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1 STATE OF OKLAHOMA
1
2 1st Session of the 60th Legislature (2025)
2
3 SENATE BILL 904 By: Rosino
3
4
4
5
5
6 AS INTRODUCED
6
7 An Act relating to the state Medicaid program;
7 amending 56 O.S. 2021, Section 1011.5, which relates
8 to the nursing facility incentive reimbursement rate
8 plan; modifying payment qualification criteria;
9 directing certain allocation of funds; creating
9 certain staff retention initiative; specifying
10 conditions for payment; conforming language; removing
10 obsolete language; modifying certain method of
11 reporting; requiring the Oklahoma Health Care
11 Authority to include certain information in annual
12 budget request; specifying calculation method of
12 certain costs; amending 63 O.S. 2021, Section 1-
13 1925.2, which relates to reimbursements from the
13 Nursing Facility Quality of Care Fund; updating
14 statutory language; expanding purpose of certain
14 advisory committee; adding certain case-mix component
15 to payment methodology; directing certain allocations
15 and apportionment; providing for codification;
16 providing an effective date; and declaring an
16 emergency.
17
17
18
18
19 BE IT ENACTED BY THE PEOPLE OF THE STATE OF OKLAHOMA:
19
20 SECTION 1. AMENDATORY 56 O.S. 2021, Section 1011.5, is
20
21 amended to read as follows:
21
22 Section 1011.5. A. 1. The Oklahoma Health Care Authority
22
23 shall develop an incentive reimbursement rate plan for nursing
23
24
24
Req. No. 599 Page 1
1 facilities focused on improving resident outcomes and resident
1
2 quality of life.
2
3 2. Under the current rate methodology, the Authority shall
3
4 reserve Five Dollars ($5.00) per patient day designated for the
4
5 quality assurance component that nursing facilities can earn for
5
6 improvement or performance achievement of resident-centered outcomes
6
7 metrics the long-stay quality measures ratings specified in
7
8 paragraph 4 of this subsection. To fund the quality assurance
8
9 component, Two Dollars ($2.00) shall be deducted from each nursing
9
10 facility's per diem rate, and matched with Three Dollars ($3.00) per
10
11 day funded by the Authority. Payments to nursing facilities that
11
12 achieve specific metrics qualify under paragraph 4 of this
12
13 subsection shall be treated as an "add back" to their net
13
14 reimbursement per diem. Dollar values assigned to each metric
14
15 rating shall be determined so that an average of the five-dollar-
15
16 quality incentive is made to qualifying nursing facilities.
16
17 3. Pay-for-performance payments may be earned quarterly and
17
18 based on facility-specific performance achievement of four equally-
18
19 weighted, Long-Stay Quality Measures as defined by the facility's
19
20 long-stay quality measures rating in the nursing home Five-Star
20
21 Quality Rating System of the Centers for Medicare and Medicaid
21
22 Services (CMS).
22
23 4. Contracted Medicaid long-term care providers may earn
23
24 payment by achieving either five percent (5%) relative improvement
24
Req. No. 599 Page 2
1 each quarter from baseline or by achieving the National Average
1
2 Benchmark or better for each individual quality metric at least a
2
3 two-star long-stay quality measures rating. Program funds shall be
3
4 allocated as follows:
4
5 a. facilities with a two-star rating shall receive forty
5
6 percent (40%) of the per-day amount reserved for the
6
7 quality assurance component per Medicaid patient day,
7
8 b. facilities with a three-star rating shall receive
8
9 sixty percent (60%) of the per-day amount reserved for
9
10 the quality assurance component per Medicaid patient
10
11 day,
11
12 c. facilities with a four-star rating shall receive
12
13 eighty percent (80%) of the per-day amount reserved
13
14 for the quality assurance component per Medicaid
14
15 patient day, and
15
16 d. facilities with a five-star rating shall receive one
16
17 hundred percent (100%) of the per-day amount reserved
17
18 for the quality assurance component per Medicaid
18
19 patient day.
19
20 5. As soon as practicable after receipt of any necessary
20
21 federal approval, and subject to appropriation of funds for a rate
21
22 increase to nursing facilities, facilities may earn up to Three
22
23 Dollars ($3.00) per Medicaid patient day by participating in an
23
24 optional Registered Nurse and Certified Nurse Aide retention
24
Req. No. 599 Page 3
1 initiative. Payments shall be allocated at One Dollar and fifty-
1
2 cents ($1.50) per long-stay quality measure, subject to the
2
3 following conditions:
3
4 a. a minimum of sixty percent (60%), or a percentage
4
5 determined by the Authority, of Registered Nurses must
5
6 be retained for not less than twelve (12) months, with
6
7 compliance measured quarterly,
7
8 b. a minimum of fifty percent (50%), or a percentage
8
9 determined by the Authority, of Certified Nurse Aides
9
10 must be retained for not less than twelve (12) months,
10
11 with compliance measured quarterly,
11
12 c. participating facilities must submit an annual
12
13 retention plan to the Authority by June 30 of each
13
14 year, and
14
15 d. participating facilities shall receive incentive
15
16 payments under this paragraph during the first year to
16
17 support retention efforts. Beginning in the second
17
18 year and thereafter, facilities must meet program
18
19 metrics as provided by this paragraph to remain
19
20 eligible for payments.
20
21 6. Pursuant to federal Medicaid approval, any funds that remain
21
22 as a result of providers failing to meet the quality assurance
22
23 metrics after all the allocations under this subsection have been
23
24 made shall be pooled and redistributed to those who achieve the
24
Req. No. 599 Page 4
1 quality assurance metrics each quarter qualify for payments under
1
2 this subsection. If federal approval is not received, any remaining
2
3 funds shall be deposited in the Nursing Facility Quality of Care
3
4 Fund authorized in Section 2002 of this title.
4
5 6. The Authority shall establish an advisory group with
5
6 consumer, provider and state agency representation to recommend
6
7 quality measures to be included in the pay-for-performance program
7
8 and to provide feedback on program performance and recommendations
8
9 for improvement. The quality measures shall be reviewed annually
9
10 and shall be subject to change every three (3) years through the
10
11 agency's promulgation of rules. The Authority shall insure
11
12 adherence to the following criteria in determining the quality
12
13 measures:
13
14 a. provides direct benefit to resident care outcomes,
14
15 b. applies to long-stay residents, and
15
16 c. addresses a need for quality improvement using the
16
17 Centers for Medicare and Medicaid Services (CMS)
17
18 ranking for Oklahoma.
18
19 7. The Authority shall begin the pay-for-performance program
19
20 focusing on improving the following CMS nursing home quality
20
21 measures:
21
22 a. percentage of long-stay, high-risk residents with
22
23 pressure ulcers,
23
24
24
Req. No. 599 Page 5
1 b. percentage of long-stay residents who lose too much
1
2 weight,
2
3 c. percentage of long-stay residents with a urinary tract
3
4 infection, and
4
5 d. percentage of long-stay residents who got an
5
6 antipsychotic medication.
6
7 B. The Oklahoma Health Care Authority shall negotiate with the
7
8 Centers for Medicare and Medicaid Services to include the authority
8
9 to base provider reimbursement rates for nursing facilities on the
9
10 criteria specified in subsection A of this section.
10
11 C. The Oklahoma Health Care Authority shall audit the program
11
12 to ensure transparency and integrity.
12
13 D. The Oklahoma Health Care Authority shall provide
13
14 electronically submit an annual report of the incentive
14
15 reimbursement rate plan to the Governor, the Speaker of the House of
15
16 Representatives, and the President Pro Tempore of the Senate by
16
17 December 31 of each year. The report shall include, but not be
17
18 limited to, an analysis of the previous fiscal year including
18
19 incentive payments, ratings, and notable trends.
19
20 SECTION 2. NEW LAW A new section of law to be codified
20
21 in the Oklahoma Statutes as Section 1011.16 of Title 56, unless
21
22 there is created a duplication in numbering, reads as follows:
22
23 A. The Oklahoma Health Care Authority in its annual budget
23
24 request submitted pursuant to Section 34.36 of Title 62 of the
24
Req. No. 599 Page 6
1 Oklahoma Statutes shall include a supplemental item reflecting the
1
2 new state and federal funding necessary to meet the additional costs
2
3 associated with reimbursing nursing facilities and intermediate care
3
4 facilities for individuals with intellectual disabilities at the
4
5 most recent audited cost.
5
6 B. Audited cost shall be calculated by using the latest cost
6
7 report submitted to the Oklahoma Health Care Authority.
7
8 SECTION 3. AMENDATORY 63 O.S. 2021, Section 1-1925.2, is
8
9 amended to read as follows:
9
10 Section 1-1925.2. A. The Oklahoma Health Care Authority shall
10
11 fully recalculate and reimburse nursing facilities and Intermediate
11
12 Care Facilities for Individuals with Intellectual Disabilities
12
13 intermediate care facilities for individuals with intellectual
13
14 disabilities (ICFs/IID) from the Nursing Facility Quality of Care
14
15 Fund beginning October 1, 2000, the average actual, audited costs
15
16 reflected in previously submitted cost reports for the cost-
16
17 reporting period that began July 1, 1998, and ended June 30, 1999,
17
18 inflated by the federally published inflationary factors for the two
18
19 (2) years appropriate to reflect present-day costs at the midpoint
19
20 of the July 1, 2000, through June 30, 2001, rate year.
20
21 1. The recalculations provided for in this subsection shall be
21
22 consistent for both nursing facilities and Intermediate Care
22
23 Facilities for Individuals with Intellectual Disabilities
23
24
24
Req. No. 599 Page 7
1 intermediate care facilities for individuals with intellectual
1
2 disabilities (ICFs/IID).
2
3 2. The recalculated reimbursement rate shall be implemented
3
4 September 1, 2000.
4
5 B. 1. From September 1, 2000, through August 31, 2001, all
5
6 nursing facilities subject to the Nursing Home Care Act, in addition
6
7 to other state and federal requirements related to the staffing of
7
8 nursing facilities, shall maintain the following minimum direct-
8
9 care-staff-to-resident ratios:
9
10 a. from 7:00 a.m. to 3:00 p.m., one direct-care staff to
10
11 every eight residents, or major fraction thereof,
11
12 b. from 3:00 p.m. to 11:00 p.m., one direct-care staff to
12
13 every twelve residents, or major fraction thereof, and
13
14 c. from 11:00 p.m. to 7:00 a.m., one direct-care staff to
14
15 every seventeen residents, or major fraction thereof.
15
16 2. From September 1, 2001, through August 31, 2003, nursing
16
17 facilities subject to the Nursing Home Care Act and Intermediate
17
18 Care Facilities for Individuals with Intellectual Disabilities
18
19 intermediate care facilities for individuals with intellectual
19
20 disabilities (ICFs/IID) with seventeen or more beds shall maintain,
20
21 in addition to other state and federal requirements related to the
21
22 staffing of nursing facilities, the following minimum direct-care-
22
23 staff-to-resident ratios:
23
24
24
Req. No. 599 Page 8
1 a. from 7:00 a.m. to 3:00 p.m., one direct-care staff to
1
2 every seven residents, or major fraction thereof,
2
3 b. from 3:00 p.m. to 11:00 p.m., one direct-care staff to
3
4 every ten residents, or major fraction thereof, and
4
5 c. from 11:00 p.m. to 7:00 a.m., one direct-care staff to
5
6 every seventeen residents, or major fraction thereof.
6
7 3. On and after October 1, 2019, nursing facilities subject to
7
8 the Nursing Home Care Act and Intermediate Care Facilities for
8
9 Individuals with Intellectual Disabilities intermediate care
9
10 facilities for individuals with intellectual disabilities (ICFs/IID)
10
11 with seventeen or more beds shall maintain, in addition to other
11
12 state and federal requirements related to the staffing of nursing
12
13 facilities, the following minimum direct-care-staff-to-resident
13
14 ratios:
14
15 a. from 7:00 a.m. to 3:00 p.m., one direct-care staff to
15
16 every six residents, or major fraction thereof,
16
17 b. from 3:00 p.m. to 11:00 p.m., one direct-care staff to
17
18 every eight residents, or major fraction thereof, and
18
19 c. from 11:00 p.m. to 7:00 a.m., one direct-care staff to
19
20 every fifteen residents, or major fraction thereof.
20
21 4. Effective immediately, facilities shall have the option of
21
22 varying the starting times for the eight-hour shifts by one (1) hour
22
23 before or one (1) hour after the times designated in this section
23
24 without overlapping shifts.
24
Req. No. 599 Page 9
1 5. a. On and after January 1, 2020, a facility may implement
1
2 twenty-four-hour-based staff scheduling; provided,
2
3 however, such facility shall continue to maintain a
3
4 direct-care service rate of at least two and nine
4
5 tenths nine-tenths (2.9) hours of direct-care service
5
6 per resident per day, the same to be calculated based
6
7 on average direct care staff maintained over a twenty-
7
8 four-hour period.
8
9 b. At no time shall direct-care staffing ratios in a
9
10 facility with twenty-four-hour-based staff-scheduling
10
11 privileges fall below one direct-care staff to every
11
12 fifteen residents or major fraction thereof, and at
12
13 least two direct-care staff shall be on duty and awake
13
14 at all times.
14
15 c. As used in this paragraph, "twenty-four-hour-based-
15
16 scheduling" "twenty-four-hour-based staff scheduling"
16
17 means maintaining:
17
18 (1) a direct-care-staff-to-resident ratio based on
18
19 overall hours of direct-care service per resident
19
20 per day rate of not less than two and ninety one-
20
21 hundredths (2.90) two and nine-tenths (2.9) hours
21
22 per day,
22
23 (2) a direct-care-staff-to-resident ratio of at least
23
24 one direct-care staff person on duty to every
24
Req. No. 599 Page 10
1 fifteen residents or major fraction thereof at
1
2 all times, and
2
3 (3) at least two direct-care staff persons on duty
3
4 and awake at all times.
4
5 6. a. On and after January 1, 2004, the State Department of
5
6 Health shall require a facility to maintain the shift-
6
7 based, staff-to-resident ratios provided in paragraph
7
8 3 of this subsection if the facility has been
8
9 determined by the Department to be deficient with
9
10 regard to:
10
11 (1) the provisions of paragraph 3 of this subsection,
11
12 (2) fraudulent reporting of staffing on the Quality
12
13 of Care Report, or
13
14 (3) a complaint or survey investigation that has
14
15 determined substandard quality of care as a
15
16 result of insufficient staffing.
16
17 b. The Department shall require a facility described in
17
18 subparagraph a of this paragraph to achieve and
18
19 maintain the shift-based, staff-to-resident ratios
19
20 provided in paragraph 3 of this subsection for a
20
21 minimum of three (3) months before being considered
21
22 eligible to implement twenty-four-hour-based staff
22
23 scheduling as defined in subparagraph c of paragraph 5
23
24 of this subsection.
24
Req. No. 599 Page 11
1 c. Upon a subsequent determination by the Department that
1
2 the facility has achieved and maintained for at least
2
3 three (3) months the shift-based, staff-to-resident
3
4 ratios described in paragraph 3 of this subsection,
4
5 and has corrected any deficiency described in
5
6 subparagraph a of this paragraph, the Department shall
6
7 notify the facility of its eligibility to implement
7
8 twenty-four-hour-based staff-scheduling privileges.
8
9 7. a. For facilities that utilize twenty-four-hour-based
9
10 staff-scheduling privileges, the Department shall
10
11 monitor and evaluate facility compliance with the
11
12 twenty-four-hour-based staff-scheduling staffing
12
13 provisions of paragraph 5 of this subsection through
13
14 reviews of monthly staffing reports, results of
14
15 complaint investigations and inspections.
15
16 b. If the Department identifies any quality-of-care
16
17 problems related to insufficient staffing in such
17
18 facility, the Department shall issue a directed plan
18
19 of correction to the facility found to be out of
19
20 compliance with the provisions of this subsection.
20
21 c. In a directed plan of correction, the Department shall
21
22 require a facility described in subparagraph b of this
22
23 paragraph to maintain shift-based, staff-to-resident
23
24 ratios for the following periods of time:
24
Req. No. 599 Page 12
1 (1) the first determination shall require that shift-
1
2 based, staff-to-resident ratios be maintained
2
3 until full compliance is achieved,
3
4 (2) the second determination within a two-year period
4
5 shall require that shift-based, staff-to-resident
5
6 ratios be maintained for a minimum period of
6
7 twelve (12) months, and
7
8 (3) the third determination within a two-year period
8
9 shall require that shift-based, staff-to-resident
9
10 ratios be maintained. The facility may apply for
10
11 permission to use twenty-four-hour staffing
11
12 methodology after two (2) years.
12
13 C. Effective September 1, 2002, facilities shall post the names
13
14 and titles of direct-care staff on duty each day in a conspicuous
14
15 place, including the name and title of the supervising nurse.
15
16 D. The State Commissioner of Health shall promulgate rules
16
17 prescribing staffing requirements for Intermediate Care Facilities
17
18 for Individuals with Intellectual Disabilities intermediate care
18
19 facilities for individuals with intellectual disabilities serving
19
20 six or fewer clients (ICFs/IID-6) and for Intermediate Care
20
21 Facilities for Individuals with Intellectual Disabilities
21
22 intermediate care facilities for individuals with intellectual
22
23 disabilities serving sixteen or fewer clients (ICFs/IID-16).
23
24
24
Req. No. 599 Page 13
1 E. Facilities shall have the right to appeal and to the
1
2 informal dispute resolution process with regard to penalties and
2
3 sanctions imposed due to staffing noncompliance.
3
4 F. 1. When the state Medicaid program reimbursement rate
4
5 reflects the sum of Ninety-four Dollars and eleven cents ($94.11),
5
6 plus the increases in actual audited costs over and above the actual
6
7 audited costs reflected in the cost reports submitted for the most
7
8 current cost-reporting period and the costs estimated by the
8
9 Oklahoma Health Care Authority to increase the direct-care, flexible
9
10 staff-scheduling staffing level from two and eighty-six one-
10
11 hundredths (2.86) hours per day per occupied bed to three and two-
11
12 tenths (3.2) hours per day per occupied bed, all nursing facilities
12
13 subject to the provisions of the Nursing Home Care Act and
13
14 Intermediate Care Facilities for Individuals with Intellectual
14
15 Disabilities intermediate care facilities for individuals with
15
16 intellectual disabilities (ICFs/IID) with seventeen or more beds, in
16
17 addition to other state and federal requirements related to the
17
18 staffing of nursing facilities, shall maintain direct-care, flexible
18
19 staff-scheduling staffing levels based on an overall three and two-
19
20 tenths (3.2) hours per day per occupied bed.
20
21 2. When the state Medicaid program reimbursement rate reflects
21
22 the sum of Ninety-four Dollars and eleven cents ($94.11), plus the
22
23 increases in actual audited costs over and above the actual audited
23
24 costs reflected in the cost reports submitted for the most current
24
Req. No. 599 Page 14
1 cost-reporting period and the costs estimated by the Oklahoma Health
1
2 Care Authority to increase the direct-care flexible staff-scheduling
2
3 staffing level from three and two-tenths (3.2) hours per day per
3
4 occupied bed to three and eight-tenths (3.8) hours per day per
4
5 occupied bed, all nursing facilities subject to the provisions of
5
6 the Nursing Home Care Act and Intermediate Care Facilities for
6
7 Individuals with Intellectual Disabilities intermediate care
7
8 facilities for individuals with intellectual disabilities (ICFs/IID)
8
9 with seventeen or more beds, in addition to other state and federal
9
10 requirements related to the staffing of nursing facilities, shall
10
11 maintain direct-care, flexible staff-scheduling staffing levels
11
12 based on an overall three and eight-tenths (3.8) hours per day per
12
13 occupied bed.
13
14 3. When the state Medicaid program reimbursement rate reflects
14
15 the sum of Ninety-four Dollars and eleven cents ($94.11), plus the
15
16 increases in actual audited costs over and above the actual audited
16
17 costs reflected in the cost reports submitted for the most current
17
18 cost-reporting period and the costs estimated by the Oklahoma Health
18
19 Care Authority to increase the direct-care, flexible staff-
19
20 scheduling staffing level from three and eight-tenths (3.8) hours
20
21 per day per occupied bed to four and one-tenth (4.1) hours per day
21
22 per occupied bed, all nursing facilities subject to the provisions
22
23 of the Nursing Home Care Act and Intermediate Care Facilities for
23
24 Individuals with Intellectual Disabilities intermediate care
24
Req. No. 599 Page 15
1 facilities for individuals with intellectual disabilities (ICFs/IID)
1
2 with seventeen or more beds, in addition to other state and federal
2
3 requirements related to the staffing of nursing facilities, shall
3
4 maintain direct-care, flexible staff-scheduling staffing levels
4
5 based on an overall four and one-tenth (4.1) hours per day per
5
6 occupied bed.
6
7 4. The Commissioner shall promulgate rules for shift-based,
7
8 staff-to-resident ratios for noncompliant facilities denoting the
8
9 incremental increases reflected in direct-care, flexible staff-
9
10 scheduling staffing levels.
10
11 5. In the event that the state Medicaid program reimbursement
11
12 rate for facilities subject to the Nursing Home Care Act, and
12
13 Intermediate Care Facilities for Individuals with Intellectual
13
14 Disabilities intermediate care facilities for individuals with
14
15 intellectual disabilities (ICFs/IID) having seventeen or more beds
15
16 is reduced below actual audited costs, the requirements for staffing
16
17 ratio levels shall be adjusted to the appropriate levels provided in
17
18 paragraphs 1 through 4 of this subsection.
18
19 G. For purposes of this subsection section:
19
20 1. "Direct-care staff" means any nursing or therapy staff who
20
21 provides direct, hands-on care to residents in a nursing facility;
21
22 2. Prior to September 1, 2003, activity and social services
22
23 staff who are not providing direct, hands-on care to residents may
23
24 be included in the direct-care-staff-to-resident ratio in any shift.
24
Req. No. 599 Page 16
1 On and after September 1, 2003, such persons shall not be included
1
2 in the direct-care-staff-to-resident ratio, regardless of their
2
3 licensure or certification status; and
3
4 3. The administrator shall not be counted in the direct-care-
4
5 staff-to-resident ratio regardless of the administrator's licensure
5
6 or certification status.
6
7 H. 1. The Oklahoma Health Care Authority shall require all
7
8 nursing facilities subject to the provisions of the Nursing Home
8
9 Care Act and Intermediate Care Facilities for Individuals with
9
10 Intellectual Disabilities intermediate care facilities for
10
11 individuals with intellectual disabilities (ICFs/IID) with seventeen
11
12 or more beds to submit a monthly report on staffing ratios on a form
12
13 that the Authority shall develop.
13
14 2. The report shall document the extent to which such
14
15 facilities are meeting or are failing to meet the minimum direct-
15
16 care-staff-to-resident ratios specified by this section. Such
16
17 report shall be available to the public upon request.
17
18 3. The Authority may assess administrative penalties for the
18
19 failure of any facility to submit the report as required by the
19
20 Authority. Provided, however:
20
21 a. administrative penalties shall not accrue until the
21
22 Authority notifies the facility in writing that the
22
23 report was not timely submitted as required, and
23
24
24
Req. No. 599 Page 17
1 b. a minimum of a one-day penalty shall be assessed in
1
2 all instances.
2
3 4. Administrative penalties shall not be assessed for
3
4 computational errors made in preparing the report.
4
5 5. Monies collected from administrative penalties shall be
5
6 deposited in the Nursing Facility Quality of Care Fund established
6
7 in Section 2002 of Title 56 of the Oklahoma Statutes and utilized
7
8 for the purposes specified in the Oklahoma Healthcare Initiative Act
8
9 such section.
9
10 I. 1. All entities regulated by this state that provide long-
10
11 term care services shall utilize a single assessment tool to
11
12 determine client services needs. The tool shall be developed by the
12
13 Oklahoma Health Care Authority in consultation with the State
13
14 Department of Health.
14
15 2. a. The Oklahoma Nursing Facility Funding Advisory
15
16 Committee is hereby created and shall consist of the
16
17 following:
17
18 (1) four members selected by the Oklahoma Association
18
19 of Health Care Providers Care Providers Oklahoma
19
20 or its successor organization,
20
21 (2) three members selected by the Oklahoma
21
22 Association of Homes and Services for the Aging
22
23 LeadingAge Oklahoma or its successor
23
24 organization, and
24
Req. No. 599 Page 18
1 (3) two members selected by the State Council on
1
2 Aging State Council on Aging and Adult Protective
2
3 Services.
3
4 The Chair chair shall be elected by the committee. No
4
5 state employees may be appointed to serve.
5
6 b. The purpose of the advisory committee will shall be
6
7 to:
7
8 (1) develop a new methodology for calculating state
8
9 Medicaid program reimbursements to nursing
9
10 facilities by implementing facility-specific
10
11 rates based on expenditures relating to direct
11
12 care staffing, and
12
13 (2) recommend changes to the incentive reimbursement
13
14 rate plan created under Section 1011.5 of Title
14
15 56 of the Oklahoma Statutes.
15
16 No nursing home will shall receive less than the
16
17 current rate at the time of implementation of
17
18 facility-specific rates pursuant to division 1 of this
18
19 subparagraph.
19
20 c. The advisory committee shall be staffed and advised by
20
21 the Oklahoma Health Care Authority.
21
22 d. The new methodology will shall be submitted for
22
23 approval to the Board of the Oklahoma Health Care
23
24 Authority by January 15, 2005, and shall be finalized
24
Req. No. 599 Page 19
1 by July 1, 2005. The new methodology will shall apply
1
2 only to new funds that become available for Medicaid
2
3 nursing facility reimbursement after the methodology
3
4 of this paragraph has been finalized. Existing funds
4
5 paid to nursing homes will shall not be subject to the
5
6 methodology of this paragraph. The methodology as
6
7 outlined in this paragraph will shall only be applied
7
8 to any new funding for nursing facilities appropriated
8
9 above and beyond the funding amounts effective on
9
10 January 15, 2005.
10
11 e. The new methodology shall divide the payment into two
11
12 components:
12
13 (1) direct care which includes allowable costs for
13
14 registered nurses, licensed practical nurses,
14
15 certified medication aides and certified nurse
15
16 aides. The direct care component of the rate
16
17 shall be a facility-specific rate, directly
17
18 related to each facility's actual expenditures on
18
19 direct care, and
19
20 (2) other costs.
20
21 f. The Oklahoma Health Care Authority, in calculating the
21
22 base year prospective direct care rate component,
22
23 shall use the following criteria:
23
24
24
Req. No. 599 Page 20
1 (1) to construct an array of facility per diem
1
2 allowable expenditures on direct care, the
2
3 Authority shall use the most recent data
3
4 available. The limit on this array shall be no
4
5 less than the ninetieth percentile,
5
6 (2) each facility's direct care base-year component
6
7 of the rate shall be the lesser of the facility's
7
8 allowable expenditures on direct care or the
8
9 limit,
9
10 (3) as soon as practicable after receipt of any
10
11 necessary federal approval, and subject to
11
12 appropriation of funds for a rate increase to
12
13 nursing facilities, the Authority shall
13
14 incorporate a case-mix component into the payment
14
15 rate methodology for nursing facilities. The
15
16 inclusion of the case-mix component shall occur
16
17 upon the availability and analysis of the
17
18 necessary data by the Authority. Appropriated
18
19 funds shall be allocated as follows:
19
20 (a) fifty percent (50%) of funds shall be
20
21 designated for the case-mix component, and
21
22 (b) the remaining fifty percent (50%) of funds
22
23 shall be allocated to the base rate
23
24 component,
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Req. No. 599 Page 21
1 (4) other rate components shall be determined by the
1
2 Oklahoma Nursing Facility Funding Advisory
2
3 Committee or the Authority in accordance with
3
4 federal regulations and requirements,
4
5 (4) (5) prior to July 1, 2020, the Authority shall
5
6 seek federal approval to calculate the upper
6
7 payment limit under the authority of CMS the
7
8 Centers for Medicare and Medicaid Services (CMS)
8
9 utilizing the Medicare equivalent payment rate,
9
10 and
10
11 (5) (6) if Medicaid payment rates to providers are
11
12 adjusted, nursing home rates and Intermediate
12
13 Care Facilities for Individuals with Intellectual
13
14 Disabilities intermediate care facilities for
14
15 individuals with intellectual disabilities
15
16 (ICFs/IID) rates shall not be adjusted less
16
17 favorably than the average percentage-rate
17
18 reduction or increase applicable to the majority
18
19 of other provider groups.
19
20 g. (1) Effective October 1, 2019, if sufficient funding
20
21 is appropriated for a rate increase, a new
21
22 average rate for nursing facilities shall be
22
23 established. The rate shall be equal to the
23
24 statewide average cost as derived from audited
24
Req. No. 599 Page 22
1 cost reports for SFY 2018, ending June 30, 2018,
1
2 after adjustment for inflation. After such new
2
3 average rate has been established, the facility
3
4 specific reimbursement rate shall be as follows:
4
5 (a) amounts up to the existing base rate amount
5
6 shall continue to be distributed as a part
6
7 of the base rate in accordance with the
7
8 existing Medicaid State Plan, and
8
9 (b) to the extent the new rate exceeds the rate
9
10 effective before the effective date of this
10
11 act October 1, 2019, fifty percent (50%) of
11
12 the resulting increase on October 1, 2019,
12
13 shall be allocated toward an increase of the
13
14 existing base reimbursement rate and
14
15 distributed accordingly. The remaining
15
16 fifty percent (50%) of the increase shall be
16
17 allocated in accordance with the currently
17
18 approved 70/30 reimbursement rate
18
19 methodology as outlined in the existing
19
20 Medicaid State Plan.
20
21 (2) Any subsequent rate increases, as determined
21
22 based on the provisions set forth in this
22
23 subparagraph, shall be allocated in accordance
23
24 with the currently approved 70/30 reimbursement
24
Req. No. 599 Page 23
1 rate methodology. When the case-mix component is
1
2 included in the rate methodology, fifty percent
2
3 (50%) of the amount allocated to direct care
3
4 shall be apportioned to the case-mix component.
4
5 The rate shall not exceed the upper payment limit
5
6 established by the Medicare rate equivalent
6
7 established by the federal CMS.
7
8 h. Effective October 1, 2019, in coordination with the
8
9 rate adjustments identified in the preceding section,
9
10 a portion of the funds shall be utilized as follows:
10
11 (1) effective October 1, 2019, the Oklahoma Health
11
12 Care Authority shall increase the personal needs
12
13 allowance for residents of nursing homes and
13
14 Intermediate Care Facilities for Individuals with
14
15 Intellectual Disabilities intermediate care
15
16 facilities for individuals with intellectual
16
17 disabilities (ICFs/IID) from Fifty Dollars
17
18 ($50.00) per month to Seventy-five Dollars
18
19 ($75.00) per month per resident. The increase
19
20 shall be funded by Medicaid nursing home
20
21 providers, by way of a reduction of eighty-two
21
22 cents ($0.82) per day deducted from the base
22
23 rate. Any additional cost shall be funded by the
23
24 Nursing Facility Quality of Care Fund, and
24
Req. No. 599 Page 24
1 (2) effective January 1, 2020, all clinical employees
1
2 working in a licensed nursing facility shall be
2
3 required to receive at least four (4) hours
3
4 annually of Alzheimer's or dementia training, to
4
5 be provided and paid for by the facilities.
5
6 3. The Department of Human Services shall expand its statewide
6
7 toll-free, Senior-Info Line Senior Info-line for senior citizen
7
8 services to include assistance with or information on long-term care
8
9 services in this state.
9
10 4. The Oklahoma Health Care Authority shall develop a nursing
10
11 facility cost-reporting system that reflects the most current costs
11
12 experienced by nursing and specialized facilities. The Oklahoma
12
13 Health Care Authority shall utilize the most current cost report
13
14 data to estimate costs in determining daily per diem rates.
14
15 5. The Oklahoma Health Care Authority shall provide access to
15
16 the detailed Medicaid payment audit adjustments and implement an
16
17 appeal process for disputed payment audit adjustments to the
17
18 provider. Additionally, the Oklahoma Health Care Authority shall
18
19 make sufficient revisions to the nursing facility cost reporting
19
20 forms and electronic data input system so as to clarify what
20
21 expenses are allowable and appropriate for inclusion in cost
21
22 calculations.
22
23 J. 1. When the state Medicaid program reimbursement rate
23
24 reflects the sum of Ninety-four Dollars and eleven cents ($94.11),
24
Req. No. 599 Page 25
1 plus the increases in actual audited costs, over and above the
1
2 actual audited costs reflected in the cost reports submitted for the
2
3 most current cost-reporting period, and the direct-care, flexible
3
4 staff-scheduling staffing level has been prospectively funded at
4
5 four and one-tenth (4.1) hours per day per occupied bed, the
5
6 Authority may apportion funds for the implementation of the
6
7 provisions of this section.
7
8 2. The Authority shall make application to the United States
8
9 Centers for Medicare and Medicaid Service for a waiver of the
9
10 uniform requirement on health-care-related taxes as permitted by
10
11 Section 433.72 of 42 C.F.R., Section 433.72.
11
12 3. Upon approval of the waiver, the Authority shall develop a
12
13 program to implement the provisions of the waiver as it relates to
13
14 all nursing facilities.
14
15 SECTION 4. This act shall become effective July 1, 2025.
15
16 SECTION 5. It being immediately necessary for the preservation
16
17 of the public peace, health or safety, an emergency is hereby
17
18 declared to exist, by reason whereof this act shall take effect and
18
19 be in full force from and after its passage and approval.
19
20
20
21 60-1-599 DC 1/19/2025 5:45:40 AM
21
22
22
23
23
24
24
Req. No. 599 Page 26Every fact on this page links to its source, starting with the official bill record.