Section 405 IAC 1-14.6-2 - DefinitionsAuthority: IC 12-15-1-10; IC 12-15-21-2
Affected: IC 12-13-7-3; IC 12-15
Sec. 2.
(a) The definitions in this section apply throughout this rule.(b) "Administrative component" means the portion of the Medicaid rate that shall reimburse providers for allowable administrative services and supplies, including prorated employee benefits based on salaries and wages. Administrative services and supplies include the following:(1) Administrator and co-administrators, owners' compensation (including director's fees) for patient-related services.(2) Services and supplies of a home office that are: (A) allowable and patient-related; and(B) appropriately allocated to the nursing facility.(3) Office and clerical staff.(4) Legal and accounting fees.(6) All staff travel and mileage.(7) Telephone and Internet.(8) License dues and subscriptions.(9) All office supplies used for any purpose, including repairs and maintenance charges and service agreements for copiers and other office equipment.(10) Working capital interest.(11) State gross receipts taxes.(12) Utilization review costs.(13) Liability insurance.(14) Management and other consultant fees.(15) Qualified intellectual disability professional.(16) Educational seminars for administrative staff.(17) Support and trouble-shooting, maintenance, and license fees for all general and administrative computer software and hardware such as accounting or other data processing activities.(18) Court appointed guardian, financial institution, or third party trust costs not covered by resident personal funds.(19) Preemployment related costs such as background checks, drug testing, and employment contingent physicals.(c) "Allowable per patient day cost" means a ratio between allowable variable cost and patient days using each provider's actual occupancy from the most recently completed desk reviewed annual financial report, plus a ratio between allowable fixed costs and patient days using the greater of:(1) the minimum occupancy requirements as contained in this rule; or(2) each provider's actual occupancy rate from the most recently completed desk reviewed annual financial report.(d) "Allowed profit add-on payment" means the portion of a facility's tentative profit add-on payment that, except as may be limited by application of the overall rate ceiling as defined in this rule, shall be included in the facility's Medicaid rate, and is based on the facility's total quality score.(e) "Annual financial report" refers to a presentation of financial data, including appropriate supplemental data and accompanying notes, derived from accounting records and intended to communicate the provider's economic resources or obligations at a point in time, or changes therein for a period of time in compliance with the reporting requirements of this rule.(f) "Average allowable cost of the median patient day" means the allowable per patient day cost (including any applicable inflation adjustment) of the median patient day from all providers when ranked in numerical order based on average allowable cost. The average allowable variable cost (including any applicable inflation adjustment) shall be computed on a statewide basis using each provider's actual occupancy from the most recently completed desk reviewed annual financial report. The average allowable fixed costs (including any applicable inflation adjustment) shall be computed on a statewide basis using an occupancy rate equal to the greater of: (1) the minimum occupancy requirements as contained in this rule; or(2) each provider's actual occupancy rate from the most recently completed desk reviewed annual financial report. The average allowable cost of the median patient day shall be maintained by the office with revisions made four (4) times per year effective January 1, April 1, July 1, and October 1.
(g) "Average historical cost of property of the median bed" means the allowable patient-related property cost per bed for facilities that are not acquired through an operating lease arrangement, when ranked in numerical order based on the allowable patient-related historical property cost per bed that shall be updated each calendar quarter. Property shall be considered allowable if it satisfies the conditions of section 14(a) of this rule.(h) "Calendar quarter" means a three (3) month period beginning January 1, April 1, July 1, or October 1.(i) "Capital component" means the portion of the Medicaid rate that shall reimburse providers for the use of allowable capital-related items. Such capital-related items include the following:(1) The fair rental value allowance.(4) Noncapitalized costs associated with minor equipment purchases that are not directly attributed to a specific department.(j) "Case mix index" or "CMI" means a numerical value score that describes the relative resource use for each resident within the groups under the resource utilization group (RUG-IV) classification system prescribed by the office based on an assessment of each resident. The facility CMI shall be based on the resident CMI, calculated on a facility-average, time-weighted basis for the following: (k) "Children's nursing facility" means a nursing facility that, as of January 1, 2009, has: (1) fifteen percent (15%) or more of its residents who are under the chronological age of twenty-one (21) years; and(2) received written approval from the office to be designated as a children's nursing facility.(l) "Cost center" means a cost category delineated by cost reporting forms prescribed by the office.(m) "Delinquent MDS resident assessment" means an assessment that is greater than one hundred thirteen (113) days old, as measured by the date defined by CMS for determining delinquency or an assessment that is not completed within the time prescribed in the requirement for use in determining the time-weighted CMI under section 9(e) of this rule. This determination is made on the fifteenth day of the second month following the end of a calendar quarter.(n) "Department head" means an individual(s) responsible for the supervision and management of a nursing facility department. Home office personnel responsible for the supervision and oversight of facility department heads qualify as general line personnel.(o) "Desk review" means a review and application of these regulations to a provider submitted annual financial report including accompanying notes and supplemental information.(p) "Direct care component" means the portion of the Medicaid rate that shall reimburse providers for allowable direct patient care services and supplies, including prorated employee benefits based on salaries and wages. Direct care services and supplies include all of the following:(1) Nursing and nursing aide services.(2) Nurse consulting services directly related to the provision of hands-on resident care.(3) Pharmacy consultants.(4) Medical director services.(8) Medical records costs.(9) Rental costs for low air loss mattresses, pressure support surfaces, and oxygen concentrators. Rental costs for these items are limited to one dollar and fifty cents ($1.50) per resident day.(10) Support and license fees for software utilized exclusively in hands-on resident care support, such as MDS assessment software and medical records software.(11) Replacement dentures for Medicaid residents provided by the facility that exceed state Medicaid plan limitations for dentures.(12) Legend and nonlegend sterile water products used for irrigation or humidification.(13) Educational seminars for direct care staff.(14) Skin protectants, sealants, moisturizers, and ointments that are applied on an as needed basis by the member, nursing facility care staff, or by prescriber's order as a part of routine care as defined in subsection (ff).(15) Parenteral and enteral nutrition costs other than meals, nutritional supplements, sterile water, and legend and nonlegend drugs.(16) Costs for the coding and input of MDS data. (q) "Fair rental value allowance" means a methodology for reimbursing nursing facilities for the use of allowable facilities and equipment, based on establishing a rental valuation on a per bed basis of such facilities and equipment, and a rental rate.(r) "Field audit" means a formal official verification and methodical examination and review, including the final written report of the examination of original books of accounts and resident assessment data and its supporting documentation by auditors.(s) "Fixed costs" means the portion of each rate component that shall be subjected to the minimum occupancy requirements as contained in this rule. The following percentages shall be multiplied by total allowable costs to determine allowable fixed costs for each rate component: Rate Component | Fixed Cost Percentage |
Direct Care | 25% |
Indirect Care | 37% |
Administrative | 84% |
Capital | 100% |
(t) "Forms prescribed by the office" means either of the following: (1) Cost reporting forms provided by the office.(2) Substitute forms that have received prior written approval by the office.(u) "General line personnel" means management personnel above the department head level who perform a policymaking or supervisory function impacting directly on the operation of the facility.(v) "Generally accepted accounting principles" or "GAAP" means those accounting principles as established by the Financial Accounting Standards Board.(w) "Indirect care component" means the portion of the Medicaid rate that shall reimburse providers for allowable indirect patient care services and supplies, including prorated employee benefits based on salaries and wages. Indirect care services and supplies include the following: (1) Dietary services and supplies.(3) Patient laundry services and supplies.(4) Patient housekeeping services and supplies.(5) Plant operations services and supplies.(8) Activities supplies and services.(9) Recreational supplies and services.(10) Repairs and maintenance.(11) Cable or satellite television throughout the nursing facility, including residents' rooms.(12) Pets, pet supplies and maintenance, and veterinary expenses.(13) Educational seminars for indirect care staff.(14) Nonambulance transportation costs related to activities and other noncovered services.(16) Behavioral and psychological consulting services.(17) Nursing consulting services, whether provided by internal facility personnel, central office personnel, or contracted, that are not directly related to the provision of hands-on resident care. Such nursing consulting services include, but are not limited to: health survey, quality assurance processes, and MDS consultation (excluding data input and coding).(x) "Medical and nonmedical supplies and equipment" includes those items generally required to assure adequate medical care and personal hygiene of patients.(y) "Minimum data set" or "MDS" means a core set of screening and assessment elements, including common definitions and coding categories, that form the foundation of the comprehensive assessment for all residents of long-term care facilities certified to participate in Medicaid. The items in the MDS standardize communication about resident problems, strengths, and conditions within facilities, between facilities, and between facilities and outside agencies. The Indiana system will employ the MDS 3.0 or subsequent revisions as approved by CMS.(z) "Normalized allowable cost" means total allowable direct care costs for each facility divided by that facility's average CMI for all residents.(aa) "Nursing home report card score" means a numerical score developed and published by ISDH that quantifies each facility's key survey results.(bb) "Ordinary patient-related costs" means costs of allowable services and supplies that are necessary in delivery of patient care by similar providers within the state.(cc) "Patient/member care" means those Medicaid program services delivered to a Medicaid enrolled member by a provider.(dd) "Reasonable allowable costs" means the price a prudent, cost-conscious buyer would pay a willing seller for goods or services in an arm's-length transaction, not to exceed the limitations set out in this rule.(ee) "Related party/organization" means that the provider:(1) is associated or affiliated with; or(2) has the ability to control or be controlled by; the organization furnishing the service, facilities, or supplies, whether or not such control is actually exercised.
(ff) "Routine care" means care that does not treat or ameliorate a specific defect or specific physical or mental illness or condition.(gg) "RUG-IV resident classification system" means the resource utilization group used to classify residents. When a resident classifies into more than one (1) RUG-IV group, the RUG-IV group with the greatest CMI will be utilized to calculate the facility-average CMI for all residents and facility-average CMI for Medicaid residents.(hh) A nursing facility with a "special care unit (SCU) for Alzheimer's disease or dementia" means a nursing facility that meets all of the following: (1) Has a locked, secure, segregated unit or provides a special program or special unit for residents with Alzheimer's disease, related disorders, or dementia.(2) The facility advertises, markets, or promotes the health facility as providing Alzheimer's care services or dementia care services, or both.(3) The nursing facility has a designated director for the Alzheimer's and dementia special care unit, who satisfies all of the following conditions: (A) Became the director of the SCU prior to August 21, 2004, or has earned a degree from an educational institution in a health care, mental health, or social service profession, or is a licensed health facility administrator.(B) Has a minimum of one (1) year work experience with dementia or Alzheimer's, or both, residents within the past five (5) years.(C) Completed a minimum of twelve (12) hours of dementia specific training within three (3) months of initial employment and has continued to obtain six (6) hours annually of dementia-specific training thereafter to:(i) meet the needs or preferences, or both, of cognitively impaired residents; and (ii) gain understanding of the current standards of care for residents with dementia.(D) Performs the following duties: (i) Oversees the operations of the unit.(ii) Ensures personnel assigned to the unit receive required in-service training.(iii) Ensures the care provided to Alzheimer's and dementia care unit residents is consistent with in-service training, current Alzheimer's and dementia care practices, and regulatory standards.(ii) "Tentative profit add-on payment" means the profit add-on payment calculated under this rule before considering a facility's total quality score.(jj) "Therapy component" means the portion of each facility's direct costs for therapy services, including any employee benefits prorated based on total salaries and wages, rendered to Medicaid residents that are not reimbursed by other payors, as determined by this rule.(kk) "Total quality score" means the sum of the quality points awarded to each nursing facility for all eight (8) quality measures as determined in section 7(m)(1) through 7(m)(8) of this rule.(ll) "Unit of service" means all patient care included in the established per diem rate required for the care of an inpatient for one (1) day (twenty-four (24) hours).(mm) "Unsupported MDS resident assessment" means an assessment where one (1) or more data items that are required to classify a resident pursuant to the RUG-IV resident classification system: (1) are not supported according to the MDS supporting documentation requirements as set forth in 405 IAC 1-15; and(2) result in the assessment being classified into a different RUG-IV category.Office ofthe Secretary of Family and Social Services; 405 IAC 1-14.6-2; filed Aug 12, 1998, 2:27p.m.: 22 IR 69, eff Oct 1, 1998; filed Mar 2, 1999, 4:42 p.m.: 22 IR 2238; readopted filed Jun 27, 2001, 9:40 a.m.: 24 IR 3822; filed Mar 18, 2002, 3:30 p.m.: 25 IR 2462; filed Oct 10, 2002, 10:47 a.m.: 26 IR 707; filed Jul 29, 2003, 4:00 p.m.: 26 IR 3869; filed Apr 24, 2006, 3:30 p.m.: 29 IR 2975; readopted filed Sep 19, 2007, 12:16p.m.: 20071010-IR-405070311RFA; filed Nov 12, 2009, 4:01 p.m.: 20091209-IR-405090215FRA; filed Nov 1, 2010, 11:37 a.m.: 20101201-IR-405100183FRA; filed May 31, 2013, 8:52 a.m.: 20130626-IR-405120279FRA; readopted filed Oct 28, 2013, 3:18 p.m.: 20131127-IR-405130241RFAFiled 4/29/2015, 3:38 p.m.: 20150527-IR-405150034FRAFiled 8/1/2016, 3:44 p.m.: 20160831-IR-405150418FRAFiled 10/13/2017, 12:09 p.m.: 20171108-IR-405160327FRAReadopted filed 5/30/2023, 11:54 a.m.: 20230628-IR-405230292RFA