Specialized Reimbursement: Certain Hcbs And Chis

01. Applicable HCBS and CHIS Programs. The following HCBS provider types and CHIS ar e reimbursed as described in this section: (7-1-25)T a. Developmental Disability Agencies (DDA) providing services to adults or children; (7-1-25)T b. Residential Habilitation Agencies; (7-1-25)T c. Supported Employment Agencies; (7-1-25)T d. Service Coordination Agencies; and (7-1-25)T e. CHIS. (7-1-25)T 02. Timing, Description, and Rate Review Results. (7-1-25)T a. The Department conducts a cost survey and reviews rates at least once every five (5) years for eac h provider type specified in this rule. Cost surveys are conducted in the order and on a schedule established by the Department. (7-1-25)T b. The Department prepares an annual trigger analysis and publishes the report on the Medicai d Providers webpage. This annual report describes the triggers for interim rate reviews, a summary of data reviewed fo r each trigger, and the Department’s determination and rationale of whether each trigger was met. The Departmen t conducts interim rate reviews when one (1) or more of the following triggers occur: (7-1-25)T i. Substantiated participant complaints, critical incidents, or both, related to a lack of qualifie d providers indicate emerging access issues; (7-1-25)T ii. Department quality reports or substantiated participant complaints and critical incidents related t o the quality of services indicate emerging quality issues; or (7-1-25)T iii. Federal or Idaho minimum wage requirements in effect at the time of a standard rate revie w significantly change. (7-1-25)T 03. Cost Survey Procedures. The Department conducts periodic cost surveys. Providers who refuse or fail to respond may be disenrolled as a Medicaid provider. (7-1-25)T 04. Rate Setting Methodology. Providers must demonstrate that the average percent of wage an d benefits paid to direct care staff (or service coordinators) meets or exceeds the percent of wages and ERE used t o establish the rates for a service type. The cost components and new rates are established in accordance with th e following components: (7-1-25)T a. Direct Care Staff and Service Coordinator wages paid to agency employees or contractors wh o perform duties described in the applicable service description for at least seventy-five percent (75%) of the tota l annual amount of time compensated. (7-1-25)T i. The wage component used to establish the new rate is set using the mean hourly wage of one (1) or more occupation profiles from the most current BLS State Occupational Employment and Wage Estimates table for Idaho that most closely aligns with the duties, education, and supervision requirements for staff providing the servic e is used. If more than one (1) occupation profile aligns, then a weighted average of the mean hourly wage of multipl e BLS occupation profiles is used. (7-1-25)T ii. When no comparable occupation profile exists, then the wage component to establish the new rat e is set using the WAHR of surveyed wages included in the final cost survey results. (7-1-25)T iii. The Department makes the final determination of BLS occupation profiles. (7-1-25)T iv. The Department evaluates an appropriate wage inflation factor based on economic data available a t the time the rate is set. (7-1-25)T b. ERE are expenses incurred by an agency to benefit direct care staff or service coordinators in thes e categories: paid leave, supplemental pay, payroll taxes, workers’ compensation, insurance coverage, and retirement contributions. The ERE component percentage (ERE%) to establish a new rate is set using the cumulative percentag e of employer costs for compensation from the most current BLS Employer Costs for Employee Compensation table for the West Region in the Mountain Division and IRS Publication 15. (7-1-25)T c. Program-Related Expenses (PRE) are wages and other expenses supporting the objectives an d provision of a service but not tied to any individual receiving a service. Regulatory requirements related to servic e delivery are PRE. (7-1-25)T i. Program-related staff are agency employees who perform duties as required by statute or rule for a t least seventy-five percent (75%) of the total annual amount of time compensated. (7-1-25)T ii. Using data in the final cost survey results, each agency’s PRE component percentage (PRE%) is calculated by dividing the agency's total PRE by their total wages. Each agency’s PRE% is ranked and the mean of the PRE% rank is used to calculate a new rate. (7-1-25)T d. General and Administrative (G&A) Expenses are wages and other expenses related to daily operations common across all businesses. (7-1-25)T i. G&A staff are agency employees who perform administrative duties for at least seventy-fiv e percent (75%) of the total annual amount of time compensated. (7-1-25)T ii. Using data in the final cost survey results, each agency’s G&A component percentage (G&A%) i s calculated by dividing the agency’s total G&A expenses by the sum of the agency’s total wages, plus total ERE, tota l PRE, and total G&A expenses. Each agency’s G&A% is ranked and the mean of the G&A% rank is used to calculat e a new rate. (7-1-25)T iii. The G&A% used to calculate a new rate will not exceed ten percent (10%) of the total rate per staf f hour. (7-1-25)T e. Total Rate Per Staff Hour of Service = ((Wage + (ERE% x Wage) + (PRE% x Wage)) / (1- (G&A%)). (7-1-25)T f. The Department is not obligated to make budget requests based on the total rate per staff hour an d takes into consideration factors of efficiency, economy, quality of care, and access to care when determining rates. Rates may be set at a percentage of the total rate per staff hour and are subject to approval by the Idaho Legislature. (7-1-25)T g. The reimbursement rates calculated for CHIS include both services and mileage. No separat e charges for mileage will be paid by the Department for provider transportation to and from the participant's home o r other service delivery location. (7-1-25)T 05. Quality Incentives. Based on the quality of services provided, a provider may be eligible fo r incentive payments. (7-1-25)T a. Quality measures and associated payment percentages are established by the Department, i n collaboration with the state’s protection and advocacy organization designated by the Governor and described in th e Idaho Medicaid Provider Handbook. The Department provides sixty (60) days prior notice of any substantiv e changes to quality measures and associated payment percentages. (7-1-25)T b. Incentive payments are subject to availability of State and federal funds and may be rescinded i f service quality declines. (7-1-25)T