D.C. Mun. Regs. tit. 29, § 4102
4102.1 The rates for ICF/IID services were developed based on Fiscal Year (FY) 2010 cost data reported by providers of different sizes serving individuals at varying acuity levels. The rates shall vary based on staffing ratios, facility size, and beneficiary acuity level.
4102.2 For the purposes of rate-setting, and independent of the classification used by the Department of Health for licensing, DHCF shall classify ICFs/IID as follows:
(a) Class I - A facility with five (5) or fewer licensed beds; and
(b) Class II - A facility with six (6) or more licensed beds.
4102.3 The residential component of the rate, as described in § 4100.5(a), shall be based on a model that includes the following seven (7) cost centers:
(a) The “Direct Service” cost center shall include expenditures as follows:
(1) Nurses, including registered nurses (RNs), licensed practical nurses (LPNs), and certified nursing assistants (CNAs);
(2) Qualified Mental Retardation Professionals (QMRPs);
(3) House managers;
(4) Direct Support Personnel;
(5) Allocated time of staff with administrative duties and who are also utilized in direct service support, subject to the results of a time study or time sheet process that has been approved by DHCF; and
(6) Fringe benefits, including but not limited to required taxes, health insurance, retirement benefits, vacation days, paid holidays, and sick leave.
(b) The “All Other Health Care and Program Related” cost center shall include expenditures for:
(1) Pharmacy co-pays and over-the-counter medications;
(2) Medical supplies;
(3) Therapy costs, including physical therapy, occupational therapy, and speech therapy;
(4) Physician services;
(5) Behavioral health services provided by psychologists or psychiatrists;
(6) Nutrition and food;
(7) Medical record maintenance and review;
(8) Insurance for non-direct care health staff;
(9) Program materials excluding active treatment;
(10) Training for direct care staff;
(11) Program development and management, including recreation;
(12) Incident management;
(13) Clothing for beneficiaries; and
(14) Quality Assurance.
(c) The “Non-Personnel Operations” cost center shall include expenditures for:
(1) Food service and supplies related to food service;
(2) Laundry;
(3) Housekeeping and linen; and
(4) Non-capital repair and maintenance.
(d) The “Administration” cost center shall include expenditures for:
(1) Payroll taxes;
(2) Salaries and consulting fees to non-direct care staff;
(3) Insurance for administrators and executives;
(4) Travel and entertainment;
(5) Training costs;
(6) Office expenses;
(7) Office space rent or depreciation;
(8) Clerical staff;
(9) Interest on working capital;
(10) Staff transportation; and
(11) Licenses.
(e) The “Non-Emergency Transportation” cost center shall include expenditures for:
(1) Vehicle license, lease, and fees;
(2) Vehicle maintenance;
(3) Depreciation of vehicle;
(4) Staffing costs for drivers and aides not otherwise covered by, or in excess of costs for, direct support personnel;
(5) Fuel; and
(6) Vehicle insurance.
(f) The “Capital” cost center shall include expenditures, less all amounts received for days reimbursed pursuant to the “Policy on Payment for Reserved Beds in Intermediate Care Facilities for the Intellectually Disabled,” page 2 of Attachment 4.19C of the State Plan, for the following:
(1) Depreciation and amortization;
(2) Interest on capital debt;
(3) Rent;
(4) Minor equipment;
(5) Real estate taxes;
(6) Property insurance;
(7) Other capital; and
(8) Utilities, including electricity, gas, telephone, cable, and water.
(g) The “Stevie Sellows Intermediate Care Facility for the Intellectually and Developmentally Disabled Quality Improvement Fund Assessment” cost center shall include only the allowable share of the Assessment expenditure consistent with 42 U.S.C. § 1396(b)(w) and 42 C.F.R. §§ 433.68, 433.70 and 433.72.
4102.4 Fiscal Year (FY) 2013 rates shall be based on Fiscal Year (FY) 2010 cost data reported by providers, legal requirements, and industry standards, and shall be paid for services delivered beginning on October 1, 2012, through September 30, 2013. FY 2013 rates, and all rates thereafter, shall be set forth in this Chapter. FY 2013 rates were developed based upon the following assumptions:
(a) FY 2013 Non-Personnel Operations per diem rates shall be based on FY 2010 costs, inflated twelve percent (12%);
(b) FY 2013 Capital per diem rates shall be based on FY 2010 costs, inflated fifteen percent (15%);
(c) FY 2013 rates for the cost centers described in § 4102.4(a) and (b) shall be calculated as the quotient of total industry expenditures divided by the total number of industry licensed bed days as reported for FY 2010;
(d) The FY 2013 rate for Non-Emergency Transportation shall be eighteen dollars ($18) per person, per day; and
(e) Capital expenditures for Class I and Class II facilities shall be calculated separately.
4102.5 FY 2014 rates shall be based on the reported FY 2013 cost reports. In establishing the rates for FY 2014, DHCF shall use FY 2013 rates as a baseline comparison to the FY 2013 cost reports. DHCF shall make appropriate adjustments to each cost center rate based on the actual reported costs. These adjustments may increase or decrease the per diem rates for each cost center. The resulting rates shall be inflated annually, beginning in FY 2014, in accordance with the index described in this chapter.
4102.6 For dates of service on or after October 1, 2016, final reimbursement rates for the residential component will be based on providers’ FY 2014 cost reports subject to audit and adjustment by DHCF.
4102.7 Direct Service cost center reimbursement rates shall be calculated based
on staffing ratios, facility size, and individuals' acuity levels. All rates shall accommodate the following staffing patterns:
Class II facilities shall also receive a rate that includes one (1) certified nurse aide (CNA) at two (2) shifts per day for three hundred sixty-five (365) days per year.
(4) Acuity Level 5 (Pervasive) rates shall vary based on the number of one-to-one services prescribed for a beneficiary. Acuity Level 5 rates shall also include one (1) DSP at two (2) or three (3) shifts per day, for five (5) or seven (7) days per week for fifty-two (52) weeks per year, at a staffing ratio of one (1) DSP to one (1) beneficiary (1:1).
(5) Acuity Level 6 (Pervasive Plus Skilled Nursing) rates shall vary based on the number of one-to-one services prescribed for a beneficiary. Acuity Level 6 rates shall also include one (1) LPN at one (1), two (2), or three (3) shifts per day for seven (7) days per week for fifty-two (52) weeks per year, at a staffing ratio of one (1) LPN to one (1) beneficiary (1:1).
(f) The base salaries used in the development of FY 2013 rates for direct care staff wages and salaries shall be as follows:
(1) DSP: $12.50 per hour;
(2) LPN: $21.00 per hour;
(3) CNA: $16.83 per hour;
(4) House Manager: $45,000 per year;
(5) RN: $70,000 per year; and
(6) QMRP: $60,000 per year.
(g) Salaries set forth in Section 4102.7(f) shall be treated as follows:
(1) "Paid time off" shall include the addition of eighty (80) hours of paid leave. Holiday pay shall include the addition of forty-four (44) hours to ensure that the rate includes the rate of pay plus one-half (1/2) the rate of pay (time and one-half) for holidays worked;
(2) Salaries shall be inflated by twenty percent (20%) and paid leave and holiday pay shall be inflated by twelve percent (12%), to accommodate fringe benefits; and
(3) All rates shall include paid time off and holiday pay for all hourly full-time equivalents (FTEs).
(h) Beginning in FY 2014 and each fiscal year thereafter, Direct Care Staff Compensation shall be inflated by the greater of any adjustment to the living wage or the associated costs of benefits and inflation based on the Centers for Medicare and Medicaid Services (CMS) Skilled Nursing Facility Market Basket Index or other appropriate index if the CMS Skilled Nursing Facility Market Basket Index is discontinued.
4102.8 All Other Health Care and Program Related Expenses cost center reimbursement rates shall be calculated based on the facility size and the direct care cost center rate, which varies by staffing ratios and individuals' acuity levels. The rate for this cost center shall be calculated as a fixed percentage of the rate for direct services, at twelve percent (12%) for Class I facilities and at seventeen percent (17%) for Class II facilities.
4102.9 The Non-Personnel Operations cost center reimbursement rates shall be calculated based on industry average reported costs. The Non-Personnel Operations reimbursement rate shall be equal to the industry average reported expenses per licensed bed day for the line items included in the cost center, and shall be uniformly set for all providers.
4102.10 The Administration cost center reimbursement rates shall be calculated based on the staffing ratios, facility size, and individuals' acuity levels. The Administration reimbursement rate shall vary based on the nature of ownership of the physical premises where the ICF/IID is housed. The Administration rate shall be a uniform percentage of the sum of the rates for all other cost centers and acuity levels.
4102.11 The Non-Emergency Transportation cost center reimbursement rates shall be based on the industry average expenses divided by the total number of licensed bed days.
4102.12 The Capital cost center reimbursement rates shall be determined in accordance with 42 C.F.R. § 413.130 and based on the industry average reported expenses per licensed bed day for the line items included in this cost center as described in Section § 4102.3. The rate shall vary based on the nature of ownership of the physical premises where the ICF/IID is housed. The Capital rate for leased premises shall be equal to the industry average reported expenses per licensed bed day for the line items included. The Capital rate for provider-owned premises shall be equal to fifty percent (50%) of the rate for leased premises. The Capital rate shall also be subject to the following principles:
(a) When a sale/leaseback of an existing ICF/IID facility occurs, the ICF/IID's allowable capital related cost may not exceed the amount that the seller/lessor would have recorded had the seller/lessor retained legal title;
(b) When depreciated buildings and building improvements are acquired, the cost basis of the depreciable asset shall be the lesser of the cost or acquisition value of the previous owner(s) less all reimbursement attributable to the asset as determined by DHCF or the fair market value of the asset at time of acquisition. Notwithstanding, if the seller makes the full payback in accordance with paragraph (e) below, the cost basis to the new owner shall be the lesser of the fair market value or the purchase price;
(c) Facilities shall employ the straight-line method for calculating depreciation subject to the limits set forth in paragraphs (d) and (e) below. Accelerated methods for calculating depreciation shall not be allowed. Subject to the limits set forth in paragraphs (d) and (e), the annual depreciation expense of an asset shall be determined by dividing the basis of the asset reduced by any estimated salvage or resale value by the estimated years of useful life of the asset at the time it is placed in service;
(d) Depreciation expense of buildings and building improvements shall be limited to the basis of each asset and shall not exceed the basis of such assets less the aggregate amount received in reimbursement for such assets in the current and prior years;
(e) Fully depreciated buildings and building improvements subsequently sold or disposed of shall be subject to payback by the owner to the program of all depreciation expense paid to the owner and all previous owners when such assets are no longer used to provide ICF/IID services or have been transferred to new owners in an arm's length transaction, provided that such payback shall be reduced by all amounts previously paid back, if any, by prior owners;
(f) ICFs/IID shall estimate assets' years of useful life in accordance with the most recent edition of "Estimated Useful Lives of Depreciable Hospital Assets" published by the American Hospital Association, or if not applicable, relevant guidance issued by the U.S. Internal Revenue Service. Subject to the limits set forth in paragraphs (d) and (e), depreciation expense for the year of disposal can be computed by using either the half-year method or the actual time method;
(g) Assets shall be recorded using historical cost, except for donated assets which shall be recorded at fair market value at the time received and based on the lesser of at least two (2) bona fide appraisals. Costs during the construction of an asset, consulting and legal fees, interest, and fund raising, should be capitalized as a part of the cost of the asset;
(h) When an asset is acquired by a trade-in, the cost of the new asset shall be the sum of the book value of the old asset and any cash or issuance of debt
as consideration paid;
(i) Facilities that previously did not maintain fixed asset records and did not record depreciation in prior years shall be entitled to any straight-line depreciation of the remaining useful life of the asset. The depreciation shall be based on the cost of the asset or fair market value of a donated asset at the time of purchase, construction or donation over its normal useful life. No depreciation may be taken on an asset that would have been fully depreciated if it had been properly recorded at the time of acquisition;
(j) Leasehold improvements made to rental property by the lessor shall be depreciated over the lesser of the asset's useful life or the remaining life of the lease;
(k) On a case by case basis, DHCF may reimburse an ICF/IID by providing an offset to capital costs that shall be equal to the daily amount computed under this subsection in situations when DDS has not filled vacant bed space(s). The ICF/IID shall receive the product of the capital cost multiplied by the administrative rate anytime this payment is made;
(l) The daily cost described in paragraph (k) shall be computed as the capital component of the daily per-diem rate, multiplied by the number of vacant bed space(s); and
(m) ICFs/IID shall incur costs and provide DHCF with proof of the vacant bed space, in order to be eligible.
4102.13 Effective October 1, 2013, and annually thereafter, the per diem rates for Non-Personnel Operations, Non-Emergency Transportation, Capital, and Active Treatment shall be adjusted for inflation in accordance with the Centers for Medicare and Medicaid Services (CMS) Skilled Nursing Facility Market Basket Index or other appropriate index if the CMS Skilled Nursing Facility Market Basket Index is discontinued.
4102.14 The Stevie Sellows Intermediate Care Facility for the Intellectually and Developmentally Disabled Quality Improvement Fund Assessment shall be a broad based assessment on all ICF/IID providers in the District of Columbia at a uniform rate of five and one-half percent (5.5%) of each ICF/IID's gross revenue. The allowable cost of the Assessment shall be calculated consistently with 42 U.S.C. § 1396(b)(w) and 42 C.F.R. §§ 433.68, 433.70, and 433.72.
4102.15 For Fiscal Year 2013, ICF/IID reimbursement rates shall be as follows:
| Beds | Facility | Direct care staffing | Other health care & program | Non-Personnel Opers. | Trans | Capital | Admin | Active Treatment | Total Rate | Tax | |
|---|---|---|---|---|---|---|---|---|---|---|---|
| Base | 4 – 5 | Leased | $291.16 | $34.94 | $18.87 | $18.00 | $58.51 | $54.79 | $82.39 | $558.67 | $30.73 |
| Owned | $291.16 | $34.94 | $18.87 | $18.00 | $29.26 | $50.99 | $82.39 | $525.61 | $28.91 | ||
| 6 | Leased | $220.23 | $37.44 | $18.87 | $18.00 | $53.44 | $45.24 | $82.39 | $475.60 | $26.16 | |
| Owned | $220.23 | $37.44 | $18.87 | $18.00 | $26.72 | $41.76 | $82.39 | $445.41 | $24.50 | ||
| Moderate | 4 – 5 | Leased | $291.16 | $34.94 | $18.87 | $18.00 | $58.51 | $54.79 | $82.39 | $558.67 | $30.73 |
| Owned | $291.16 | $34.94 | $18.87 | $18.00 | $29.26 | $50.99 | $82.39 | $525.61 | $28.91 | ||
| 6 | Leased | $283.56 | $48.21 | $18.87 | $18.00 | $53.44 | $54.87 | $82.39 | $559.34 | $30.76 | |
| Owned | $283.56 | $48.21 | $18.87 | $18.00 | $26.72 | $51.40 | $82.39 | $529.15 | $29.10 | ||
| Extensive behavioral | 4 – 5 | Leased | $354.50 | $42.54 | $18.87 | $18.00 | $58.51 | $64.02 | $82.39 | $638.83 | $35.14 |
| Owned | $354.50 | $42.54 | $18.87 | $18.00 | $29.26 | $60.21 | $82.39 | $605.77 | $33.32 | ||
| 6 | Leased | $325.79 | $55.38 | $18.87 | $18.00 | $53.44 | $61.29 | $82.39 | $615.17 | $33.83 | |
| Owned | $325.79 | $55.38 | $18.87 | $18.00 | $26.72 | $57.82 | $82.39 | $584.98 | $32.17 | ||
| Extensive medical | 4 – 5 | Leased | $397.57 | $47.71 | $18.87 | $18.00 | $58.51 | $70.29 | $82.39 | $693.34 | $38.13 |
| Owned | $397.57 | $47.71 | $18.87 | $18.00 | $29.26 | $66.48 | $82.39 | $660.28 | $36.32 | ||
| 6 | Leased | $348.01 | $59.16 | $18.87 | $18.00 | $53.44 | $64.67 | $82.39 | $644.54 | $35.45 | |
| Owned | $348.01 | $59.16 | $18.87 | $18.00 | $26.72 | $61.20 | $82.39 | $614.35 | $33.79 | ||
| Pervasive DSP 1:1 8 h / 7 d | 4 – 5 | Leased | $417.84 | $50.14 | $18.87 | $18.00 | $58.51 | $73.24 | $82.39 | $718.99 | $39.54 |
| Owned | $417.84 | $50.14 | $18.87 | $18.00 | $29.26 | $69.43 | $82.39 | $685.93 | $37.73 | ||
| 6 | Leased | $346.90 | $58.97 | $18.87 | $18.00 | $53.44 | $64.50 | $82.39 | $643.08 | $35.37 | |
| Owned | $346.90 | $58.97 | $18.87 | $18.00 | $26.72 | $61.03 | $82.39 | $612.89 | $33.71 | ||
| Pervasive DSP 1:1 8 h / 5 d | 4 – 5 | Leased | $377.58 | $45.31 | $18.87 | $18.00 | $58.51 | $67.38 | $82.39 | $668.04 | $36.74 |
| Owned | $377.58 | $45.31 | $18.87 | $18.00 | $29.26 | $63.57 | $82.39 | $634.98 | $34.92 | ||
| 6 | Leased | $306.64 | $52.13 | $18.87 | $18.00 | $53.44 | $58.38 | $82.39 | $589.86 | $32.44 | |
| Owned | $306.64 | $52.13 | $18.87 | $18.00 | $26.72 | $54.91 | $82.39 | $559.66 | $30.78 | ||
| Pervasive DSP 1:1 16 h | 4 – 5 | Leased | $544.52 | $65.34 | $18.87 | $18.00 | $58.51 | $91.68 | $82.39 | $879.31 | $48.36 |
| Owned | $544.52 | $65.34 | $18.87 | $18.00 | $29.26 | $87.88 | $82.39 | $846.26 | $46.54 |
| 6 | Leased | $473.58 | $80.51 | $18.87 | $18.00 | $53.44 | $83.77 | $82.39 | $810.56 | $44.58 | |
|---|---|---|---|---|---|---|---|---|---|---|---|
| Owned | $473.58 | $80.51 | $18.87 | $18.00 | $26.72 | $80.30 | $82.39 | $780.37 | $42.92 | ||
| Pervasive DSP 24 h | 4 – 5 | Leased | $671.20 | $80.54 | $18.87 | $18.00 | $58.51 | $110.13 | $82.39 | $1,039.64 | $57.18 |
| Owned | $671.20 | $80.54 | $18.87 | $18.00 | $29.26 | $106.32 | $82.39 | $1,006.58 | $55.36 | ||
| 6 | Leased | $600.26 | $102.04 | $18.87 | $18.00 | $53.44 | $103.04 | $82.39 | $978.04 | $53.79 | |
| Owned | $600.26 | $102.04 | $18.87 | $18.00 | $26.72 | $99.57 | $82.39 | $947.85 | $52.13 | ||
| Nursing 1:1 8 h / 7 d | 4 – 5 | Leased | $503.98 | $60.48 | $18.87 | $18.00 | $58.51 | $85.78 | $82.39 | $828.01 | $45.54 |
| Owned | $503.98 | $60.48 | $18.87 | $18.00 | $29.26 | $81.98 | $82.39 | $794.95 | $43.72 | ||
| 6 | Leased | $433.04 | $73.62 | $18.87 | $18.00 | $53.44 | $77.61 | $82.39 | $756.97 | $41.63 | |
| Owned | $433.04 | $73.62 | $18.87 | $18.00 | $26.72 | $74.13 | $82.39 | $726.77 | $39.97 | ||
| Nursing 1:1 8 h / 5 d | 4 – 5 | Leased | $436.35 | $52.36 | $18.87 | $18.00 | $58.51 | $75.93 | $82.39 | $742.41 | $40.83 |
| Owned | $436.35 | $52.36 | $18.87 | $18.00 | $29.26 | $72.13 | $82.39 | $709.35 | $39.01 | ||
| 6 | Leased | $365.41 | $62.12 | $18.87 | $18.00 | $53.44 | $67.32 | $82.39 | $667.55 | $36.72 | |
| Owned | $365.41 | $62.12 | $18.87 | $18.00 | $26.72 | $63.85 | $82.39 | $637.35 | $35.05 | ||
| Nursing 1:1 16 hours | 4 – 5 | Leased | $716.80 | $86.02 | $18.87 | $18.00 | $58.51 | $116.77 | $82.39 | $1,097.35 | $60.35 |
| Owned | $716.80 | $86.02 | $18.87 | $18.00 | $29.26 | $112.96 | $82.39 | $1,064.29 | $58.54 | ||
| 6 | Leased | $645.86 | $109.80 | $18.87 | $18.00 | $53.44 | $109.98 | $82.39 | $1,038.34 | $57.11 | |
| Owned | $645.86 | $109.80 | $18.87 | $18.00 | $26.72 | $106.50 | $82.39 | $1,008.14 | $55.45 | ||
| Nursing 1:1 24 hours | 4 – 5 | Leased | $929.62 | $111.55 | $18.87 | $18.00 | $58.51 | $147.75 | $82.39 | $1,366.69 | $75.17 |
| Owned | $929.62 | $111.55 | $18.87 | $18.00 | $29.26 | $143.95 | $82.39 | $1,333.64 | $73.35 | ||
| 6 | Leased | $858.68 | $145.98 | $18.87 | $18.00 | $53.44 | $142.35 | $82.39 | $1,319.70 | $72.58 | |
| Owned | $858.68 | $145.98 | $18.87 | $18.00 | $26.72 | $138.87 | $82.39 | $1,289.51 | $70.92 |
SOURCE: Final Rulemaking published at 60 DCR 11590 (August 9, 2013).