Final Action for the Essential Public Safety Net Nursing Facility Payment Program
The South Carolina Department of Health and Human Services (SCDHHS), pursuant to the requirements of Section 1902(a)(13)(A) of the Social Security Act, gives notice of the following action regarding its methods and standards for setting payments for the Essential Public Safety Net (EPSN) Nursing Facility Payment Program under the State Plan under Title XIX of the Social Security Act Medical Assistance Program (Medicaid).
The Medicare program is currently converting its payment methodology for Part A skilled nursing care services from a Resource Utilization Group, Version IV (RUG-IV) to a Patient Driven Payment Model (PDPM) methodology. There are two main ways in which the Medicare transition to PDPM may affect the state Medicaid programs’ calculation of the Upper Payment Limit (UPL) and changes in nursing facility (NF) reimbursement for case-mix states. With regard to the UPL calculation, while budget neutral in the aggregate and not impacting the scope of services covered under the Skilled Nursing Facility (SNF) Prospective Payment System (PPS), PDPM implementation changes how payment is made for SNF services, which can have an impact on UPL calculations. The new PDPM methodology was created without any consideration to state Medicaid NF payment programs. SCDHHS only uses the Medicare RUGs-IV payment methodology in order to determine the EPSN NF supplemental payments. Therefore in order to assist states in this transition, CMS will allow states that use the Medicare RUG-IV payment methodology rates in their UPL calculations to increase the Oct. 1, 2018, RUGS-IV rates by the increase in the average annual increase in Medicare rates per the fiscal year (FY) 2020 final rule. Therefore, effective for payments beginning on or after Jan. 1, 2020/service dates beginning on and after October 1, 2019, the SCDHHS will increase the Oct. 1, 2018, RUGS-IV rates by the increase in the average annual increase in Medicare rates per the FY 2020 final rule.
This action is not a new action, but one that continues the pre-Oct. 1, 2019, Medicare Part A payment methodology for skilled nursing services. Therefore, SCDHHS has determined this action to be budget neutral.
Copies of this notice are available at each South Carolina Healthy Connections Medicaid county office and at www.scdhhs.govfor public review. Additional information regarding this action is available upon request at the address cited below.
Any written comments submitted may be reviewed by the public at the SCDHHS, Reimbursement Methodology and Policy Department, Room 1219, 1801 Main Street, Columbia, South Carolina, Monday through Friday between 9 a.m.-5 p.m.