PURPOSE: This regulation is necessary to outline the provisions allowed in House Bill 1362.

PUBLISHER’S NOTE: The secretary of state has determined that publication of the entire text of the material that is incorporated by reference as a portion of this rule would be unduly cumbersome or expensive. This material as incorporated by reference in this rule shall be maintained by the agency at its headquarters and shall be made available to the public for inspection and copying at no more than the actual cost of reproduction. This note applies only to the reference material. The entire text of the rule is printed here.

1. (1) Nursing Facility Reimbursement Allowance (NFRA). NFRA shall be assessed as described in this section.

   1. (A) Definitions.

      1. 1. Nursing facility. An institution or a distinct part of an

institution which—

1. A. Is primarily engaged in providing to residents—

   1. (I) Skilled nursing care and related services for

residents who require medical or nursing care; or

1. (II) Rehabilitation services for the rehabilitation of

injured, disabled, or sick persons; or

1. (III) On a regular basis, health-care and services

to individuals who, because of their mental or physical condition, require care and services (above the level of room and board) which can be made available to them only through institutional facilities and is not primarily for the care and treatment of mental diseases; and

1. B. Has in effect a transfer agreement with one (1) or more

hospitals as required by federal law; and

1. C. Meets the requirements for a nursing facility described

in section 1919(b)–(d) of the Social Security Act; or

1. D. Is licensed in accordance with Chapter 198, RSMo, as

a skilled nursing facility.

1. 2. Fiscal period. A facility’s twelve- (12-) month fiscal

reporting period. If the facility is also participating in the Title XVIII Medicare (Medicare) program, the Medicaid cost report period shall be the same as the Medicare cost report period. If the provider does not participate in Medicare, the Medicaid cost report should have the same twelve- (12-) month fiscal year consistent with the facility’s accounting and reporting period.

1. 3. Department. Department of Social Services.
2. 4. Director. Director of the Department of Social Services.
3. 5. Division. MO HealthNet Division, Department of Social

Services.

1. 6. Department of Health and Senior Services (DHSS). The

Missouri state agency responsible for licensing and inspecting all long-term care facilities operating in Missouri and certifying annually those facilities participating in the Medicare or Medicaid program.

1. 7. Engaging in the business of providing nursing facility

services. Accepting payment for nursing facility services rendered.

1. 8. Quarterly survey. The survey filled out each quarter by

a nursing facility providing data on its licensed and certified beds and the related resident occupancy days (ROD) that is submitted to the DHSS. The survey, “Missouri Department of Health and Senior Services, Certificate of Need Quarterly Survey,” incorporated by reference in this rule, is published by the Department of Health and Senior Services, Division of Senior Services and Regulation, PO Box 570, Jefferson City, MO 65102 and is available at https://consurvey.dhss.mo.gov/ CONFacility/Login.aspx, June 23, 2025. This rule does not incorporate any subsequent amendments or additions.

1. 9. Applicable quarterly survey. The quarterly survey used

by the division from which the patient occupancy days are taken to determine the NFRA assessment for a given period as set forth in section (2).

1. 10. Patient occupancy days. The number of days that

residents occupied the licensed beds in a nursing facility as shown on the quarterly survey, line D. “Number of occupied RODs (days patients in beds or beds held).”

1. 11. Annualized level of patient occupancy days. The annual

level of patient occupancy days used to determine the annual NFRA assessment.

1. A. For existing nursing facilities whose NFRA assessment

is set in accordance with paragraph (1)(B)1. of this regulation, the annualized level of patient occupancy days is calculated by taking the number of patient occupancy days shown on line D. of the quarterly survey multiplied by four (4).

1. B. For nursing facilities whose NFRA assessment is not

set by the general rule set forth in paragraph (1)(B)1. (i.e., it is an exception set under subparagraph (1)(B)1.A., is a new facility set under paragraph (1)(B)2., qualifies for a NFRA adjustment in accordance with section (3), etc.), the annualized level of patient occupancy days may be calculated differently and is set forth in those sections.

1. 12. Licensed beds. Any skilled nursing facility or intermedi-

ate care facility bed meeting the licensing requirement of the Missouri Department of Health and Senior Services.

1. 13. Licensed bed days. The total number of patient days

available for use during a given period for all licensed beds. For purposes of this regulation, licensed bed days are calculated for an annual period and is the number of licensed beds times three hundred sixty-five (365) days.

1. 14. Change of ownership. A change in the ownership,

control, operator, or leasehold interest.

1. (B) Each nursing facility, except any nursing facility operated by the Department of Mental Health, engaging in the business of providing nursing facility services in Missouri shall pay a Nursing Facility Reimbursement Allowance (NFRA).

   1. 1. The NFRA owed for existing nursing facilities shall be

calculated by multiplying the NFRA rate by the annualized level of patient occupancy days from the applicable quarterly survey. The NFRA shall be divided by and collected over the number of months for which each NFRA rate is effective. The NFRA rates, effective dates, and applicable quarterly surveys are set forth in section (2).

1. A. Exceptions.

   1. (I) If an existing nursing facility is not open for the

entire quarter relative to the applicable quarterly survey, as set forth in section (2), and the applicable quarterly survey does not represent a full quarter’s worth of days due to a termination, temporary closure, change of ownership, etc., the annualized level of patient occupancy days used to determine the NFRA shall be the greater of—

1. (a) The annualized level of patient occupancy days

from the quarterly survey immediately prior to the applicable quarterly survey, if it represents a full quarter’s worth of days; or

1. (b) Fifty percent (50%) of licensed bed days (i.e.,

number of licensed beds times three hundred sixty-five (365) days times fifty percent (50%)).

1. (II) If an existing nursing facility did not submit the

applicable quarterly survey, the annualized level of patient occupancy days used to determine the NFRA shall be the greater of—

1. (a) The facility’s current NFRA assessment (i.e., the

NFRA assessment that is in effect prior to the new SFY update for which the facility did not submit a survey); or

1. (b) Eighty percent (80%) of licensed bed days.
2. (III) If a nursing facility has intermediate care facility

1. (ICF) licensed beds and skilled nursing facility (SNF) licensed beds and none of the beds are Medicaid certified, only the SNF beds are subject to NFRA. The annualized level of patient occupancy days used to determine the NFRA shall be determined by multiplying the occupancy percentage from the applicable quarterly survey by the licensed bed days for the SNF licensed beds (i.e., number of SNF licensed beds times three hundred sixty-five (365) days).

   1. (IV) If two (2) existing nursing facilities merge, with

one (1) nursing facility terminating and transferring its beds to the remaining facility, the NFRA for the two (2) previously independent nursing facilities shall be added together and assessed to the remaining facility.

1. 2. The initial NFRA owed by a newly licensed nursing

facility that just opened as a result of receiving a Certificate of Need (CON) for a new nursing facility shall be calculated by multiplying the NFRA rate by the annualized level of patient occupancy days based on fifty percent (50%) of licensed bed days. The NFRA shall be prorated for the number of months remaining in the NFRA period. If a nursing facility’s licensure date is after the first day of a month, the NFRA will be collected beginning with the first day of the month following the actual licensure date.

1. 3. If a nursing facility ceases to provide nursing facility

services, the nursing facility is not required to pay the NFRA during the months in which it does not have residents, even though it may retain a license due to temporary closure for renovations, replacement, etc. If a nursing facility provided nursing facility services for any portion of a month, it shall pay the NFRA for the entire month (i.e., the NFRA shall not be prorated for the month in which it ceases to provide nursing facility services). If the facility reopens, it shall resume paying the NFRA. It shall owe the same NFRA as it did prior to closing, if the NFRA has not changed per section (2) below. If the NFRA has changed, the facility shall be assessed in accordance with paragraph (1)(B)1. above.

1. (C) Payment of the NFRA.

   1. 1. Offset. Each nursing facility may request that their

Nursing Facility Reimbursement Allowance be offset against any Missouri Medicaid payment due to that nursing facility. A statement authorizing the offset must be on file with the division before any offset may be made relative to the nursing facility reimbursement allowance by the nursing facility. Assessments shall be allocated and deducted over the applicable service period. Any balance due after the offset shall be remitted by the nursing facility to the department. The remittance shall be made payable to the Director of the Department of Revenue and deposited in the state treasury to the credit of the Nursing Facility Reimbursement Allowance Fund. If the remittance is not received before the next Medicaid payment cycle, the division shall offset the balance due from that check.

1. 2. Check. If no offset has been authorized by the nursing

facility, the division will begin collecting the nursing facility reimbursement allowance on the first day of each month. The NFRA shall be remitted by the nursing facility to the department. The remittance shall be made payable to the director of the Department of Revenue and deposited in the state treasury to the credit of the Nursing Facility Reimbursement Allowance Fund.

1. 3. Failure to pay the NFRA. If a nursing facility fails to pay

its NFRA within thirty (30) days of notice, the NFRA shall be delinquent. For any delinquent NFRA, the department may proceed to enforce the state’s lien of the property of the nursing facility, may cancel or refuse to issue, extend, or reinstate the Medicaid provider agreement or may seek denial, suspension, or revocation of license granted under Chapter 198, RSMo. The new owner, as a result of a change in ownership, shall have his/her NFRA paid by the same method the previous owner elected.

1. (D) Each nursing facility, upon receiving written notice of the final determination of its Nursing Facility Reimbursement Allowance, may file a protest with the director of the department setting forth the grounds on which the protest is based, within thirty (30) days from the date of receipt of written notice from the department. The director of the department shall reconsider the determination and, if the nursing facility so requested, the director or the director’s designee shall grant the nursing facility a hearing to be held within forty-five (45) days after the protest is filed, unless extended by agreement between the nursing facility and the director. The director shall issue a final decision within forty-five (45) days of the completion of the hearing. After a final decision by the director, a nursing facility’s appeal of the director’s final decision shall be to the Administrative Hearing Commission in accordance with sections 208.156 and 621.055, RSMo.

1. (2) NFRA Rates. The amount of the fees imposed under this rule shall not exceed the percentage of net patient service revenues permitted by federal regulation pursuant to 42 CFR 433.68 as determined by the department on a per occupied bed per day basis. Federal regulation 42 CFR 433.68 specifies that permissible health care related taxes shall produce revenues that are less than or equal to six percent (6%) of the revenues received by the health care provider. Federal regulation 42 CFR 433.68 is incorporated by reference as published by Office of the Federal Register, National Archives and Records Administration, 732

2. N. Capitol Street NW, Washington, DC 20401, October 1, 2024. This rule does not incorporate any subsequent amendments or additions. The NFRA rates determined by the division are as follows:

   1. (A) The NFRA will be two dollars and seventy-six cents ($2.76) per patient occupancy day for the period January 1, 1995, through September 30, 1995, and collected over nine (9) months (February 1995 through October 1995). The applicable quarterly survey for this period shall be the Division of Aging’s June 1994 quarterly survey;
   2. (B) The NFRA will be three dollars and fifty-five cents ($3.55) per patient occupancy day for the period October 1, 1995, through September 30, 1996, and collected over twelve (12) months (November 1995 through October 1996). The applicable quarterly survey for this period shall be the Division of Aging’s June 1995 quarterly survey;
   3. (C) The NFRA will be five dollars and thirty cents ($5.30) per patient occupancy day for the period October 1, 1996, through September 30, 1997, and collected over twelve (12) months (November 1996 through October 1997). The applicable quarterly survey for this period shall be the Division of Aging’s June 1996 quarterly survey;
   4. (D) The NFRA will be five dollars and eighty-eight cents ($5.88) per patient occupancy day for the period October 1, 1997, through September 30, 1998, and collected over twelve

3. (12) months (November 1997 through October 1998). The applicable quarterly survey for this period shall be the Division of Aging’s June 1997 quarterly survey;

   1. (E) The NFRA will be five dollars and eighty-eight cents ($5.88) per patient occupancy day for the period October 1, 1998, through September 30, 1999, and collected over twelve

4. (12) months (November 1998 through October 1999). The applicable quarterly survey for this period shall be the Division of Aging’s June 1998 quarterly survey;

   1. (F) The NFRA will be seven dollars and four cents ($7.04) per patient occupancy day, effective October 1, 1999. The applicable quarterly survey for this period shall be the Division of Aging’s June 1999 quarterly survey;
   2. (G) The NFRA will be seven dollars and fifty cents ($7.50) per patient occupancy day, effective July 1, 2000. The applicable quarterly survey for this period shall be the Division of Aging’s December 1999 quarterly survey;
   3. (H) The NFRA will be seven dollars and thirty cents ($7.30) per patient occupancy day, effective July 1, 2001. The applicable quarterly survey for this period shall be the Division of Aging’s December 2000 quarterly survey;
   4. (I) The NFRA will be eight dollars and forty-two cents ($8.42) per patient occupancy day, effective July 1, 2003. The applicable quarterly survey for this period shall be the Department of Health and Senior Services’ December 2002 quarterly survey;
   5. (J) Effective January 1, 2005, the applicable quarterly survey shall be the June 2004 quarterly survey. The NFRA will continue to be eight dollars and forty-two cents ($8.42) per patient occupancy day;
   6. (K) Effective July 1, 2005, the applicable quarterly survey shall be updated at the beginning of each state fiscal year using the previous December’s quarterly survey;
   7. (L) Effective July 1, 2009, the NFRA will be nine dollars and seven cents ($9.07) per patient occupancy day. The applicable quarterly survey shall be as defined in subsection (2)(K);
   8. (M) Effective January 1, 2010, the NFRA will be nine dollars and twenty-seven cents ($9.27) per patient occupancy day. The applicable quarterly survey shall be as defined in subsection (2)(K);
   9. (N) Effective October 1, 2011, the NFRA will be eleven dollars and seventy cents ($11.70) per patient occupancy day. The applicable quarterly survey shall be as defined in subsection (2)(K);
   10. (O) Effective July 1, 2012, the NFRA will be twelve dollars and eleven cents ($12.11) per patient occupancy day. The applicable quarterly survey shall be as defined in subsection (2)(K);
   11. (P) Effective July 1, 2015, the NFRA will be thirteen dollars and forty cents ($13.40) per patient occupancy day. The applicable quarterly survey shall be as defined in subsection (2)(K); and
   12. (Q) Effective July 1, 2018, the NFRA will be twelve dollars and ninety-three cents ($12.93) per patient occupancy day. The applicable quarterly survey shall be as defined in subsection (2)(K).

5. (3) NFRA Adjustment Request. A facility being assessed the NFRA may request that its current NFRA assessment be adjusted, as set forth below.

   1. (A) Qualifying Criteria. In order for a facility to receive an adjustment to its current NFRA assessment, it must meet all of the following criteria:

      1. 1. The facility must decrease its licensed bed capacity by at

least fifteen percent (15%).

1. 2. The facility must draft a written statement documenting

that the decrease in licensed bed capacity is intended to be permanent.

1. A. If the facility increases its licensed capacity back to

the original capacity within one (1) year of the decrease, the NFRA adjustment shall be voided and the facility shall resume paying the original NFRA beginning with the first of the month in which the facility made the request to DHSS to increase licensed capacity.

1. 3. The annualized level of patient occupancy days currently

being assessed is not possible to attain because it is greater than one hundred percent (100%) of its new licensed capacity. For example, assume a facility had one hundred thirty (130) licensed beds and was being assessed on an average of one hundred (100) beds:

1. A. If a facility decreased its license by twenty (20) beds,

being left with a total of one hundred ten (110) licensed beds, the facility could still obtain the occupancy at which it was assessed (i.e., one hundred (100) beds being assessed is less than the one hundred ten (110) licensed bed capacity). Therefore, it would not meet the criteria for a NFRA adjustment.

1. B. If a facility decreased its license by forty (40) beds,

being left with a total of ninety (90) licensed beds, the facility could not obtain the occupancy at which it was assessed (i.e., one hundred (100) beds being assessed is greater than the ninety (90) licensed bed capacity). Therefore, it would meet the criteria for a NFRA adjustment.

1. 4. The facility must submit a written request to the division

that includes an explanation as to why it believes it qualifies for an adjustment to its NFRA and documentation supporting its request. The following documentation is required:

1. A. A copy of the facility’s request submitted to the DHSS

and/or the CON program that its licensed bed capacity be decreased.

1. B. A copy of the license issued as a result of the request

for the decrease and all licenses issued from that point forward to the current license.

1. C. If the facility’s request submitted to the DHSS and/or

the CON program to decrease its licensed bed capacity did not include a statement that the facility intended for the decrease to be permanent, such a statement must be submitted with the NFRA Adjustment Request.

1. D. The division may obtain this documentation and any

other documentation it deems relevant to satisfy itself that the facility’s licensed bed capacity has been decreased and the facility intends for the decrease to be permanent from the facility, the DHSS, the CON program, or any other source it deems appropriate.

1. E. If the division makes a written request for additional

information and the facility does not comply within ninety (90) days of the request, the division shall consider the NFRA Adjustment Request withdrawn.

1. (B) Calculation of Adjustment. A nursing facility meeting the criteria for a NFRA Adjustment shall have its NFRA recalculated and it shall replace the current NFRA. The revised, adjusted NFRA shall be calculated as follows:

   1. 1. The facility’s new, decreased licensed bed capacity

shall be multiplied by three hundred sixty-five (365) days to determine the annualized level of patient occupancy days;

1. 2. The new annualized level of patient occupancy days

shall be multiplied by the current NFRA rate set forth in section (2) to determine the revised annual assessment; and

1. 3. The revised annual assessment shall be divided by twelve

1. (12) months to determine the revised monthly assessment that the facility will owe beginning with the effective date of the adjustment.

   1. (C) Effective Date of NFRA Adjustment. The effective date of the NFRA Adjustment shall be the first day of the month following the date the request is received; it will not be retroactive back to the effective date of the original NFRA.

AUTHORITY: sections 198.401, 198.403, 198.406, 198.409, 198.412, 198.416, 198.418, 198.421, 198.424, 198.427, 198.431, 198.433, 198.436, 208.159, and 208.201, RSMo 2016, and sections 198.439 and 208.153, RSMo Supp. 2025.* Emergency rule filed Dec. 21, 1994, effective Jan. 1, 1995, expired April 30, 1995. Emergency rule filed April 21, 1995, effective May 1, 1995, expired Aug. 28, 1995. Original rule filed Dec. 15, 1994, effective July 30, 1995. Emergency amendment filed Sept. 5, 1995, effective Oct. 1, 1995, expired March 28, 1996. Amended: Filed May 30, 1995, effective Dec. 30, 1995. Amended: Filed Sept. 5, 1995, effective March 30, 1996. Emergency amendment filed Sept. 20, 1996, effective Oct. 1, 1996, expired March 29, 1997. Emergency amendment filed Sept. 19, 1997, effective Oct. 1, 1997, expired March 29, 1998. Amended: Filed Sept. 25, 1997, effective March 30, 1998. Emergency amendment filed Sept. 21, 1998, effective Oct. 1, 1998, expired March 29, 1999. Amended: Filed Sept. 21, 1998, effective May 30, 1999. Emergency amendment filed Sept. 20, 1999, effective Oct. 1, 1999 expired March 29, 2000. Amended: Filed Aug. 30, 1999, effective March 30, 2000. Amended: Filed Feb. 29, 2000, effective Oct. 30, 2000. Emergency amendment filed Aug. 29, 2001, effective Sept. 8, 2001, expired March 6, 2002. Amended: Filed Aug. 29, 2001, effective March 30, 2002. Emergency amendment filed Sept. 22, 2003, effective Oct. 1, 2003, terminated Oct. 29, 2003. Amended: Filed Sept. 22, 2003, effective May 30, 2004. Emergency amendment filed Dec. 17, 2004, effective Jan. 1, 2005, expired June 29, 2005. Amended: Filed Dec. 17, 2004, effective July 30, 2005. Emergency amendment filed Nov. 9, 2009, effective Nov. 19, 2009, expired Dec. 31, 2009. Amended: Filed July 1, 2009, effective Jan. 30, 2010. Emergency amendment filed Dec. 1, 2009, effective Jan. 1, 2010, expired June 29, 2010. Amended: Filed Dec. 1, 2009, effective June 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. Emergency amendment filed June 20, 2012, effective July 1, 2012, expired Dec. 28, 2012. Amended: Filed July 2, 2012, effective Jan. 30, 2013. Emergency amendment filed June 19, 2015, effective July 1, 2015, expired Dec. 28, 2015. Amended: Filed July 1, 2015, effective Jan. 30, 2016. 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 June 23, 2025, effective July 8, 2025, expired Feb. 26, 2026. Amended: Filed Aug. 12, 2025, effective March 30, 2026. *Original authority: 198.401, RSMo 1994; 198.403, RSMo 1994; 198.406, RSMo 1994; 198.409, RSMo 1994; 198.412, RSMo 1994; 198.416, RSMo 1994; 198.418, RSMo 1994; 198.421, RSMo 1994, amended 2014; 198.424, RSMo 1994; 198.427, RSMo 1994; 198.431, RSMo 1994; 198.433, RSMo 1994; 198.436, RSMo 1994, amended 1995; 198.439, RSMo 1994, amended 1996, 1999, 2002, 2005, 2006, 2007, 2011, 2015, 2016, 2018, 2019, 2020, 2021, 2024; 208.153, RSMo 1967, amended 1967, 1973, 1989, 1990, 1991, 2007, 2012, 2024; 208.159, RSMo 1979; and 208.201, RSMo 1987, amended 2007.