shall be calculated by multiplying the weights for each trend factor group within each region times the respective July 1, 1992 roll factors determined pursuant to section 86-2.12 excluding prospective adjustments made pursuant to section 86-2.12(f).

(b) For calendar years beginning January 1, 1993 and on January 1 of each subsequent year, the 1992 rate of payment as identified in section 86-7.2(c) shall be increased by a roll factor to project allowable cost increases for the rate period. The trend factor(s) used in the calculation of the roll factor shall be determined in a manner consistent with the methodology set forth in section 86-2.12. A weighted average roll factor shall be calculated for each region. The weighted average roll factor for the rate period shall be computed utilizing the weights developed from the computation in subparagraph (a) of this paragraph adjusted to reflect any changes in trend factor groups made pursuant to section 86-2.12. The regional weighted average roll factor for the rate period shall also include the prospective annual adjustments to the RHCF trend factors made pursuant to section 86-2.12(f).

(c) The rate of payment shall not exceed customary charges to the general public.
 

Effective Date: 
Monday, December 20, 1993
Doc Status: 
Complete

Section 86-7.4 - Federal financial participation

86-7.4 Federal Financial Participation

(a) This Subpart shall be effective if, and as long as, federal financial participation is available for medical assistance expenditures made pursuant to this Subpart.
 

Effective Date: 
Monday, December 20, 1993
Doc Status: 
Complete