405 IAC 1-12-9 Criteria limiting rate adjustment granted by office

Sec. 9. During rebasing years and for base rate reviews, the Medicaid reimbursement system is based on recognition of the provider's allowable costs plus a potential profit add-on payment. The payment rate established during rebasing years and for base rate reviews is subject to the following limitations: (1) In no instance shall the approved Medicaid rate be higher than the rate paid to that provider by the general public for the same type of services. For purposes of this rule, the rates paid by the general public shall not include rates paid by the DDRS. (2) Should the rate calculations produce a rate higher than the reimbursement rate requested by the provider, the approved rate shall be the rate requested by the provider. (3) Inflated allowable per patient or per resident day costs plus the allowed profit add-on payment as determined by the methodology in Table I. (4) In no instance shall the approved Medicaid rate exceed the overall rate limit percent (Column A) in Table II, times the average inflated allowable cost of the median patient or resident day. TABLE I Profit Add-On The profit add-on is equal to the percent (Column A) of the difference (if greater than zero (0)) between a provider's inflated allowable per patient or resident day cost, and the ceiling (Column B) times the average inflated allowable per patient or resident day cost of the median patient or resident day. Under no circumstances shall a provider's per patient or resident day profit add-on exceed the cap (Column C) times the average inflated allowable per patient or resident day cost of the median patient or resident day. Level of Care (A) Percent (B) Ceiling (C) Cap Sheltered living 40% 105% 10% Intensive training 40% 120% 10% Child rearing 40% 130% 12% Nonstate-operated ICF/IID 40% 125% 12% Developmental training 40% 110% 10% Child rearing with a specialized program 40% 120% 12% Small behavior management residences for children 40% 120% 12% Basic developmental 40% 110% 10% Small extensive medical needs residences for adults 40% 110% 10% Extensive support needs residences for adults 40% 110% 10% TABLE II Overall Rate Limit Level of Care (A) Percent Sheltered living 115% Intensive training 120% Child rearing 130% Developmental training 120% Child rearing with a specialized program 120% Small behavior management residences for children 120% Basic developmental 120% Small extensive medical needs residences for adults 120% Extensive support needs residences for adults 120% Nonstate-operated ICF/IID 107%