49.45(6m)(am)3.b. b. Water and sewer services.
49.45(6m)(am)4. 4. Net property tax or allowable municipal service costs incurred by the owner of the facility for the facility.
49.45(6m)(am)5. 5. Allowable administrative and general costs, including costs related to the facility's overall management and administration and allowable expenses that are not recognized or reimbursed in other cost centers and including the costs of commercial estimators approved by the department under par. (ar) 6.
49.45(6m)(am)5m. 5m. Allowable interest expense of the facility, less interest income of the facility and less interest income of affiliated entities, to the extent required under the approved state plan for services under 42 USC 1396.
49.45(6m)(am)6. 6. Capital payment necessary for the provision of service over time, including allowable facility expenses for suitable space, furnishings, property insurance and movable equipment for patient care.
49.45(6m)(ar) (ar) In determining payments for a facility under par. (ag), the department may establish minimum patient day occupancy standards for determining costs per patient day and shall apply the following methods to calculate amounts payable for the rate year for the cost centers described under par. (am):
49.45(6m)(ar)1. 1. For direct care costs:
49.45(6m)(ar)1.a. a. The department shall establish standards for payment of allowable direct care costs that are at least 110% of the median for direct care costs for facilities that do not primarily serve the developmentally disabled and separate standards for payment of allowable direct care costs that are at least 110% of the median for direct care costs for facilities primarily serving the developmentally disabled. The standards shall be adjusted by the department for regional labor cost variations. The department may decrease the percentage established for the standards only if amounts available under par. (ag) (intro.) are insufficient to provide total payment under par. (am), less capital costs under subd. 6.
49.45(6m)(ar)1.b. b. The department shall establish the direct care component of the facility rate for each facility by comparing actual allowable direct care cost information of that facility adjusted for inflation to the standards established under subd. 1. a.
49.45(6m)(ar)1.c. c. If a facility has an approved program for provision of service to emotionally disturbed or mentally retarded residents, residents dependent upon ventilators, or residents requiring supplemental skilled care due to complex medical conditions, a supplement to the direct care component of the facility rate under subd. 1. b. may be made to that facility according to a method developed by the department.
Effective date note NOTE: Subd. par. c. is amended eff. 7-1-97 by 1995 Wis. Act 27 to read:
49.45 Note c. If a facility has an approved program for provision of service to mentally retarded residents, residents dependent upon ventilators, or residents requiring supplemental skilled care due to complex medical conditions, a supplement to the direct care component of the facility rate under subd. 1. b. may be made to that facility according to a method developed by the department.
49.45(6m)(ar)1.cm. cm. Notwithstanding the limitations under par. (ag) 8., funding distributed to facilities for the provision of active treatment to residents with a diagnosis of developmental disability shall be distributed in accordance with a method developed by the department which is consistent with a prudent buyer approach to payment for services.
49.45(6m)(ar)2. 2. For support service costs:
49.45(6m)(ar)2.a. a. The department shall establish one or more standards for the payment of support service costs that are not less than the median of support service costs for a sample of all facilities within the state.
49.45(6m)(ar)2.b. b. The department shall establish the support service component of the facility rate for each facility by comparing actual allowable support service cost information of that facility, adjusted for inflation, to the applicable standard established under subd. 2. a.
49.45(6m)(ar)2.d. d. The department may provide an efficiency incentive payment to a facility whose allowable support service costs are less than the standards set forth under subd. 2. a. and a cost share payment to a facility whose allowable support service costs are greater than the standards set forth under subd. 2. a.
49.45(6m)(ar)3. 3. For fuel and utility costs:
49.45(6m)(ar)3.a. a. The department shall establish standards, adjusted for heating degree day variations in the state, for payment of fuel and utility costs that are not less than the median of heating fuel and utility costs for a sample of all facilities within the state.
49.45(6m)(ar)3.b. b. The department shall establish the fuel and utility component of the facility rate for each facility by comparing actual allowable fuel and utility cost information of that facility, adjusted for inflation, to the standard established under subd. 3. a.
49.45(6m)(ar)3.c. c. The department may provide an efficiency incentive payment to a facility whose allowable heating fuel and utility costs are less than the standard set forth under subd. 3. a. and a cost share payment to a facility whose allowable heating fuel and utility costs are greater than the standards set forth under subd. 3. a.
49.45(6m)(ar)4. 4. For net property taxes or municipal services, payment shall be made for those costs that range from the amount of the previous calendar year's tax or the amount of municipal service costs for a period specified by the department to a maximum limit as determined by the department.
49.45(6m)(ar)5. 5. For administrative and general costs:
49.45(6m)(ar)5.a. a. The department shall establish one or more standards for the payment of administrative and general costs that are not less than the median of administrative and general costs for a sample of all facilities within the state.
49.45(6m)(ar)5.b. b. The department shall establish the administrative and general component of the facility rate for each facility by comparing actual allowable administrative and general cost information of that facility, adjusted for inflation, to the applicable standard established under subd. 5. a.
49.45(6m)(ar)5.c. c. The department may provide an efficiency incentive payment to a facility whose allowable administrative and general costs are less than the standards set forth under subd. 5. a.
49.45(6m)(ar)6. 6. Capital payment shall be based on a replacement value for a facility. The replacement value shall be determined by a commercial estimator contracted for by the department and paid for by the facility. The replacement value shall be subject to limitations determined by the department, except that the department may not reduce final capital payment of a facility by more than $3.50 per patient day.
49.45(6m)(av)1.1. The department shall calculate a payment rate for a facility by applying the criteria set forth under pars. (ag) 1. to 5., 7. and 8., (am) 1. to 5. and (ar) 1. to 5. to information from cost reports submitted by the facility.
49.45(6m)(av)2. 2. The department shall compile an average payment rate for each facility based on that facility's rates for cost centers described under par. (am) 1. to 5. that were in effect on June 30, 1994. The department may develop a method for adjusting the facility's rate for the cost center under par. (am) 1. in compiling the average payment rate under this subdivision.
49.45(6m)(av)3. 3. The department shall calculate the facility's projected cost per patient day, based on that facility's cost centers under par. (am) 1. to 5., adjusted for inflation.
49.45(6m)(av)4. 4. If the facility's payment rate under subd. 1. is a decrease from its average payment rate under subd. 2., and if the figure calculated under subd. 3. exceeds the payment rate for the facility under subd. 1., the facility's average payment rate shall be the greater of its average payment rate under subd. 2. or its rate under subd. 1.
49.45(6m)(av)5. 5. If subd. 4. does not apply, the facility's payment rate shall be the payment rate calculated under subd. 1.
49.45(6m)(av)5m. 5m. Notwithstanding the limitations under par. (ag) 8., the rate under subd. 1., 4. or 5. may be adjusted by the department to reflect payments for the provision of active treatment to facility residents with a diagnosis of developmental disability.
49.45(6m)(av)6. 6. The total payment rate for a facility as calculated under subd. 1., 4., 5. or 5m. shall be the sum of the rate so calculated, plus capital payment calculated under pars. (am) 6. and (ar) 6. and payment for ancillary services and materials under par. (b) and for nonprescription drugs under par. (bc).
49.45(6m)(b) (b) The charges for ancillary materials and services that would be incurred by a prudent buyer may be included as an adjustment to the rate determined by par. (av) when so determined by the department. The department may not authorize any adjustments to the rate established under par. (av) to pay for a cost overrun that the department fails to approve under s. 150.11 (3). Ancillary materials and services for which payment may be made include, if provided, oxygen, medical transportation and laboratory and X-ray services. Payment for these services and materials shall not exceed medical assistance limitations for reimbursement of the services and materials. For services in a facility for which the department may make payment to a service provider other than a facility, the department may make payment to the facility but not in excess of the estimated amount of payment available if a separate service provider provided the service. The department may promulgate rules setting forth conditions of and limitations to this paragraph.
49.45(6m)(bc) (bc) The department may include charges for nonprescription drugs approved by the department as an adjustment to the rate determined under par. (av).
49.45(6m)(bg) (bg) The department shall determine payment levels for the provision of skilled, intermediate, limited, personal or residential care or care for the mentally retarded in the state centers for the developmentally disabled and in the Wisconsin veterans home at King separately from the payment principles, applicable costs and methods established under this subsection.
49.45(6m)(bm) (bm) Except as provided in par. (bo), the department may establish payment methods for a facility for which any of the following apply:
49.45(6m)(bm)1. 1. The facility is newly constructed.
49.45(6m)(bm)2. 2. The total of licensed beds for the facility has significantly increased or decreased prior to calculation of its rate under the payment system.
49.45(6m)(bm)3. 3. The facility has undergone a change in certification or licensure level.
49.45(6m)(bm)5. 5. The facility has received approval or disapproval for provision of service to residents requiring supplemental skilled care due to complex medical conditions.
49.45(6m)(bm)6. 6. The facility has received approval or been disapproved for provision of service to residents who have any of the following:
49.45(6m)(bm)6.a. a. Brain injury, as defined in s. 51.01 (2g).
49.45(6m)(bm)6.b. b. A diagnosis of acquired immunodeficiency syndrome.
49.45(6m)(bm)6.c. c. An HIV infection, as defined in s. 252.01 (2), and illness or injury associated with the development of acquired immunodeficiency syndrome.
49.45(6m)(bo) (bo) The department may establish payment methods for capital payment for a newly constructed facility that first provided services after June 30, 1984.
49.45(6m)(bp) (bp) Notwithstanding pars. (ag) 3m., (am) 6. and (ar) 6., the department may establish payment methods based on actual costs for capital payment for a facility to which, after December 31, 1982, any of the following applies:
49.45(6m)(bp)1. 1. The facility was constructed.
49.45(6m)(bp)2. 2. The facility was purchased.
49.45(6m)(bp)3. 3. The facility incurred annual remodeling costs of more than $600,000.
49.45(6m)(bp)4. 4. The facility incurred remodeling costs necessary to meet physical plant requirements under 42 USC 1396a (a) (13) (A).
49.45(6m)(br) (br) If the federal department of health and human services disallows use of the allocation of matching federal medical assistance funds under applicable federal acts or programs for the reduction of operation deficits under sub. (6u), all of the following apply:
49.45(6m)(br)1. 1. Notwithstanding s. 20.410 (3) (cd), 20.435 (1) (bt) or (bu) or (7) (b) or 20.445 (3) (de), the department shall reduce allocations of funds to counties in the amount of the disallowance from the appropriations under s. 20.410 (3) (cd) or 20.435 (1) (bt) or (bu) or (7) (b), or the department shall direct the department of industry, labor and job development to reduce allocations of funds to counties or Wisconsin works agencies in the amount of the disallowance from the appropriation under s. 20.445 (3) (de) or (dz), in accordance with s. 16.544 to the extent applicable.
49.45(6m)(br)2. 2. If a city, village or town owns and operates a facility that has received funds to reduce an operating deficit, the city, village or town shall reimburse the county in which the city, village or town is located in the amount of funds so received.
49.45(6m)(c) (c) As a condition of payment under this section a facility shall:
49.45(6m)(c)1. 1. Meet the staffing standard requirements for direct care costs including the supplement, if any, made under par. (ar) 1. c. and maintain such records as prescribed by the department to document that such level of care was actually provided.
49.45(6m)(c)2. 2. Provide at the time of a patient's admission to a home, for the development and implementation of a rehabilitation plan including the development of an alternate care plan for the patient.
49.45(6m)(c)3. 3. Provide, upon request, cost information relating to the overall financial operation of the facility, including, but not limited to wages and hours worked, costs of food, housekeeping, maintenance and administration.
49.45(6m)(c)4. 4. Agree to admit patients 7 days of the week.
49.45(6m)(c)5. 5. Admit only patients assessed or who waive or are exempt from the requirement of assessment under s. 46.27 (6) (a).
49.45(6m)(c)6. 6. Provide, upon request, such information as the department considers necessary to determine allowable interest expenses under par. (am) 5m.
49.45(6m)(d) (d) The department shall:
49.45(6m)(d)2. 2. Terminate payment to a facility for a patient, unless a utilization review team established pursuant to federal regulations upon review of the patient's needs and the implementation of a rehabilitation plan for that patient determines that the patient's need for care and services can only be provided in a facility and determines the appropriate level of care.
49.45(6m)(d)3. 3. Establish, maintain, and periodically update a patient needs evaluation system to be used in determining the need and level of care at a facility, which shall include the social and rehabilitative needs of the patient, provide levels of care to correspond to the actual staff time required to provide such care, and define the contents of the services to be provided.
49.45(6m)(d)4. 4. Periodically audit all nursing homes and intermediate care facilities receiving funds under this paragraph, and recover payments made where the home is not meeting the conditions under which the payment was made as specified in par. (c) 1. and 2. Erroneous information provided under par. (c) 3. shall constitute grounds for recovery.
49.45(6m)(d)5. 5. Beginning October 1, 1989, deny payment to a facility for a patient who is admitted to the facility after the department has provided newspaper notice and notice under s. 50.03 (2m) (b) that the facility violates 42 USC 1396 to 1396s and before the date, if any, that the department determines that the facility is in substantial compliance with 42 USC 1396 to 1396s.
49.45(6m)(e) (e) The department shall establish an appeals mechanism within the department to review petitions from facilities providing skilled, intermediate, limited, personal or residential care or providing care for the mentally retarded for modifications to any payment under this subsection. The department may, upon the presentation of facts, modify a payment if demonstrated substantial inequities exist for the period appealed. Upon review of the department's decision the secretary may grant the modifications, which may exceed maximum payment levels allowed under this subsection but may not exceed federal maximum reimbursement levels. The department shall develop specific criteria and standards for granting payment modifications, and shall take into account the following, without limitation because of enumeration, in reviewing petitions for modification:
49.45(6m)(e)1. 1. The efficiency and effectiveness of the facility if compared with facilities providing similar services and if valid cost variations are considered.
49.45(6m)(e)2. 2. The effect of rate modifications upon compliance with federal regulations authorized under 42 USC 1396 to 1396p.
49.45(6m)(e)3. 3. The need for additional revenue to correct licensure and certification deficiencies.
49.45(6m)(e)4. 4. The relationship between total revenue and total costs for all patients.
49.45(6m)(e)5. 5. The existence and effectiveness of specialized programs for the chronically mentally ill or developmentally disabled.
49.45(6m)(e)6. 6. Exceptional patient needs.
49.45(6m)(e)7. 7. Demonstrated experience in providing high quality patient care.
49.45(6m)(g) (g) Payment under this section to a facility may not include the cost of care reimbursable for persons eligible for medicare benefits under 42 USC 1395 to 1395zz. Medical assistance recipients are not liable for these costs. The department may require that a facility recover these costs from the appropriate agencies. The department may, by rule, require medicare certification under 42 USC 1395 to 1395zz, in whole or in part, of skilled nursing facilities. Any intermediate care facility or skilled nursing facility is subject to a fine of not less than $10 nor more than $100 for each day it refuses to recover costs or refuses to obtain the required certification.
49.45(6m)(h) (h) The department may require by rule that all claims for payment of services provided facility residents under this subchapter be submitted or countersigned by the respective facility administrator. The department may specify those categories of services for which payment will be made only if the services are rendered or authorized in writing by a primary health care provider designated by the recipient for the particular category of services.
49.45(6m)(i)1.1. On or after October 1, 1981, medical assistance payment for inpatient nursing care may only be provided for persons receiving skilled, intermediate or limited levels of nursing care as these levels are defined under s. HSS 132.13, Wis. adm. code.
49.45(6m)(i)2. 2. Payment for personal or residential care is available for a person in a facility certified under 42 USC 1396 to 1396p only if the person entered a facility before the date specified in subd. 1. and has continuously resided in a facility since the date specified in subd. 1. If the person has a primary diagnosis of developmental disabilities or chronic mental illness, payment for personal or residential care is available only if the person entered a facility on or before November 1, 1983.
49.45(6m)(j) (j) The department may develop a separate rate of payment, under this subsection, for persons requiring intense skilled nursing care, as defined by the department.
49.45(6m)(k) (k) Notwithstanding pars. (ag) to (b), (bp) and (br), the department may participate in a demonstration project on case mix nursing home reimbursement authorized under 42 USC 1315 (a) and may modify the payment system under this section, on an experimental basis, as necessary for participation in the demonstration project.
49.45(6m)(L) (L) For purposes of ss. 46.27 (11) (c) 7. and 46.277 (5) (e), the department shall, by July 1 annually, determine the statewide medical assistance daily cost of nursing home care and submit the determination to the department of administration for review. The department of administration shall approve the determination before payment may be made under s. 46.27 (11) (c) 7. or 46.277 (5) (e).
49.45(6r) (6r)Assessments to providers.
49.45(6r)(a)(a) In this section:
49.45(6r)(a)1. 1. "Ambulatory surgery center" has the meaning given under 42 CFR 416.2.
49.45(6r)(a)1g. 1g. "Facility" means a nursing home as defined in s. 50.01 (3) or a community-based residential facility that is licensed under s. 50.03 and that is certified by the department as a provider of medical assistance.
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This is an archival version of the Wis. Stats. database for 1995. See Are the Statutes on this Website Official?