Health & Family Services
(Medical Assistance Reimbursement of Nursing Homes)
State of Wisconsin Medicaid Nursing Facility Payment Plan: FY 98-99
The State of Wisconsin reimburses Medicaid-certified nursing facilities for long-term care and health care services provided to eligible persons under the authority of Title XIX of the Federal Social Security Act and ss. 49.43 to 49.47, Wisconsin Statutes. This program, administered by the State's Department of Health and Family Services, is called Medical Assistance (MA) or Medicaid. Federal statutes and regulations require that a state plan be developed that provides the methods and standards for setting payment rates for nursing facility services covered by the payment system. A plan that describes the nursing home reimbursement system for Wisconsin is now in effect as approved by the Federal Health Care Financing Administration (HCFA).
The Department is proposing changes in the methodology for establishing rates of payment to nursing homes in the plan describing the nursing home reimbursement system. The changes will be effective July 1, 1998. The proposed changes that comprise this plan amendment will not be finalized until the public comment period is concluded. The public comment period will continue until at least September 1, 1998. The plan amendment's changes will be effective retroactive to July 1, 1998. Rates for facilities will be final only after they are set pursuant to the methodologies that are ultimately adopted. A computer model is used to ensure that the methods conform to the budget. A printout of the budgetary impact of the methods as a whole and rates in aggregate is generated. Individuals and organizations may obtain or review copies of the draft proposed changes covered by the plan amendment, draft copies of the model printout, and a worksheet that may be used to calculate approximate individual facility rates based on the proposed methodologies (i.e., the proposed rates). Opportunity to comment on the proposed changes will be provided in public meetings. See the end of this notice for information about the public meetings and where to send for or to review copies of the draft proposed changes and the printout.
The proposed changes would update the payment system and make various payment-related policy changes. Some of the changes are necessary to implement policies that were included in the Wisconsin 1997-99 Budget Act; some of the changes are technical in nature; some clarify various payment plan provisions.
The estimated increase in annual aggregate expenditures attributable to these changes for nursing homes serving MA recipients is approximately $30,322,500 all funds ($18,193,500 federal), excluding patient liability.
Proposed changes are as follows:
1. Modify the methodology to distribute approximately 3.5% or $30,322,500 (all funds), excluding patient liability, whichever is less, in the payment rate year of July 1, 1998, through June 30, 1999. Specifically, we will create Section 7.00 to provide the methods for an increase for all rate elements except capital. Section 7.00 will contain a sample rate calculation included as part of the plan amendment, the policy on applicable formula maximums drafted to clarify the implementation of the Section 7.00 rate on rate payment system, and references to other sections of the plan. The Department will update the parameters for calculating the capital rates.
2. Revise various references to specific years and related provisions to clarify what is the base year, and to incorporate Section 7.00, the rate year and various payment policies that are specific to a given year.
3. Clarify and update the bed banking provisions.
4. Incorporate technical and style revisions as needed in select sections requiring clarification.
5. Incorporate miscellaneous changes as necessary to implement the intent of the payment plan.
Copies of the Proposed Changes:
Copies of the proposed changes may be obtained free of charge by calling or writing as follows:
Attention: Nursing Home Medicaid Payment Plan
Bureau of Health Care Financing
Division of Health
P.O. Box 309
Madison, WI 53701-0309
Telephone (608) 264-6730
Attention: Nursing Home Medicaid Payment Plan
FAX number (608) 264-7720
Copies of the proposed changes will be available for review at the main office of any county department of social services or human services from July 15 through at least September 1.
Since changes will be continuously developed during the public comment period, additional materials will be developed and will be available by the options above or by attending the public meetings. If you request copies of the proposed changes, you will receive a copy of the final changes or the final plan amendment.
Before finalizing the plan amendment, the Department may modify its proposed changes after considering the comments received during the public comment period. The plan amendment will not be submitted to the federal government until after the public comment period and will be effective retroactively to July 1, 1998.
Except for the public meetings, only
written comments will be considered. Written comments on the proposed changes may be sent by FAX, E-mail, or regular mail to the Bureau of Health Care Financing. The FAX number is (608) 264-7720. The E-mail address is: firstname.lastname@example.org
. Regular mail may be sent to the above address. All written comments will be reviewed and considered.
The written comments will be available for public review between the hours of 7:45 a.m. and 4:30 p.m. daily in Room 250 of the State Office Building, 1 West Wilson Street, Madison, Wisconsin. Revisions may be made in the proposed changes, based on comments received.
There will also be public meetings to seek input on the proposed plan amendment. If you would like to be sent a public meeting notice, please fax or write using the above addresses. The proposed changes may be revised, based on comments received at these forums.
Health & Family Services
(Medical Assistance Reimbursement of Hospitals)
The State of Wisconsin reimburses hospitals for medical services provided to low-income persons under the authority of Title XIX of the Federal Social Security Act and ss. 49.43 to 49.47, Wisconsin Statutes. The State's Department of Health and Family Services administers this program which is called Medicaid or Medical Assistance (MA). Federal statutes and regulations require state plans, one for outpatient services and one for inpatient services, which provide the methods and standards for paying for hospital outpatient and inpatient services.
State plans are now in effect for the reimbursement of outpatient hospital services and inpatient hospital services. The Department is proposing to make several changes in these plans effective July 1, 1998.
Outpatient Hospital Services
Proposed changes in the state plan for reimbursement for outpatient hospital services may include:
1. Revision of the rural hospital adjustment percentages to ensure that payments do not exceed authorized funds. Modification of the qualifying criteria that requires a 55% combined Medicare and Medicaid utilization rate to allow greater consistency from year to year with regard to whether a hospital qualifies and to allow a number of hospitals with utilization rates consistently just below the qualifying rate to also qualify. The amount paid for this adjustment would not change. However, this modification would cause a redistribution of the funds among qualifying hospitals.
2. Modification of supplemental payments to essential access city hospitals (EACH) to maintain compliance with federal payments limits.
3. For the indigent care allowance, adjustment of the maximum available funding, modification of the criteria for a hospital to qualify for an allowance, and modification of the methodology for distributing the available funds to qualifying hospitals in order to carry out provisions of 1997 Wis. Act 27 and to maintain compliance with federal payment limits.
4. Modification of the procedures for processing administrative adjustments to require a hospital to respond to the Department's proposed adjustment only if there is a disagreement with the calculation. If the hospital does not respond by the specified due date, the proposed adjustment will be final. This will simplify what has been an administratively burdensome notification and response process.
5. Modification of the qualifying criteria for funding of Medicaid deficits in governmental hospitals to require a hospital to submit a request for this funding to the Department so it may determine if the hospital qualifies for funding under these provisions.
Inpatient Hospital Services
Proposed changes in the state plan for reimbursement for inpatient hospital services may include:
1. For the payment system which is based on diagnosis-related groups (DRGs), adjustment of DRG weighting factors, standard DRG base rates, area wage indices, and capital and medical education payments to implement the average rate adjustment provided by 1997 Wis. Act 27.
2. Updating the time period used for the qualifying criteria and determination of the payment for the pediatric supplement to reflect the most recent time period. Also, revision of the definition of Medicaid pediatric days to:
a) Exclude days of Medicaid covered stays on which Medicaid made no payment due to the stay being covered by some other payer such as private hospitalization insurance to more accurately reflect the intent of this provision; and
b) Count only the days for discharges that occurred within the specified year and not count a portion of the days related to discharges that occurred outside the specified year.
3. Modification of the cost report requirements for major border-status hospitals to allow the Department to use the most recent audited cost report available to establish rates, which is consistent with the basis for which the Department establishes rates for in-state hospitals.
4. Modification of the qualifying criteria for funding of Medicaid deficits in governmental hospitals to require a hospital to submit a request for this funding to the Department so it may determine if the hospital qualifies for funding under these provisions.
5. Revision of the rural hospital adjustment percentages to ensure that payments do not exceed authorized funds. Modification of the qualifying criteria that requires a 55% combined Medicare and Medicaid utilization rate to allow greater consistency from year to year with regard to whether a hospital qualifies and to allow a number of hospitals with utilization rates consistently just below the qualifying rate to also qualify. The total amount paid for this adjustment would not change. However, this modification would cause a redistribution of the funds among qualifying hospitals.