PURPOSE: This rule sets forth the global per diem adjustments to be applied to nursing facility reimbursement rates, established in 13 CSR 70-10.015, and HIV nursing facility reimbursement rates, established in 13 CSR 70-10.080. The global per diem adjustments were previously included in 13 CSR 70-10.015 and 13 CSR 70-10.080.

1. (1) Authority. This regulation is established pursuant to the authorization granted to the Department of Social Services (department), MO HealthNet Division (division), to promulgate rules and regulations.
2. (2) Purpose. This regulation sets forth the global per diem adjustments to be applied to nursing facility reimbursement rates, established in 13 CSR 70-10.015, and Human Immunodeficiency Virus (HIV) nursing facility reimbursement rates, established in 13 CSR 70-10.080. All principles and definitions set forth in 13 CSR 70-10.015 are applicable to nursing facilities, and all principles and definitions set forth in 13 CSR 70-10.080 are applicable to HIV nursing facilities. The terms “facility” or “facilities” as used in this regulation shall apply to both nursing facilities and HIV nursing facilities.

3. (3) Adjustments to the Reimbursement Rates. Subject to the limitations prescribed in 13 CSR 70-10.015, a nursing facility’s reimbursement rate may be adjusted as described in this section. Subject to the limitations prescribed in 13 CSR 70- 10.080, an HIV nursing facility’s reimbursement rate may be adjusted as described in this section.

   1. (A) Global Per Diem Rate Adjustments. A facility with either an interim rate or a prospective rate may qualify for the global per diem rate adjustments. Global per diem rate adjustments shall be added to the specified cost component ceiling.

      1. 1. FY-96 negotiated trend factor—

         1. A. Facilities with either an interim rate or prospective

rate in effect on October 1, 1995, shall be granted an increase to their per diem effective October 1, 1995, of four and six-tenths percent (4.6%) of the cost determined in paragraphs (11)(A)1., (11) (B)1., (11)(C)1., and the property insurance and property taxes detailed in subsection (11)(D) of 13 CSR 70-10.015; or

1. B. Facilities that were granted a prospective rate based

on paragraph (12)(A)2. of 13 CSR 70-10.015 that is in effect on October 1, 1995, shall have their increase determined by subsection (3)(S) of 13 CSR 70-10.015.

1. 2. FY-97 negotiated trend factor—

   1. A. Facilities with either an interim rate or prospective

rate in effect on October 1, 1996, shall be granted an increase to their per diem effective October 1, 1996, of three and seventenths percent (3.7%) of the cost determined in paragraphs (11) (A)1., (11)(B)1., (11)(C)1., and the property insurance and property taxes detailed in subsection (11)(D) of 13 CSR 70-10.015; or

1. B. Facilities that were granted a prospective rate based

on paragraph (12)(A)2. of 13 CSR 70-10.015 that is in effect on October 1, 1995, shall have their increase determined by subsection (3)(S) of 13 CSR 70-10.015.

1. 3. Nursing Facility Reimbursement Allowance (NFRA).

Effective October 1, 1996, all facilities with either an interim rate or a prospective rate shall have its per diem adjusted to include the current NFRA as an allowable cost in its reimbursement rate calculation.

1. 4. Minimum wage adjustment. All facilities with either

an interim rate or a prospective rate in effect on November 1, 1996, shall be granted an increase to their per diem effective November 1, 1996, of two dollars and forty-five cents ($2.45) to allow for the change in minimum wage. Utilizing Fiscal Year 1995 cost report data, the total industry hours reported for each payroll category was multiplied by the fifty-cent (50¢) increase, divided by the patient days for the facilities reporting hours for that payroll category, and factored up by eight and sixty-seven hundredths percent (8.67%) to account for the related increase to payroll taxes. This calculation excludes the director of nursing, the administrator, and assistant administrator.

1. 5. Minimum wage adjustment. All facilities with either

an interim rate or a prospective rate in effect on September 1, 1997, shall be granted an increase to their per diem effective September 1, 1997, of one dollar and ninety-eight cents ($1.98) to allow for the change in minimum wage. Utilizing Fiscal Year 1995 cost report data, the total industry hours reported for each payroll category was multiplied by the forty-cent (40¢) increase, divided by the patient days for the facilities reporting hours for that payroll category, and factored up by eight and sixty-seven hundredths percent (8.67%) to account for the related increase to payroll taxes. This calculation excludes the director of nursing, the administrator, and assistant administrator.

1. 6. FY-98 negotiated trend factor—

   1. A. Facilities with either an interim rate or prospective

rate in effect on October 1, 1997, shall be granted an increase to their per diem effective October 1, 1997, of three and four-tenths percent (3.4%) of the cost determined in paragraphs (11)(A)1., (11) (B)1., (11)(C)1., and the property insurance and property taxes detailed in subsection (11)(D) of 13 CSR 70-10.015 for nursing facilities and 13 CSR 70-10.080 for HIV nursing facilities; or

1. B. Facilities that were granted a prospective rate based

on paragraph (12)(A)2. of 13 CSR 70-10.015 that is in effect on October 1, 1995, shall have their increase determined by subsection (3)(S) of 13 CSR 70-10.015.

1. 7. FY-99 negotiated trend factor—

   1. A. Facilities with either an interim rate or prospective

rate in effect on October 1, 1998, shall be granted an increase to their per diem effective October 1, 1998, of two and one-tenth percent (2.1%) of the cost determined in paragraphs (11)(A)1., (11)(B)1., (11)(C)1., the property insurance and property taxes detailed in subsection (11)(D) of 13 CSR 70-10.015 for nursing facilities and 13 CSR 70-10.080 for HIV nursing facilities, and the minimum wage adjustments detailed in paragraphs (3)(A)4. and (3)(A)5. of this regulation; or

1. B. Facilities that were granted a prospective rate based

on paragraph (12)(A)2. of 13 CSR 70-10.015 that is in effect on October 1, 1998, shall have their increase determined by subsection (3)(S) of 13 CSR 70-10.015.

1. 8. FY-2000 negotiated trend factor—

   1. A. Facilities with either an interim rate or prospective

rate in effect on July 1, 1999, shall be granted an increase to their per diem effective July 1, 1999, of one and ninetyfour hundredths percent (1.94%) of the cost determined in subsections (11)(A), (11)(B), (11)(C), the property insurance and property taxes detailed in subsection (11)(D) of 13 CSR 70-10.015 for nursing facilities and 13 CSR 70-10.080 for HIV nursing facilities, and the minimum wage adjustments detailed in paragraphs (3)(A)4. and (3)(A)5. of this regulation; or

1. B. Facilities that were granted a prospective rate based

on paragraph (12)(A)2. of 13 CSR 70-10.015 that is in effect on July 1, 1999, shall have their increase determined by subsection (3) (S) of 13 CSR 70-10.015.

1. 9. FY-2004 nursing facility operations adjustment—

   1. A. Facilities with either an interim rate or prospective

rate in effect on July 1, 2003, shall be granted an increase to their per diem effective for dates of service beginning July 1, 2003, through June 30, 2004, of four dollars and thirty-two cents ($4.32) for the cost of nursing facility operations. Effective for dates of service beginning July 1, 2004, the per diem adjustment shall be reduced to three dollars and seventy-eight cents ($3.78); and

1. B. The operations adjustment shall be added to the

facility’s current rate as of June 30, 2003, and is effective for payment dates after August 1, 2003.

1. 10. FY-2007 quality improvement adjustment—

   1. A. Facilities with either an interim rate or prospective

rate in effect on July 1, 2006, shall be granted an increase to their per diem effective for dates of service beginning July 1, 2006, of three dollars and seventeen cents ($3.17) to improve the quality of life for nursing facility residents; and

1. B. The quality improvement adjustment shall be added

to the facility’s current rate as of June 30, 2006, and is effective for dates of service beginning July 1, 2006, and after.

1. 11. FY-2007 trend adjustment—

   1. A. Facilities with either an interim rate or a prospective

rate in effect on February 1, 2007, shall be granted an increase to their per diem rate effective for dates of service beginning February 1, 2007, of three dollars and zero cents ($3.00) to allow for a trend adjustment to ensure quality nursing facility services; and

1. B. The trend adjustment shall be added to the facility’s

reimbursement rate as of January 31, 2007, and is effective for dates of service beginning February 1, 2007, for payment dates after March 1, 2007.

1. 12. FY-2008 trend adjustment—

   1. A. Facilities with either an interim rate or a prospective

rate in effect on July 1, 2007, shall be granted an increase to their per diem rate effective for dates of service beginning July 1, 2007, of six dollars and zero cents ($6.00) to allow for a trend adjustment to ensure quality nursing facility services; and

1. B. The trend adjustment shall be added to the facility’s

current rate as of June 30, 2007, and is effective for dates of service beginning July 1, 2007.

1. 13. FY-2009 trend adjustment—

   1. A. Facilities with either an interim rate or a prospective

rate in effect on July 1, 2008, shall be granted an increase to their per diem rate effective for dates of service beginning July 1, 2008, of six dollars and zero cents ($6.00) to allow for a trend adjustment to ensure quality nursing facility services; and

1. B. The trend adjustment shall be added to the facility’s

current rate as of June 30, 2008, and is effective for dates of service beginning July 1, 2008.

1. 14. FY-2010 trend adjustment—

   1. A. Facilities with either an interim rate or a prospective

rate in effect on July 1, 2009, shall be granted an increase to their per diem rate effective for dates of service beginning July 1, 2009, of five dollars and fifty cents ($5.50) to allow for a trend adjustment to ensure quality nursing facility services; and

1. B. The trend adjustment shall be added to the facility’s

current rate as of June 30, 2009, and is effective for dates of service beginning July 1, 2009.

1. 15. FY-2012 trend adjustment—

   1. A. Facilities with either an interim rate or a prospective

rate in effect on October 1, 2011, shall be granted an increase to their per diem rate effective for dates of service beginning October 1, 2011, of six dollars and zero cents ($6.00) to allow for a trend adjustment to ensure quality nursing facility services;

1. B. The trend adjustment shall be added to the facility’s

current rate as of September 30, 2011, and is effective for dates of service beginning October 1, 2011; and

1. C. This increase is contingent upon the federal

assessment rate limit increasing to six percent (6%) and is subject to approval by the Centers for Medicare and Medicaid Services.

1. 16. FY-2013 trend adjustment—

   1. A. Facilities with either an interim rate or a prospective

rate in effect on July 1, 2012, shall be granted an increase to their per diem rate effective for dates of services beginning July 1, 2012, of six dollars and zero cents ($6.00) to allow for a trend adjustment to ensure quality nursing facility services;

1. B. The trend adjustment shall be added to the facility’s

current rate as of June 30, 2012, and is effective for dates of service beginning July 1, 2012; and

1. C. This increase is contingent upon approval by the

Centers for Medicare and Medicaid Services.

1. 17. FY-2014 trend adjustment—

   1. A. Facilities with either an interim rate or a prospective

rate in effect on July 1, 2013, shall be granted an increase to their per diem rate effective for dates of services beginning July 1, 2013, of three percent (3.0%) of their current rate, less certain fixed cost items. The fixed cost items are the per diem amounts included in the facility’s current rate from the following: subsection (2)(O) of 13 CSR 70-10.110, paragraphs (11) (D)1., (11)(D)2., (11)(D)3., (11)(D)4., (13)(B)3., and (13)(B)10. of 13 CSR 70-10.015;

1. B. The trend adjustment shall be added to the facility’s

current rate as of June 30, 2013, and is effective for dates of service beginning July 1, 2013; and

1. C. This increase is contingent upon approval by the

Centers for Medicare and Medicaid Services.

1. 18. FY-2015 trend adjustment—

   1. A. Facilities with either an interim rate or a prospective

rate in effect on July 1, 2014, shall be granted an increase to their per diem rate effective for dates of services beginning July 1, 2014, of one dollar and twenty-five cents ($1.25) to allow for a trend adjustment to ensure quality nursing facility services;

1. B. The trend adjustment shall be added to the facility’s

current rate as of June 30, 2014, and is effective for dates of service beginning July 1, 2014; and

1. C. This increase is contingent upon approval by the

Centers for Medicare and Medicaid Services.

1. 19. January 1, 2016 – June 30, 2016 trend adjustment—

   1. A. Facilities with either an interim rate or a prospective

rate in effect on January 1, 2016, shall be granted an increase to their per diem rate effective for dates of services beginning January 1, 2016, of two dollars and nine cents ($2.09) to allow for a trend adjustment to ensure quality nursing facility services;

1. B. The trend adjustment will not be added to the

facility’s rate after June 30, 2016; and

1. C. This increase is contingent upon approval by the

Centers for Medicare and Medicaid Services and sufficient funding available through the Tax Amnesty Fund.

1. 20. Continuation of FY-2016 trend adjustment and FY-2017

trend adjustment—

1. A. Facilities with either an interim rate or a prospective

rate in effect on July 1, 2016, shall continue to be granted an increase to their per diem rate effective for dates of service beginning July 1, 2016, of two dollars and nine cents ($2.09);

1. B. Facilities with either an interim rate or a prospective

rate in effect on July 1, 2016, shall be granted an increase to their per diem rate effective for dates of services beginning July 1, 2016, of two dollars and eighty-three cents ($2.83) to allow for a trend adjustment to ensure quality nursing facility services;

1. C. The trend adjustment of two dollars and eighty-three

cents ($2.83) shall be added to the facility’s rate as of June 30, 2016, which includes the two dollars and nine cents ($2.09) increase, and is effective for dates of service beginning July 1, 2016; and

1. D. These increases are contingent upon approval by the

Centers for Medicare and Medicaid Services.

1. 21. FY-2018 per diem adjustment—

   1. A. Facilities with either an interim rate or a prospective

rate in effect on August 1, 2017, shall be subject to a decrease in their per diem rate effective for dates of services August 1, 2017 through June 30, 2018, of five dollars and thirty-seven cents ($5.37);

1. B. The per diem adjustment of five dollars and thirty-

seven cents ($5.37) shall be deducted from the facility’s current rate as of July 31, 2017, and is effective for dates of service beginning August 1, 2017;

1. C. Effective for dates of service beginning July 1, 2018,

the per diem decrease shall be reduced to four dollars and eighty-three cents ($4.83). A per diem adjustment of fifty-four cents ($0.54) shall be added to the facilities current rate as of June 30, 2018, which includes the five dollars and thirty-seven cents ($5.37) decrease, and is effective for dates of service beginning July 1, 2018; and

1. D. This decrease is contingent upon approval by the

Centers for Medicare and Medicaid Services.

1. 22. FY-2019 trend adjustment—

   1. A. Facilities with either an interim rate or a prospective

rate in effect on July 1, 2018, shall be granted an increase to their per diem rate effective for dates of services beginning July 1, 2018, of seven dollars and seventy-six cents ($7.76) to allow for a trend adjustment to ensure quality nursing facility services;

1. B. The rate to which the FY-2019 trend adjustment of

seven dollars and seventy-six cents ($7.76) shall be added is the facility’s rate as of June 30, 2018, plus the fifty-four cents ($0.54) per diem adjustment effective July 1, 2018, set forth in subparagraph (3)(A)21.C. and is effective for dates of service beginning July 1, 2018. This trend adjustment shall result in a rate no greater than eight dollars and thirty cents ($8.30) higher than the rate in effect on January 1, 2018; and

1. C. This increase is contingent upon approval by the

Centers for Medicare and Medicaid Services.

1. 23. FY-2019 additional trend adjustment—

   1. A. Facilities with either an interim rate or a prospective

rate in effect on February 1, 2019, shall be granted an increase to their per diem rate effective for dates of service February 1, 2019 through June 30, 2019, of one dollar and twenty-nine cents ($1.29) to allow for a trend adjustment to ensure quality nursing facility services;

1. B. The per diem adjustment of one dollar and twenty-

nine cents ($1.29) shall be added to the facility’s rate as of January 31, 2019, and is effective for dates of service beginning February 1, 2019 through June 30, 2019;

1. C. Effective for dates of service beginning July 1, 2019,

the per diem increase shall be reduced to fifty-four cents ($0.54). A per diem adjustment of seventy-five cents ($0.75) shall be deducted from the facility’s rate as of June 30, 2019, which includes the one dollar and twenty-nine cents ($1.29) increase, and is effective for dates of service beginning July 1, 2019.

1. D. These per diem adjustments are contingent upon

approval by the Centers for Medicare and Medicaid Services.

1. 24. FY-2020 trend adjustment—

   1. A. Facilities with either an interim rate or a prospective

rate in effect on August 1, 2019, shall be granted an increase to their per diem rate effective for dates of service August 1, 2019 through June 30, 2020, of one dollar and sixty-one cents ($1.61) to allow for a trend adjustment to ensure quality nursing facility services;

1. B. The rate to which the FY-2020 trend adjustment of one

dollar and sixty-one cents ($1.61) shall be added is the facility’s rate as of July 31, 2019 set forth in subparagraph (13)(A)23.C. The FY-2020 trend adjustment shall be effective for dates of service beginning August 1, 2019 through June 30, 2020.

1. C. Effective for dates of service beginning July 1, 2020,

the per diem increase shall be reduced to one dollar and forty-nine cents ($1.49). A per diem adjustment of twelve cents ($0.12) shall be deducted from the facility’s rate as of June 30, 2020, which includes the one dollar and sixty-one cents ($1.61) increase, and is effective for dates of service beginning July 1, 2020.

1. D. These per diem adjustments are contingent upon

approval by the Centers for Medicare and Medicaid Services

1. 25. FY-2022 COVID-19 National Emergency adjustment—

   1. A. Facilities with either an interim rate or a prospective

rate in effect on July 1, 2021, shall be granted an increase to their per diem rate effective for dates of service July 1, 2021, through June 30, 2022, of ten dollars and eighteen cents ($10.18) to allow for an adjustment for increases in costs associated with staffing, supplies, social distancing standards, and other factors due to the COVID-19 national emergency;

1. B. The rate to which the FY-2022 adjustment of ten

dollars and eighteen cents ($10.18) shall be added is the facility’s rate as of June 30, 2021, set forth in subparagraph (13) (A)24.C. The FY-2022 adjustment shall be effective for dates of service beginning July 1, 2021, through June 30, 2022.

1. C. The FY-2022 adjustment will not be included in the

per diem rate for dates of service after June 30, 2022. A per diem adjustment of ten dollars and eighteen cents ($10.18) shall be deducted from the facility’s rate as of June 30, 2022, which includes the ten dollars and eighteen cents ($10.18) increase, and is effective for dates of service beginning July 1, 2022.

AUTHORITY: sections 208.153, 208.159, 208.201, and 660.017, RSMo 2016.* Original rule filed July 1, 2008, effective Jan. 30, 2009. Emergency rule filed Oct. 3, 2008, effective Oct. 13, 2008, expired April 10, 2009. Emergency amendment filed Nov. 9, 2009, effective Nov. 19, 2009, expired Jan. 30, 2010. Amended: Filed July 1, 2009, effective Jan. 30, 2010. Emergency amendment filed Sept. 20, 2011, effective Oct. 1, 2011, expired March 28, 2012. Amended: Filed July 1, 2011, effective Dec. 30, 2011. Amended: Filed June 20, 2012, effective Jan. 30, 2013. Amended: Filed Oct. 30, 2013, effective May 30, 2014. Amended: Filed July 15, 2014, effective Jan. 30, 2015. Amended: Filed Nov. 16, 2015, effective May 30, 2016. Amended: Filed May 16, 2016, effective Nov. 30, 2016. Emergency amendment filed July 21, 2017, effective Aug. 1, 2017, expired Feb. 22, 2018. Amended: Filed July 21, 2017, effective Jan. 30, 2018. Amended: Filed Sept. 28, 2018, effective April 30, 2019. Emergency amendment filed Dec. 21, 2018, terminated May 31, 2019. Emergency amendment filed May 9, 2019, effective June 1, 2019, expired Dec. 30, 2019. Amended: Filed May 9, 2019, effective Dec. 30, 2019. Emergency amendment filed Jan. 16, 2020, effective Jan. 31, 2020, expired July 28, 2020. Amended: Filed Jan. 16, 2020, effective Aug. 30, 2020. Emergency amendment filed Sept. 13, 2021, effective Sept. 27, 2021, expired March 25, 2022. Amended: Filed Sept. 13, 2021, effective March 30, 2022. *Original authority: 208.153, RSMo 1967, amended 1967, 1973, 1989, 1990, 1991, 2007, 2012; 208.159, RSMo 1979; 208.201, RSMo 1987, amended 2007; and 660.017, RSMo 1993, amended 1995.