Nf: Special Rates

The Department pays NFs an addition to their daily rate when a patient’s needs exceed the scope of NF services, and the cost is not adequately reflected in the calculated rates. This rate is in addition to any payments under other provisions and excluded from the computation of payments or rates under other sections of these rules. (7-1-26) 01. Determination. The Department approves special rates per patient based on identified conditions expected to continue for more than thirty (30) days. No rate is allowed if payment for these needs is available from a non-Medicaid source. (7-1-26) 02. Effective Date. Upon approval, a special rate is effective on the date set by the Department. (7-1-26) 03. Reporting. Costs equivalent to payments for special rate add-on amounts are removed from cost components subject to limits and reported separately. (7-1-26) 04. Limitation. Special rates cannot exceed a NF's charges to other patients for similar services. (7-1-26) 05. Prospective Rate Treatment. Special rates are paid under a prospective payment system. (7-1-26) 06. Payment for Qualifying Residents. The Department calculates special rate add-on amounts using one (1) of the following methods: (7-1-26) a. For NFs operating as a one hundred percent (100%) special care unit including Medicaid residents, the direct care cost per diem is not subject to the direct care cost limit. However, the direct care costs are case mix adjusted based on the ratio of a NF's Medicaid CMI for the rate period to the NF-wide CMI for the cost reporting period. (7-1-26) b. The Department pays for equipment and non-therapy supplies not addressed in the coverage and limitations section in accordance with DMEPOS, as an add-on amount. (7-1-26) c. NFs providing care to residents who are ventilator-dependent or receive tracheostomy care are eligible to submit requests for a fixed add-on amount, in addition to the NF’s rate for residents receiving this type of care. Approved requests are effective the date a resident needs this care, no earlier than sixty (60) days prior to request receipt. Add-on rates include the cost for equipment and supplies and for additional RN and CNA hours, as appropriate for each care type. Costs for equipment and supplies are adjusted annually for inflation, and skilled nursing costs are adjusted according to annual WAHR survey results. (7-1-26) i. The Department reviews approved add-on rates for these residents annually to ensure the add-on rate remains necessary for the resident’s care needs. (7-1-26) ii. NFs must inform the Department when an approved add-on rate is no longer needed or a resident’s IDAHO ADMINISTRATIVE CODE IDAPA 16.03.26 Department of Health & Welfare Medicaid Plan Benefits Section 492 Page 106 special needs change. (7-1-26) iii. The hourly add-on rate for staffing in an out-of-state NF equals the current WAHR CNA or RN wage rate plus a benefits allowance based on annual cost report data and weighted to remove CNA minimum daily staffing time adjusted for the appropriate staff skill level. (7-1-26) 07. Treatment of Special Rates In Future Rate Setting Periods. Special rates are established on a prospective basis as with the overall NF rate. When a cost report used to set rates contains a special add-on cost, the Department makes an adjustment to reduce costs by an amount equal to total incremental revenues, or add-on payments received by the NF during the cost reporting period. The amount received is calculated by multiplying the special rate add-on amount paid for each qualifying resident by the number of days paid. No related adjustment is made to the NF's CMIs. (7-1-26) 08. Special Rate for NF Ownership Change or Closure. The Department does not require a closing cost report, and reviews special rates made in the closing cost reporting period. (7-1-26)