OAR 411-027-0075: Special Payment Contracts

(1) The Department may authorize three different types of special payment contract arrangements. (a) Supplemented Program Contract. A supplemented program contract pays a rate in excess of the rate schedule to providers in return for additional services delivered to target populations. (b) Consistent Revenue Contract. A consistent revenue contract allows a payment rate based on average facility case mix. The contracted rate is in the range allowed by the rate schedule and is based on individual needs. (c) Specific Needs Setting Contract. A specific needs setting contract pays a rate in excess of the rate schedule to providers who care for a group of individuals all of whose service needs exceed the service needs encompassed in the base payment and all add-ons. (2) SUPPLEMENTED PROGRAM CONTRACTS. (a) The Department may authorize a service payment rate not included in the rate schedule for Residential Care Facilities, Assisted Living Facilities and Adult Foster Homes providing additional services to a targeted population, pursuant to a written contract with the Department. To qualify, the facility must demonstrate to the Department that: (A) There is a documented need for additional services to the target population. (B) The administrative and care staff have sufficient program knowledge and skills to achieve program goals and provide the additional services. (C) The facility provides substantial additional services beyond those covered under the rate schedule. (D) There is a comprehensive ongoing staff training program targeted to the population's needs. (E) The facility has made any modifications necessary to provide the additional services. (F) The Medicaid individuals served in the facility demonstrate increasing need for assistance with activities of daily living and cognitive abilities due to Alzheimer's Disease or other dementia. (i) "Alzheimer's Disease" means a chronic, progressive disease of unknown cause that attacks brain cells or tissues. (ii) "Dementia" means a clinical syndrome characterized by a decline in mental function of long duration in an alert individual. Symptoms of dementia include memory loss and the loss or diminution of other cognitive abilities such as learning ability, judgment, comprehension, attention and orientation to time and place and to oneself. (G) The facility has provided the additional service for at least six months prior to the date on which the supplemented program contract takes effect. Additionally, the Department may approve supplemented program contracts to be effective prior to the date on which the facility has provided the additional service for six months based on: (i) The Department experience of provider ability to provide the additional service; (ii) The recommendation of the Department and AAA local office staff; or (iii) Unmet community need for the additional services to be offered under the contract. (H) The facility may identify, at the time of application for the supplemented program contract, the additional costs the facility incurs to deliver the additional services. The facility shall include, at a minimum, the additional staffing and training costs it incurs as a result of delivery of the additional services. (b) The Department must evaluate the information submitted by the facility, and may authorize a contracted payment amount. (c) A contract may be renewed at the appropriate payment rate on an annual basis for a facility that continues to meet the criteria stated in section (1)(a) of this rule. (A) At the time of the request for renewal, or at any other time the Department requests, the facility shall provide the Department with information on actual costs incurred in delivery of the additional services. Information provided by the facility shall be in the format prescribed by the Department and shall, at a minimum, include the costs of staffing the additional services and of training for direct care staff. (B) The Department must evaluate the information submitted by the facility, and may re-authorize a contracted payment amount. (d) The supplemented program contract rate may be increased only if the Legislative Assembly authorizes the Department to do so and appropriates the funds needed to pay the increase. (3) CONSISTENT REVENUE CONTRACTS. The Department may authorize a service payment rate not included in the rate schedule for Residential Care Facilities, Assisted Living Facilities and Adult Foster Homes that request a consistent revenue rate pursuant to a written contract with the Department. (a) In a consistent revenue contract, the Department establishes a uniform service payment rate for all individuals. The uniform service payment rate is equivalent to the average service payment rate the Department pays under the rate schedule. In no case shall the consistent revenue contract payment exceed the average amount the Department pays to the facility under the rate schedule. (b) A provider must request a consistent revenue contract in writing. The request must include the suggested payment amount and justify the calculation of that amount by attaching copies of the most recent three full calendar months Provider Individual Summary Form. (A) If a request for a consistent revenue contract and the required justification are received by the Department on or before the 15th of the month, the consistent revenue contract payment amount is effective for payment for services rendered on or after the first day of the month immediately following receipt of the request. (B) If a request for a consistent revenue contract and the required justification are received by the Department after the 15th of the month, the consistent revenue contract payment amount is effective for payment for services rendered on or after the first day of the second month following receipt of the request. (c) A consistent revenue contract may be terminated by the facility by providing 30 days written notice to the Department. If a consistent revenue contract is terminated, service payments for individuals are made in accordance with the rate schedule. (d) The Department may terminate a consistent revenue contract by providing 30 days written notice to the facility. If a consistent revenue contract is terminated, service payments for individuals are made in accordance with the rate schedule. (e) Payment rates under consistent revenue contracts may be adjusted due to changes in facility case mix. (A) The Department must review facility case mix annually at contract renewal. The determination of average facility case mix is based on the average service payment level to which the Department has assigned individuals over the three calendar months that precede the determination. (B) Notwithstanding section (3)(e)(A) of this rule, in the first year during which a facility is paid under a consistent revenue contract, the facility may request that the consistent revenue contract payment be recalculated after six months. The request must include the recommended payment amount and justification of that amount. (f) Service payment rate amounts paid under a consistent revenue contract are increased as a result of legislatively approved increases at the same time and in the same way as are other facilities of the same licensure. (4) SPECIFIC NEEDS SETTING CONTRACTS. (a) Specific needs settings are found in Adult Foster Homes, Residential Care Facilities and Assisted Living Facilities. These settings provide community-based care services for individuals whose needs are not met by the rate schedule. (b) Determination of facility eligibility for a specific needs setting contract is at the discretion of the Department. In making its determination, the Department shall consider: (A) The needs of the individuals being provided care; (B) The availability of other community long-term care options to meet individual needs; and (C) The proportion of facility individuals demonstrating the specific needs setting care need and other factors as the Department may determine. (c) The provider shall submit information to the Department in the form and at the time requested in order to determine the Medicaid rate to be paid. (d) The total rate for specific needs setting contracts shall be approved by the Department. The approved rate is a single rate paid for all Title XIX individuals with the specific needs setting care need that live in the eligible facility.