Title 7 . Health and Social Services

Chapter 43 . Hearings

Section 708. Exceptional relief to prospective payment rate setting

7 AAC 43.708. Exceptional relief to prospective payment rate setting

(a) If application of the methodology in 7 AAC 43.676 - 7 AAC 43.689, 7 AAC 43.860, or 7 AAC 43.872 results in a permanent prospective payment rate that does not allow reasonable access to quality patient care provided by an efficiently and economically managed facility, the facility may apply to the deputy commissioner for exceptional relief from the rate-setting methodology.

(b) To apply for exceptional relief under (a) of this section, at a minimum the facility's application should include

(1) the amount by which the facility estimates that the prospective payment rate should be increased to allow reasonable access to quality patient care provided by an efficiently managed facility;

(2) the reasons and the need for the exceptional relief requested, including any resolution by the facility's governing body to support the reasons offered, and why such a rate increase cannot be obtained through the existing rate-setting regulations;

(3) the description of management actions taken by the facility to respond to the situation on which the exceptional relief request is based;

(4) the audited financial statement for the facility for the most recently completed facility fiscal year and financial data, including a statement of income and expenses, a statement of assets, liabilities, and equities, and a monthly facility cash flow analysis, for the fiscal year for which the exception is requested;

(5) a detailed description of recent efforts by the facility to offset the deficiency by securing revenue sharing, charity or foundation contributions, or local community support;

(6) an analysis of community needs for the service on which the exception request is based;

(7) a detailed analysis of the options of the facility if the exception is denied by the deputy commissioner;

(8) a plan for future action to respond to the problem; and

(9) an analysis of how Medicaid patients will lose access to Medicaid services available to the general public in the same geographic area if exceptional relief is not granted.

(c) The facility shall provide other information requested by the deputy commissioner in order to evaluate the request. If a facility fails to supply the requested information within a reasonable period, the deputy commissioner, in his or her sole discretion, will deny the request.

(d) The deputy commissioner may, in his or her sole discretion, use any information available in department records to evaluate the request. The deputy commissioner shall provide copies of the additional material to the facility upon request of the facility.

(e) Repealed 1/1/2004.

(f) The deputy commissioner may increase the prospective payment rate, by all or part of the facility's request, if the deputy commissioner finds by clear and convincing evidence that the rate established under the methodology in 7 AAC 43.676 - 7 AAC 43.689, 7 AAC 43.860, or 7 AAC 43.872 does not allow for reasonable access to quality patient care provided by an efficiently and economically managed facility, and that the granting of an exception is in the public interest. In determining whether the exception is in the public interest, the deputy commissioner may consider at least

(1) the necessity of the rate increase to allow reasonable access to quality care provided by an efficiently and economically managed facility, including any findings of the governing body of the facility to support the need;

(2) the assessment of continued need for the facility's services in the community;

(3) whether the facility has taken effective steps to respond to the crisis and has adopted effective management strategies to alleviate or avoid the future need for exceptional relief;

(4) whether Medicaid patients will lose access to Medicaid services available to the general public in the same geographic area if exceptional relief is not granted;

(5) the availability of other resources available to the facility to respond to the crisis;

(6) whether the relief from an exception should have been obtained under the existing rate methodology; and

(7) other factors relevant to assess reasonable access to quality patient care provided by an efficiently and economically managed facility.

(g) The deputy commissioner may, in his or her sole discretion, impose conditions on the receipt of exceptional relief. Such conditions include

(1) the facility sharing the cost of the prospective payment rate exception granted;

(2) the facility taking effective steps in the future to alleviate the need for future requests for exceptional relief;

(3) the facility providing documentation as specified by the deputy commissioner of the continued need for the exception; or

(4) a maximum amount of exceptional relief to be granted to this facility under this section.

(h) If the deputy commissioner grants exceptional relief under this section, any amount granted may not be included as part of the base on which future prospective payment rates are determined.

(i) Exceptional relief granted under this section is effective prospectively from the date of the exceptional relief decision, and for a period of time not to extend beyond the end of the facility's rate-setting year. A facility may apply for exceptional relief in the following year by submitting a new application under (a) of this section.

(j) Notwithstanding 7 AAC 43.703, a party aggrieved by a decision of the deputy commissioner concerning exceptional relief may, within 30 days after the date of mailing of the decision to that party, request an administrative hearing to the commissioner of the department. The commissioner will consider the request for appeal as untimely filed if the commissioner has not received the request within 30 days after the deputy commissioner's mailing of the notice of the decision to the party. The exceptional relief granted by the deputy commissioner will be effective subject to adjustment based on the decision reached by the commissioner on the appeal. A copy of the commissioner's decision on appeal will be provided to the facility, to the deputy commissioner, and to the department staff that oversees Medicaid payment rates.

(k) The deputy commissioner shall send copies of the decision of the deputy commissioner concerning exceptional relief to the facility, to the director of the division of the department responsible for paying Medicaid program claims, and to the department staff that oversees Medicaid payment rates. The exceptional relief decision shall be accompanied by a certificate showing the date of mailing to the persons listed in this subsection.

History: Eff. 3/13/89, Register 110; readopt 8/7/96, Register 139; am 9/5/97, Register 143; am 1/1/2004, Register 168; am 7/1/2004, Register 170; am 3/18/2006, Register 177

Authority: AS 47.05.010

AS 47.07.070

AS 47.07.073

Editor's note: Effective 8/7/96, Register 139, the Department of Health and Social Services readopted 7 AAC 43.708 in its entirety, without change, under AS 47.07. Executive Order No. 72 transferred certain rate-setting authority to the department.