Medicaid Cost Reimbursement Nursing Home Trends 1998-2009 January 16, 2009 (Updated with Trends, February 19, 2009) Workgroup on Nursing Facility Reimbursement Agency for Health Care Administration Tallahassee, Florida
Operating. Components of the Reimbursement Per Diem Patient Care. Direct Care. Indirect Care. Property. Cost Based. Fair Rental Value System (FRVS). 1
Target and Ceiling Limitations Target Limitations. Provider Target Limitation. New Provider Target Limitation. Ceilings. Cost-Based Class Ceilings. Target Rate Class Ceilings. 2
Per Diem $250.00 Nursing Homes Reimbursement 1998-2009 Total Costs vs Total Reimbursement $200.00 $150.00 $100.00 $50.00 $- $26.02 $16.46 $15.67 $12.27 $11.59 $10.71 $11.10 $11.34 $13.52 $7.99 $7.78 $8.60 $11.48 $15.74 $18.76 $5.50 $11.20 $10.58 $6.21 $11.12 $12.50 $(2.98) $(5.06) $(50.00) 199801 199807 199901 199907 200001 200007 200101 200107 200201 200207 200301 200307 200401 200407 200501 200507 200601 200607 200701 200707 200801 200807 200901 Rate Semester Weighted Average Total Cost Weighted Average Total Reimbursement Total Difference 3
Percentage 1.0000 Nursing Homes Reimbursement 1998-2009 Occupancy & Medicaid Utilization Percentages 0.9500 0.9000 0.8500 0.8000 0.7500 0.7000 0.6500 0.6000 0.5500 0.5000 199801 199807 199901 199907 200001 200007 200101 200107 200201 200207 200301 200307 200401 200407 200501 200507 200601 200607 200701 200707 200801 200807 200901 Rate Semester Mean Occupancy Mean Medicaid Utilization 4
Operating Component
Plan Changes to Operating Component by Rate Semester July 1, 2000. Interim Rate Request provision for General and Professional Liability Insurance. July 1, 2002. Partial Rebase of Target Limits to address General and Professional Liability Insurance issue ($27 million). 6
Plan Changes to Operating Component by Rate Semester July 1, 2003. Repeal of $27 million for partial rebase of Target Limits due to non-recurring funds. July 1, 2007. Full Re-basing of Targets and Ceilings. Floors established for Provider Targets and Target Ceilings. January 1, 2008. Provider Specific Target Inflation Multiplier is 2.0. New Targets established based on 7/07 rates. 7
Per Diem Nursing Homes Reimbursement 1998-2009 Operating Cost vs Reimbursement $50.00 $45.00 $40.00 $35.00 $30.00 $25.00 $20.00 $15.00 $10.00 $5.00 $2.92 $3.46 $4.16 $4.94 $5.60 $5.85 $2.79 $2.82 $3.55 $0.75 $4.76 $7.01 $7.04 $7.17 $7.97 $4.62 $5.69 $5.66 $7.33 $1.91 $2.84 $3.35 $6.06 $- 199801 199807 199901 199907 200001 200007 200101 200107 200201 200207 200301 200307 200401 200407 200501 200507 200601 200607 200701 200707 200801 200807 200901 Rate Semester Operating Weighted Average Cost Operating Weighted Average Reimbursement Operating Difference 8
Patient Care Component
Plan Changes to Patient Care Component By Rate Semester July 1, 1998. $.25 Add-on. April 1, 1999. Case Mix Add-on. January 1, 2000. Partial Rebase of Target Limits. April 1, 2000. Direct Care Staffing Add-on (DCSA). 10
Plan Changes to Patient Care Component By Rate Semester January 1, 2001. Prorate DCSA for cost reports that include periods after April 2000. November/December 2001. Direct Patient Care Add on. January 1, 2002. Eliminated Case Mix Add-on. Patient Care component split into two subcomponents: Direct Patient Care. Indirect Patient Care. 11
Per Diem $160.00 Nursing Home Reimbursement 1998-2009 Total Patient Care Cost vs Reimbursement $140.00 $120.00 $100.00 $80.00 $60.00 $40.00 $20.00 $- $6.51 $6.75 $5.23 $4.71 $4.51 $4.06 $5.00 $6.04 $(8.54) $(0.37) $(3.84) $(2.85) $0.00 $2.75 $(2.84) $1.20 $0.56 $5.44 $2.66 $4.25 $(1.62) $11.38 $(20.00) $(40.00) $(26.46) 199801 199807 199901 199907 200001 200007 200101 200107 200201 200207 200301 200307 200401 200407 200501 200507 200601 200607 200701 200707 200801 200807 200901 Rate Semester Patient Care Weighted Average Reimbursement Patient Care Weighted Average Cost Patient Care Difference 12
Direct Patient Care Salaries and benefits of direct care staff providing nursing care directly to the residents. January 1, 2002. Elimination of Target Limits. Limited to lower of Cost or Cost-Based Class Ceiling. Increased staffing ratio minimums. CNA from 1.7 hours/ppd to 2.3 hours/ppd. RN/LPN from.6 hours/ppd to 1.0 hours/ppd. Gross-up adjustment. 13
Direct Patient Care January 1, 2003. Increased staffing ratio minimums. CNA from 2.3 hours /ppd to 2.6 hours/ppd. Gross-up adjustment. July 1, 2004. Direct Patient Care Cost receives its own inflation factor. January 1, 2007. Increased staffing ratio minimums. CNA from 2.6 hours/ppd to 2.7 hours/ppd min with weekly avg of 2.9. 14
Per Diem $100.00 Nursing Homes Reimbursement 1998-2009 Direct Care Cost vs Reimbursement $80.00 $60.00 $40.00 $20.00 $7.67 $- $(5.38) $(0.62) $(2.84) $(2.25) $(2.51) $(1.17) $(3.53) $(0.58) $(1.30) $1.96 $(0.69) $1.11 $2.20 $(20.00) $(22.02) $(40.00) 200201 200207 200301 200307 200401 200407 200501 200507 200601 200607 200701 200707 200801 200807 200901 Rate Semester Direct Care Weighted Average Cost Direct Care Weighted Average Reimbursement Direct Care Difference 15
Indirect Patient Care All other patient care costs. January 1, 2002. Elimination of Target Limits. Limited to lower of Cost or Cost-Based Class Ceiling. July 1, 2002. Target Limits return. 16
Indirect Patient Care July 1, 2007. Full Re-basing of Targets and Ceilings. Floors established for Provider Targets and Target Ceilings. January 1, 2008. Provider Specific Target Inflation Multiplier is 2.0. New Targets based on 7/07 rates. 17
Per Diem $60.00 Nursing Homes Reimbursement 1998-2009 Indirect Care Costs vs Reimbursement $50.00 $40.00 $30.00 $20.00 $10.00 $- $(4.44) $(3.16) $0.25 $(1.00) $(0.60) $2.51 $3.92 $0.70 $1.78 $1.85 $3.48 $(0.93) $1.55 $2.05 $3.72 $(10.00) 200201 200207 200301 200307 200401 200407 200501 200507 200601 200607 200701 200707 200801 200807 200901 Rate Semester Indirect Care Weighted Average Cost Indirect Care Weighted Average Reimbursement Indirect Care Difference 18
Property and ROE
Per Diem $25.00 Nursing Home Reimbursement 1998-2009 Property + ROE Cost vs Reimbursement $20.00 $15.00 $10.00 $7.28 $7.27 $7.55 $5.00 $2.61 $3.15 $3.70 $3.51 $4.16 $2.25 $1.84 $3.62 $4.16 $4.64 $4.62 $5.79 $3.23 $4.22 $4.36 $5.46 $6.22 $- 199907 200001 200007 200101 200107 200201 200207 200301 200307 200401 200407 200501 200507 200601 200607 200701 200707 200801 200807 200901 Rate Semester All Property + ROE Costs Not FRVS Property + ROE Reimbursed Not FRVS Property + ROE Cost Not FRVS Property + ROE Difference 20
Per Diem $25.00 Nursing Homes Reimbursement 1998-2009 Property + ROE vs FRVS $20.00 $15.00 $10.00 $7.66 $5.00 $4.75 $4.71 $5.02 $5.24 $5.29 $2.94 $2.39 $3.58 $3.72 $3.65 $4.27 $4.93 $3.77 $4.32 $4.37 $6.04 $5.16 $5.47 $5.38 $- 199907 200001 200007 200101 200107 200201 200207 200301 200307 200401 200407 200501 200507 200601 200607 200701 200707 200801 200807 200901 Rate Semester All Property + ROE Costs FRVS Property + ROE Cost FRVS Rate FRVS Property + ROE vs Rate Difference 21
The End!!!!!