49.45(6m)(ag)3m.
3m. For state fiscal year 1995-96, rates that shall be set by the department based on information from cost reports for the 1994 fiscal year of the facility and for state fiscal year 1996-97, rates that shall be set by the department based on information from cost reports for the 1995 fiscal year of the facility.
49.45(6m)(ag)6.
6. Standards for capital payment that will be based upon replacement value of a facility as determined by a commercial estimator with which the department contracts and criteria and limitations as determined by the department.
49.45(6m)(ag)7.
7. Assurance of an acceptable quality of care for all medical assistance recipients provided nursing home care.
49.45(6m)(ag)8.
8. Calculation of total payments and supplementary payments to facilities that permits an increase in funds allocated under
s. 20.435 (1) (b) and
(o) for nursing home care provided medical assistance recipients over that paid for services provided in state fiscal year 1994-95 of no more than 4.25% during state fiscal year 1995-96 and over that paid for services provided in state fiscal year 1995-96 of no more than 3.5% during state fiscal year 1996-97, excluding increases in total payments attributable to increases in recipient utilization of facility care, payments for the provision of active treatment to facility residents with developmental disability or chronic mental illness and payments for preadmission screening of facility applicants and annual reviews of facility residents required under
42 USC 1396r (e).
49.45(6m)(am)
(am) In determining payments for a facility under the payment system in
par. (ag), the department shall consider all of the following cost centers:
49.45(6m)(am)1.
1. Allowable direct care costs, including, if provided, any of the following:
49.45(6m)(am)1.d.
d. Services of facility medical personnel that are not separately billable under medical assistance requirements.
49.45(6m)(am)1.e.
e. Nonbillable services of a registered nurse, licensed practical nurse, nursing assistant, ward clerk, activity person, recreation person, social worker, volunteer coordinator, teacher for residents aged 22 and older, vocational counselor for residents aged 22 and older, religious person, therapy aide, therapy assistant and counselor on resident living.
49.45(6m)(am)2.
2. Allowable support service costs, including the following allowable facility expenses:
49.45(6m)(am)2.a.
a. Dietary service for the provision of meals to facility residents.
49.45(6m)(am)2.b.
b. Environmental service for the provision of maintenance, housekeeping, laundry and security service.
49.45(6m)(am)3.
3. Allowable fuel and utility costs, including the facility expenses that the department determines are allowable for the provision of:
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.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.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.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.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)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.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)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)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)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)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)3.
3. The need for additional revenue to correct licensure and certification deficiencies.
