PURPOSE: This rule implements a supplemental payment program for qualifying private and public nursing facilities.

1. (1) Effective for dates of service on or after April 1, 2012, through June 30, 2013, supplemental payments will be made as set forth in subsections (1)(A)–(1)(D) in each following calendar quarter from the Long-Term Support Upper Payment Limit (UPL) Fund to qualifying private and public nursing facilities for services rendered during the quarter on or after April 1, 2012 through June 30, 2013. Maximum payments to all qualifying private and public nursing facilities shall not exceed the upper payment limit defined in 42 CFR 447.272 in each state fiscal year.

   1. (A) Qualifying Criteria. The nursing facilities named in Section (13)(E)7. of the Medicaid State Plan are eligible for the Partnership Supplemental Payment and shall be referred to as qualifying nursing facilities. In addition, to qualify for the supplemental payment, a private or public nursing facility must be enrolled in MO HealthNet at the time the supplemental payment is calculated and made.

      1. 1. A private nursing facility is defined as

being owned and operated by a private entity.

1. 2. A public nursing facility is defined as

being owned or operated by a public entity.

1. (B) Reimbursement Methodology. Qualifying private and public nursing facilities are eligible to receive supplemental payments for nursing facility services. Supplemental payments will be made in each calendar quarter after April 1, 2012.

   1. 1. Calculating qualifying nursing facili-

ties quarterly Partnership Supplemental Per Diems—The quarterly per diem amount for each qualifying nursing facility shall be calculated as follows:

1. A. Dividing the available annual

funding listed in Section (13)(E)6. of the Medicaid State Plan by the number of quarters in the fiscal period to obtain the quarterly funding amount;

1. B. Allotment between qualifying pub-

licly owned and qualifying privately owned nursing facilities will be calculated as follows:

1. (I) The allotment for qualifying

publicly owned nursing facilities will be the funding in subparagraph (1)(B)1.A. of this rule multiplied by eighty percent (80%); and

1. (II) The allotment for qualifying pri-

vately owned nursing facilities will be the funding calculated in subparagraph (1)(B)1.A. of this rule multiplied by twenty percent (20%);

1. C. The public nursing facility per

diem is calculated by dividing the amount calculated in part (1)(B)1.B.(I) of this rule by the number of Medicaid paid days from the previous full state fiscal year divided by the four (4) quarters in the year for all qualifying public nursing facilities enrolled in the Medicaid program at the time the supplemental payments are made; and

1. D. The private nursing facility per

diem is calculated by dividing the amount calculated in part (1)(B)1.B.(II) of this rule by the number of Medicaid paid days from the previous full state fiscal year divided by the four (4) quarters in the year for all qualifying private nursing facilities enrolled in the Medicaid program at the time the supplemen- 13 CSR 70-10

tal payments are made.

1. 2. Calculating qualifying nursing facili-

ties’ quarterly Partnership Supplemental Payments—The quarterly payment amount for each qualifying nursing facility enrolled in the Medicaid program shall be calculated as follows:

1. A. Each Medicaid enrolled qualifying

nursing facility’s Medicaid paid days from the previous full state fiscal year divided by the four (4) quarters in the year shall be multiplied by the Partnership Supplemental Payment per diem calculated in subparagraph (1)(B)1.C. of this rule for qualifying public nursing facilities and subparagraph (1)(B)1.D. of this rule for qualifying private nursing facilities to obtain each qualifying nursing facility’s quarterly amount.

1. 3. The time period used in calculating

paragraphs (1)(B)1. and 2. of this rule will be the most recent state fiscal year for which data is available for the full fiscal year.

1. (C) Payment Limitations.

   1. 1. Public Nursing Facilities—Annual

payment distributions for all qualifying individual public nursing facilities enrolled in the Medicaid program shall be limited to the qualifying individual public nursing facility’s annual amount of unreimbursed Medicaid costs.

1. 2. Private Nursing Facilities—Annual

payment distributions for all qualifying private nursing facilities enrolled in the Medicaid program shall be limited to the difference between the qualifying nursing facility’s Medicare equivalent payments as determined in the Medicare upper payment limit calculation and Medicaid payments the qualifying nursing facility receives for covered services provided to Medicaid recipients.

1. 3. Any amount over the payment limita-

tion for a qualifying individual nursing facility will be distributed to qualifying nursing facilities enrolled in the Medicaid program that have not reached their payment limitations as follows:

1. A. If any qualifying public nursing

facility reaches its limitation described in paragraph (1)(C)1. above—

1. (I) The amount exceeding the limi-

tation will be divided by the Medicaid days for the qualifying public nursing facilities enrolled in the Medicaid program within the pool that have not exceeded their limitations to obtain an additional Partnership Supplemental Payment Per Diem;

1. (II) This additional per diem will

be paid to each qualifying public nursing facility enrolled in the Medicaid program that has not exceeded its limitation by multiplying the facility’s Medicaid days by the per diem calculated in part (1)(C)3.A.(I) of this rule;

1. (III) The calculation in parts

(1)(C)3.A.(I) and (II) of this rule will be repeated until the entire amount allocated to qualifying public nursing facilities enrolled in the Medicaid program has been expended or all of the qualifying public facilities enrolled in the Medicaid program have reached their limits as specified in paragraph (1)(C)1. of this rule; and

1. (IV) If any funding amount from

the public allocation remains, it will be used to make Partnership Supplemental Payments to qualifying private nursing facilities enrolled in the Medicaid program.

1. B. If any qualifying private nursing

facility reaches its limitation described in paragraph (1)(C)2. above—

1. (I) The amount exceeding the limi-

tation will be divided by the Medicaid days for the qualifying private nursing facilities enrolled in the Medicaid program within the pool that have not exceeded their limitations to obtain an additional Partnership Supplemental Payment Per Diem;

1. (II) This additional per diem will

be paid to each qualifying private nursing facility enrolled in the Medicaid program that has not exceeded its limitation by multiplying the facility’s Medicaid days by the per diem calculated in part (1)(C)3.B.(I) of this rule;

1. (III) The calculation in parts

(1)(C)3.B.(I) and (II) of this rule will be repeated until the entire amount allocated to qualifying private nursing facilities has been expended or all of the qualifying private facilities have reached their limits as specified in paragraph (1)(C)2. of this rule; and

1. (IV) Any remaining funding from

the private allocation will be used to make Partnership Supplemental Payments to public nursing facilities.

1. C. Any remaining quarterly funding

from either pool that cannot be paid due to payment limitations will be used in the reconciliation process described in subsection (1)(D) of this rule.

1. 4. The time period used in calculating

subsection (1)(C) of this rule will be the most recent state fiscal year for which data is available for the full fiscal year.

1. (D) Partnership Supplemental Payment Reconciliation—Prior to making payments each quarter, the department will calculate a reconciliation factor by—

   1. 1. Determining an amended aggregate

payment amount by adjusting the available funding amount by any residual amount from subparagraph (1)(C)3.C. of this rule;

1. 2. Dividing the amount established in

paragraph (1)(D)1. of this rule by the original available funding amount to establish the reconciliation factor; and

1. 3. The reconciliation factor from para-

graph (1)(D)2. of this rule will be applied to the payments identified in subsection (1)(B) of this rule that are made during that fiscal year unless the department is unable to make the adjustment during the fiscal year due to the timing of the payments. In that case, the payments for the subsequent fiscal year will be adjusted by the difference between the amounts from paragraph (1)(D)1. of this rule and the available annual funding amount listed in Section (13)(E)6. of the Medicaid State Plan.

1. (2) Effective for dates of service beginning July 1, 2013, Nursing Facility UPL Payments shall be made as set forth below in subsections (2)(A)–(2)(C). Maximum aggregate payments to all qualifying nursing facilities shall not exceed the upper payment limit defined in 42 CFR 447.272 in each state fiscal year.

   1. (A) An annual UPL Payment shall be made at the end of each state fiscal year (SFY) to qualifying nursing facilities.
   2. (B) Qualifying Criteria. Public nursing facilities that have executed an agreement with the department are eligible for a UPL Payment and shall be referred to as qualifying nursing facilities. In addition, to qualify for the UPL Payment, each nursing facility must be enrolled in the Medicaid program at the time the UPL payments are calculated and made.
   3. (C) Reimbursement Methodology. The annual UPL Payment will be made to qualifying nursing facilities based on each facility’s unreimbursed costs determined from the facility’s second prior year Medicaid cost report, subject to the Medicare Upper Payment Limit.

AUTHORITY: section 208.201, RSMo Supp. 2014.* Original rule filed Feb. 15, 2012, effective Aug. 30, 2012. Amended: Filed July 1, 2013, effective Jan. 30, 2014. Amended: Filed Aug. 15, 2014, effective Feb. 28, 2015.

*Original authority: 208.201, RSMo 1987, amended 2007.