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) 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) 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) 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 seven-tenths 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 facil-

ities 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 facil-

ities 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 ninety-four 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 adjust-

ment 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 13 CSR 70-10

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 dol-

lars 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.

AUTHORITY: section 208.159, RSMo 2000, and sections 208.153 and 208.201, RSMo Supp. 2013. 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. *Original authority: 208.153, RSMo 1967, amended 1967, 1973, 1989, 1990, 1991, 2007, 2012; 208.159, RSMo 1979; and 208.201, RSMo 1987, amended 2007.