Overview

The primary functions of Reimbursement and Certificate of Need (CON) include establishment of payment rates for medical and residential care services, cost report auditing, and performing certificate of need reviews for nursing facilities, residential care homes, and ICF/IID development projects. Cost based rates are issued on an annual basis by the unit for services including hospitals, nursing facilities, home health care, clinics, and community residences for the elderly and disabled; as well as state-operated psychiatric hospitals, ICF/IID and federal Medicaid waiver services. Since rate changes have a significant impact on the Department's budget, Reimbursement and Certificate of Need also conducts special rate projection analysis. Rate appeals and hearings are processed through the unit, while cost report audits are conducted through a contract with a major accounting firm and the Department's Quality Assurance Division. The unit is comprised of twelve staff including a Director, a Manager, an office position, and nine analysts.

Reimbursement and Certificate of Need (CON) is Responsible for:

Certificate of Need (CON)
CON is a formal statement by the Department approving, denying, or modifying a health care facility request to undertake an expansion or reduction in services. The CON process is an attempt to prevent an oversupply and excess of expenditures.

Community Living Arrangements (CLA)
The majority of CLA residences are enrolled under a Medicaid Home and Community Based Waiver administered by DSS. Reimbursement and CON is responsible for seeking federal reimbursement for Medicaid services provided to eligible residences.

Continuing Care Facility (CCF)
Conducting investigations to determine whether a CCF has complied with statutorily provisions governing the management of the continuing care retirement community. Reviewing required CCF filing of disclosure statements and annual financial documents.

Durable Medical Equipment (DME) Medicaid Reimbursement
Establishing reimbursement rates for Durable Medial Equipment (DME) to comply with federal regulations.

Federally Qualified Health Center (FQHC)
Establishing reimbursement methodologies for Federally Qualified Health Centers (FQHC).

Intermediate Care Facilities for Individuals with Intellectual Disabilities (ICF/IID)
Establishing reimbursement methodologies for ICF/IIDs, and development of Medicaid State Plan Amendments that are necessary to obtain Federal matching funds.

Medicaid Birth to Three
Reimbursement and Certificate of Need (CON) is Responsible for the administration and adherence to all Medicaid requirements associated with the Birth to Three program.

Medicaid Methadone Clinics
Reimbursement and CON is responsible for establishing reimbursement methodologies for methadone clinics and review of annual Medicaid provider cost report submissions.

Medicaid Hospital Reimbursement
Establishing Medicaid reimbursement methodologies for inpatient services, outpatient hospital services, Disproportionate Share Hospital (DSH) payments and hospital supplemental payments. Reimbursement and CON is also responsible for Medicaid State Plan Amendments that are necessary to obtain Federal matching funds.

Medicaid Nursing Facility Reimbursement
Establishing Medicaid reimbursement methodologies for Medicaid nursing homes, and development of Medicaid State Plan Amendments that are necessary to obtain Federal matching funds.

Medicaid Nursing Facility Reimbursement Modernization to Acuity-Based Methodology
Reimbursement and CON will be transitioning Medicaid nursing facility reimbursement from a cost-based methodology to a prospective acuity-based or case mix payment system. This method will aid DSS in its goals of moving toward a system that is data driven, improves transparency, and benefits patient outcomes.

Medicaid School Based Child Health (SBCH)
Reimbursement and CON is responsible for administering the SBCH program which allows school districts to seek federal reimbursement for Medicaid services provided to eligible students.

Residential Care Homes (RCH)
Reimbursement and CON is responsible for establishing reimbursement methodologies for Residential Care Homes (RCH).