1. A. Non-State Governmental Organization Nursing Facilities

   1. 1. Effective for dates of service on or after January 20, 2016, any nursing facility that is owned or operated by a non-state governmental organization (NSGO), and that has entered into an agreement with the department to participate, shall qualify for a Medicaid supplemental payment adjustment, in addition to the uniform Medicaid rates paid to nursing facilities. The only qualifying nursing facilities are:

      1. a. Gueydan Memorial Guest Home;
      2. b. LaSalle Nursing Home;
      3. c. Natchitoches Parish Hospital LTC Unit; and
      4. d. St. Helena Parish Nursing Home.
   2. 2. The supplemental Medicaid payment to a non-state, government-owned or operated nursing facility shall not exceed the facility’s upper payment limit (UPL) pursuant to 42 CFR 447.272.

   3. 3. Payment Calculations. The Medicaid supplemental payment for each state fiscal year (SFY) shall be calculated immediately following the July quarterly Medicaid rate setting process. The total Medicaid supplemental payment for each individual NSGO will be established as the individual nursing facility differential between the estimated Medicare payments for Medicaid nursing facility residents, and the adjusted Medicaid payments for those same nursing facility residents. A more detailed description of the Medicaid supplemental payment process is described below.

      1. a. The calculation of the total annual Medicaid supplemental payment for nursing facilities involves the following four components:

         1. i. calculate Medicare payments for Louisiana Medicaid nursing facility residents using Medicare payment principles;
         2. ii. determining Medicaid payments for Louisiana Medicaid nursing facility residents;
         3. iii. adjust payments for coverage difference between Medicare payment principles and Louisiana Medicaid payment principles; and
         4. iv. calculating the differential between the calculated Medicare payments for Medicaid nursing facility residents, and Medicaid payments for those same residents.

      2. b. Calculating Medicaid Rates Using Medicare Payment Principles. The prospective payment system (PPS), Medicare rates will be calculated based on Medicaid acuity data. The following is a summary of the steps involved.

         1. i. The applicable PDPM classification for Medicaid residents is identified using each resident’s minimum data set assessment. A full listing of Medicaid residents with the applicable Medicare PDPM classification is then generated.

            1. (a). The resident minimum data set assessments will be from the most recently available minimum data set assessments utilized in Medicaid rate setting processes as of the development of the Medicaid supplemental payment calculation demonstration.

         2. ii. Rural and urban rate differentials, wage index adjustments, and value-based purchasing adjustments will be used to adjust the Medicare rate tables for each component of PDPM after the Medicaid listing is developed. The non-therapy ancillary component of PDPM will be adjusted to exclude the estimated portion of payments related to pharmacy, laboratory, and radiology services based on a statewide percentage derived from Medicare cost report data to account for differences between what the Medicare PPS rate covers and what the Medicaid program reimburses. Medicare rate tables will be applicable to SFY periods.

            1. (a). Medicare rate tables will be established using information published in 42 CFR part 483 where available. Should the finalized Medicare rate tables for any portion of the applicable SFY period be unavailable, the most recent preliminary Medicare rate adjustment percentage published in the Federal Register available as of the development of the Medicaid supplemental payment calculation demonstration will be utilized as the basis of the Medicare rate for that portion of the SFY period.
            2. (b). Medicare rates for each Medicaid resident in the listing are calculated using the relevant Medicare rate tables for each period of the SFY and then averaged by nursing facility. The nursing facility’s average rates are then pro-rated based on the length of active time of each Medicare rate table during the SFY. The calculated rate will be multiplied by an estimate of Medicaid paid claims days for the specified period. Medicaid paid claims days will be compiled from the state’s Medicaid Management Information System’s (MMIS) most recent 12 months, as of the development of the Medicaid supplemental payment calculation demonstration.

      3. c. Determining Medicaid Payments for Medicaid Nursing Facility Residents. The most current Medicaid nursing facility reimbursement rates as of the development of the Medicaid supplemental payment calculation demonstration will be utilized. These reimbursement rates will be multiplied by Medicaid paid claims compiled from the state’s MMIS system from the most recent 12 months, as of the development of the Medicaid supplemental payment calculation demonstration, to establish total Medicaid per diem payments. Total calculated Medicaid payments made outside of the standard nursing facility per diem are summed with total Medicaid reimbursement from the per diem payments to establish total Medicaid payments. Payments made outside of the standard nursing facility per diem are reimbursement for the following services.

         1. i. Specialized Care Services Payments. Specialized care services reimbursement is paid outside of the standard per diem rate as an add-on payment to the current facility per diem rate. The established specialized care add-on per diems will be multiplied by Medicaid paid claims for specialized care days compiled from the state’s MMIS system from the most recent 12 months, as of the development of the Medicaid supplemental payment calculation demonstration, to establish projected specialized care services payments for the applicable SFY.
         2. ii. Home/Hospital Leave Day (Bed Hold) Payments. Allowable Medicaid leave days were established using Medicaid paid claims days compiled from the state’s MMIS system from the most recent 12 months, as of the development of the Medicaid supplemental payment calculation demonstration. Allowable Medicaid Leave days will be multiplied by the most recent Medicaid leave day quarterly reimbursement rates as of the of the Medicaid supplemental payment calculation demonstration to established projected Medicaid Leave day payments for the SFY.
         3. iii. Private Room Conversion Payments. Private room conversion (PRC) Medicaid days will be established utilizing the most recently reviewed or audited Medicaid supplemental cost reports as of the development of the Medicaid supplemental payment calculation demonstration. The applicable cost reporting period information will be annualized to account for short year cost reporting periods. Allowable PRC Medicaid days will be multiplied by the PRC incentive payment amount of $5 per allowable day to establish the total projected Medicaid PRC payments for the SFY.
      4. d. Calculating the Differential between the Calculated Medicare Payments for Medicaid Nursing Facility Residents, and Medicaid Payments for those Same Residents. The total annual Medicaid supplemental payment will be equal to the individual NSGO nursing facility’s differential between their calculated Medicare payments and the calculated Medicaid payments for the applicable SFY, as detailed in the sections above.
   4. 4. Frequency of Payments and Calculations. The Medicaid supplemental payments will be reimbursed through a calendar quarter based lump sum payment. The amount of the calendar quarter lump sum payment will be equal to the SFY total annual Medicaid supplemental payment divided by four. The total annual Medicaid supplemental payment calculation will be performed for each SFY immediately following the July quarterly Medicaid rate setting process.
   5. 5. No payment under this section is dependent on any agreement or arrangement for provider or related entities to donate money or services to a governmental entity.

Authority Note

AUTHORITY NOTE: Promulgated in accordance with R.S. 36:254 and Title XIX of the Social Security Act.

Historical Note

HISTORICAL NOTE: Promulgated by the Department of Health and Hospitals, Bureau of Health Services Financing, LR 42:63 (January 2016), amended by the Department of Health, Bureau of Health Services Financing, LR 43:529 (March 2017), LR 47:476 (April 2021), LR 51:1613 (October 2025).