Title: Section 86-10.6 - Transition periods and reimbursement
86-10.6 Transition periods and reimbursement.
(a) Transition to new methodology. The reimbursement methodology described in this subpart will be phased-in over a three-year period, with a year for purposes of the transition period meaning a twelve month period from July first to the following June thirtieth, and with full implementation in the beginning of the fourth year. During this transition period, the base operating rate will transition to the target rate according to the phase-in schedule immediately below. The base operating rate will remain fixed and the target rate, as determined by the reimbursement methodology in this subpart, will be updated to reflect rebasing of cost data, trend factors and other appropriate adjustments.
(b) Transition from monthly to daily units of service. Reimbursement for residential habilitation provided in supervised community residences shall be according to a daily unit of service. From the period beginning July first, two thousand fourteen through June thirtieth, two thousand fifteen, providers that receive reimbursement of residential habilitation in supervised community residences pursuant to this Subpart shall determine and report to the Department retainer days, therapeutic leave days and vacant bed days.
(1) Retainer days shall mean days during which an individual is on medical leave from the community residence, or associated days when any other institutional or in-patient Medicaid payment is made for providing services to the individual. For the period beginning July first, two thousand fourteen through June thirtieth, two thousand fifteen, retainer days shall be reimbursed at zero dollars.
(2) Therapeutic leave days shall mean days during which an individual is away from the community residence and is not receiving services from residential habilitation staff, and the absence is for the purpose of visiting with family or friends, or a vacation. Therapeutic leave days shall be reimbursed at the level described in subdivision (a) of this section.
(3) Vacant bed days shall mean days for which the provider is unable to bill due to a resident moving from one residential site to another, or due to a resident passing away.
At the midpoint of the initial period and again at the conclusion of the period ending June thirtieth, two thousand fifteen, the Department will reconcile the services recorded under the retainer days in order to determine the amount of reimbursement owed to the provider. Providers shall be paid for retainer days at the level described in subdivision (a) of this section. Providers shall not be paid for more than fourteen retainer days per annual period for any one individual. Providers will be paid for vacant bed days at seventy five percent of the level described in subdivision (a) of this section, up to a maximum of ninety days per bed.
(c) For periods subsequent to June 30, 2015:
(1) The daily rate, as determined pursuant to this Subpart, excluding section 86-10.8, will be adjusted to include an occupancy factor. For the period beginning May 1, 2021, the occupancy adjustment will be 0%.
(2) Retainer days shall be reimbursed at the daily rate as determined pursuant to subparagraph (1) of this paragraph. Such reimbursement shall be limited to 14 days per rate year, multiplied by certain capacity. Effective on or after May 1, 2021, Retainer days will be reimbursed at a rate of 50 percent of the provider’s established rate.
(3) Therapeutic leave days shall be reimbursed per individual at the daily rate as determined pursuant to subparagraph (1) of this paragraph. Effective May 1, 2021, a provider is limited to being paid 96 therapy days per rate year per person. All Therapy days will be reimbursed at a rate of 50 percent of the provider’s established rate. The therapy day must be described in the person’s plan of care to be eligible for payment and the person may not receive another Medicaid-funded residential or in-patient service on that day.
(4) Effective May 1, 2021, the methodology will update cost data within four years from the previous rebase utilizing an available and complete CFR. Thereafter, the Department will follow a rate cycle utilizing the base period CFR. For years in which the Department does not update the base year, the Department will update to-from transportation from the CFR and update property using an available and complete CFR.
VOLUME A-2 (Title 10)