reglab/statecodes huggingface dataset:
Code of Maine Rules › 10 - DEPARTMENT OF HEALTH AND HUMAN SERVICES › 144 - DEPARTMENT OF HEALTH AND HUMAN SERVICES - GENERAL › Chapter 101 - MAINECARE BENEFITS MANUAL (FORMERLY MAINE MEDICAL ASSISTANCE MANUAL) › Chapter III - Allowances for Services › Section 144-101-III-67 - Principles of Reimbursement for Nursing Facilities › Subsection 144-101-III-67-15 - COST COMPONENTS

Current through 2024-29, July 17, 2024
15.1 In the
					 prospective case mix system of reimbursement, allowable costs are grouped into
					 cost categories. The nature of the expenses dictates which costs are allowable
					 under these Principles of Reimbursement. The costs shall be grouped into the
					 following three (3) cost categories:
15.1.1
					 Direct Care Costs,
15.1.2 Routine
					 Costs, and
15.1.3 Fixed Costs.
Principles 16-18 describe the cost centers in each
						of these categories, the limitations and allowable costs placed on each of
						these cost centers.
The basis for reimbursement within the direct care cost
						component is a resident classification system that groups residents into
						classes according to their assessed conditions and the resources required to
						care for them.
Code of Maine Rules › 10 - DEPARTMENT OF HEALTH AND HUMAN SERVICES › 144 - DEPARTMENT OF HEALTH AND HUMAN SERVICES - GENERAL › Chapter 101 - MAINECARE BENEFITS MANUAL (FORMERLY MAINE MEDICAL ASSISTANCE MANUAL) › Chapter III - Allowances for Services › Section 144-101-III-67 - Principles of Reimbursement for Nursing Facilities › Subsection 144-101-III-67-16 - DIRECT CARE COST COMPONENT

Current through 2024-29, July 17, 2024
16.1
Direct
					 care costs
include salary, wages, and benefits for:
16.1.1 registered nurses salaries/wages
					 (excluding Director of Nursing),
16.1.2 licensed practical nurses
					 salaries/wages,
16.1.3 nurse aides
					 salaries/wages,
16.1.4 patient
					 activities personnel salaries/wages,
16.1.5 ward clerks' salaries/wages,
16.1.6 contractual labor costs,
16.1.7 fringe benefits for the positions in
					 Principles 16.1.1 through 16.1.5 include:
(1)
					 payroll taxes,
(2) qualified
					 retirement plan contributions,
(3)
					 group health, dental, and life insurance,
(4) cafeteria plans,
*(5) health savings accounts (if
					 cost-effective), and
*(6) flexible
					 spending accounts (if cost-effective).
*The Department shall submit to CMS and anticipates
						approval for a State Plan Amendment related to these
						provisions.
16.1.8
Cost of Educational Activities
(1)
Principle.
An appropriate
					 part of the net cost of educational activities is an allowable cost.
					 Appropriate means the net cost of the activity apportioned in accordance with
					 the methods set forth in these Principles. Expenses for education activities
					 may be evaluated as to appropriateness; quality and cost may not be included as
					 an allowable cost based on findings.
(2)
Orientation, On-the-Job Training,
					 In-Service Education and Similar Work Learning.
Orientation, on-the-job
					 training, in-service education and similar work learning programs are not
					 within the scope of this principle, but, if provided by a staff person, are
					 recognized as normal operating costs for routine services in accordance with
					 the Principles relating thereto.
(3)
Basic Education.
Educational
					 training programs, which a staff member must successfully complete in order to
					 qualify for a position or a job, shall be considered basic education. Cost
					 related to this education are not within the scope of reimbursement.
(4)
Educational Activities.
Educational activities mean formally organized or planned workshops, seminars,
					 or programs of study usually engaged in by the staff members of a facility in
					 order to enhance the quality of resident care within the facility. These
					 continuing education activities are distinguished from and do not include
					 orientation, basic education programs, on-the-job training, in-service
					 education and similar learning programs.
16.1.9 Medical supplies, medicine and drugs
					 that are supplied as part of the regular rate of reimbursement. See
MaineCare Benefits Manual
, Section
					 60. Excluded are
					 costs that are an integral part of another cost center.
Code of Maine Rules › 10 - DEPARTMENT OF HEALTH AND HUMAN SERVICES › 144 - DEPARTMENT OF HEALTH AND HUMAN SERVICES - GENERAL › Chapter 101 - MAINECARE BENEFITS MANUAL (FORMERLY MAINE MEDICAL ASSISTANCE MANUAL) › Chapter III - Allowances for Services › Section 144-101-III-67 - Principles of Reimbursement for Nursing Facilities › Subsection 144-101-III-67-18 - FIXED COSTS COMPONENT

Current through 2024-29, July 17, 2024
*The Department shall submit to CMS and anticipates
						approval for a State Plan Amendment related to these provisions.
18.1 *The base year costs for the fixed cost
					 component shall be the costs incurred by the facility in the most recently
					 audited fiscal year. Fixed costs include:
18.1.1 depreciation on buildings, fixed and
					 movable equipment and motor vehicles.
18.1.2 depreciation on land improvements and
					 amortization of leasehold improvements,
18.1.3 real estate and personal property
					 taxes,
18.1.4 real estate
					 insurance, including liability and fire insurance,
18.1.5 interest on long term debt,
18.1.6 rental expenses,
18.1.7 amortization of finance
					 costs,
18.1.8 amortization of
					 start-up costs and organizational costs,
18.1.9 motor vehicle insurance,
18.1.10 facility's liability insurance,
					 including malpractice costs and Workers compensation,
18.1.11 administrator in training,
18.1.12 water & sewer fees necessary for
					 the initial connection to a sewer system/water system,
18.1.13 portion of the acquisition cost for
					 the rights to a nursing facility license,
18.1.14 nursing facility health care provider
					 tax.
18.1.15 payment for High
					 MaineCare Utilization as defined in Principle 18.12
For a more complete description of allowable costs in
						each of these cost centers, see the explanations in Principle
						18.2.
Code of Maine Rules › 10 - DEPARTMENT OF HEALTH AND HUMAN SERVICES › 144 - DEPARTMENT OF HEALTH AND HUMAN SERVICES - GENERAL › Chapter 101 - MAINECARE BENEFITS MANUAL (FORMERLY MAINE MEDICAL ASSISTANCE MANUAL) › Chapter III - Allowances for Services › Section 144-101-III-67 - Principles of Reimbursement for Nursing Facilities › Subsection 144-101-III-67-19 - WAIVER

Current through 2024-29, July 17, 2024
The failure of the Department to insist, in any one (1)
						or more instances, upon the performance of any of the terms or conditions of
						these Principles, or to exercise any right under these principles, or to
						disapprove of any practice, accounting procedure, or item of account in any
						audit, shall not be construed as a waiver of future performance of the right.
						The obligation of the Provider with respect to future performance shall
						continue, and the Department shall not be stopped from requiring such future
						performance.
Code of Maine Rules › 10 - DEPARTMENT OF HEALTH AND HUMAN SERVICES › 144 - DEPARTMENT OF HEALTH AND HUMAN SERVICES - GENERAL › Chapter 101 - MAINECARE BENEFITS MANUAL (FORMERLY MAINE MEDICAL ASSISTANCE MANUAL) › Chapter III - Allowances for Services › Section 144-101-III-67 - Principles of Reimbursement for Nursing Facilities › Subsection 144-101-III-67-20 - SPECIAL SERVICE ALLOWANCE

Current through 2024-29, July 17, 2024
20.1
Principle.
A special ancillary service is to be distinguished from
					 a service generally provided in the nursing facility.
20.1.1 A special ancillary service is that of
					 an individual nature required in the case of a specific resident. This type of
					 service is limited to professional services such as physical therapy,
					 occupational therapy, and speech and hearing services. Special services of this
					 nature must be billed monthly to the Department as separate items required for
					 the care of individual members.
20.1.2 For eligible members, including those
					 with other related conditions, the Department will reimburse community support
					 services for persons with Development Disabilities in accordance with Chapter
					 III, Section
					 21, Home and Community
					 Benefits for Members with Mental Retardation or Autistic Disorder. The costs
					 associated with community support are not included in the nursing facility per
					 diem rate.
Code of Maine Rules › 10 - DEPARTMENT OF HEALTH AND HUMAN SERVICES › 144 - DEPARTMENT OF HEALTH AND HUMAN SERVICES - GENERAL › Chapter 101 - MAINECARE BENEFITS MANUAL (FORMERLY MAINE MEDICAL ASSISTANCE MANUAL) › Chapter III - Allowances for Services › Section 144-101-III-67 - Principles of Reimbursement for Nursing Facilities › Subsection 144-101-III-67-21 - OMNIBUS RECONCILIATION ACT OF 1987 (OBRA 87)

Current through 2024-29, July 17, 2024
OBRA 1987 has eliminated the distinction between ICFs and
						SNFs and the method of payment by such classifications. The statute provides
						for only one (1) type of nursing facility. All nursing homes are now classified
						as a "nursing facility" with a single payment methodology.
Code of Maine Rules › 10 - DEPARTMENT OF HEALTH AND HUMAN SERVICES › 144 - DEPARTMENT OF HEALTH AND HUMAN SERVICES - GENERAL › Chapter 101 - MAINECARE BENEFITS MANUAL (FORMERLY MAINE MEDICAL ASSISTANCE MANUAL) › Chapter III - Allowances for Services › Section 144-101-III-67 - Principles of Reimbursement for Nursing Facilities › Subsection 144-101-III-67-23 - INTERIM, SUBSEQUENT, AND PROSPECTIVE RATES

Current through 2024-29, July 17, 2024
23.1
Interim Rate and Subsequent Year
					 Rates.
Fifteen (15) days prior to the beginning of the State fiscal
					 year, an interim rate will be established by using the fixed cost component of
					 the latest audited cost report and adding to it the inflated routine cost
					 components of the base year. The interim rate in subsequent fiscal years will
					 be determined in the same manner as outlined above. The direct cost component
					 is computed as specified in Principle 22.3.4.
23.2
Fixed costs
may be adjusted
					 upon request of the provider when sufficient documentation (determined by the
					 DHHS) has been provided to the Department. These adjustments will be effective
					 with the next issuance of an interim rate.
23.3
Prospective Rate.
The
					 prospective rate, excluding fixed costs, shall be calculated to be 100 percent
					 (100%) of all of the calculated Direct Care Cost Components and all of the
					 Routine Cost Components.
Code of Maine Rules › 10 - DEPARTMENT OF HEALTH AND HUMAN SERVICES › 144 - DEPARTMENT OF HEALTH AND HUMAN SERVICES - GENERAL › Chapter 101 - MAINECARE BENEFITS MANUAL (FORMERLY MAINE MEDICAL ASSISTANCE MANUAL) › Chapter III - Allowances for Services › Section 144-101-III-67 - Principles of Reimbursement for Nursing Facilities › Subsection 144-101-III-67-24 - FINAL PROSPECTIVE RATE

Current through 2024-29, July 17, 2024
Upon final audit of all nursing facility's base year cost
						reports, the Department will determine a final prospective rate, which cannot
						be greater than 100 percent (100%) of all of the calculated direct Care Cost
						Components and all of the Routine Cost Components.
24.1 A cost report is settled if there is no
					 request for reconsideration of the Division of Audit's findings made within the
					 required time frame or, if such request for reconsideration was made and the
					 Division of Audit has issued a final revised audit report.
Code of Maine Rules › 10 - DEPARTMENT OF HEALTH AND HUMAN SERVICES › 144 - DEPARTMENT OF HEALTH AND HUMAN SERVICES - GENERAL › Chapter 101 - MAINECARE BENEFITS MANUAL (FORMERLY MAINE MEDICAL ASSISTANCE MANUAL) › Chapter III - Allowances for Services › Section 144-101-III-67 - Principles of Reimbursement for Nursing Facilities › Subsection 144-101-III-67-25 - FINAL AUDIT OF FIRST AND SUBSEQUENT PROSPECTIVE YEARS

Current through 2024-29, July 17, 2024
25.1
Principle
. All facilities
					 will be required to submit a cost report in accordance with Principle 13.2 at
					 the end of their fiscal year on cost report forms approved by the Department.
					 The Department will conduct a final audit of each facility's cost report, which
					 may consist of a full scope examination by Department personnel and which will
					 be conducted on an annual basis.
25.2 Upon final audit of a facility's cost
					 report for the first and subsequent prospective years, the Department will:
25.2.1 Determine the actual allowable fixed
					 costs incurred by the facility during the cost reporting period,
25.2.2 Determine the occupancy levels of the
					 nursing facility,
25.2.3 Determine
					 reimbursable direct care costs incurred by the facility during the reporting
					 period per Principle 22.3.4.4.
25.2.4 Determine the actual allowable routine
					 costs incurred by the facility during the cost reporting period per Principle
					 22.4.6.
25.2.5 Determine if the
					 payment criteria as described in 18.12 has been met.
25.2.6 Calculate a final rate.
25.2.7 Determine final settlement by
					 calculating the difference between the audited final rate and the interim
					 rate(s) paid to the provider times the MaineCare utilization.
Nursing facilities that transfer a cost center from one
						(1) cost component to another cost component resulting in increased MaineCare
						costs will have the affected cost components adjusted at time of audit. Upon
						final audit of a facility's cost report, the Department will calculate a final
						prospective rate and determine the lump sum settlement amount either due to or
						from the nursing facility.
The Division of Audit final audit adjustment to the
						nursing facility's annual cost report will consider the impact of days waiting
						placement as specified in the Principles of Reimbursement for Residential Care
						Facilities. Fixed cost reimbursement for the nursing facility will not be
						affected by days waiting placement reimbursement to the nursing
						facilities.
Code of Maine Rules › 10 - DEPARTMENT OF HEALTH AND HUMAN SERVICES › 144 - DEPARTMENT OF HEALTH AND HUMAN SERVICES - GENERAL › Chapter 101 - MAINECARE BENEFITS MANUAL (FORMERLY MAINE MEDICAL ASSISTANCE MANUAL) › Chapter III - Allowances for Services › Section 144-101-III-67 - Principles of Reimbursement for Nursing Facilities › Subsection 144-101-III-67-26 - SETTLEMENT OF FIXED EXPENSES

Current through 2024-29, July 17, 2024
26.1 The Department
					 will reimburse facilities for the actual allowable fixed costs which are
					 incurred during a fiscal year. Upon final audit of a facility's cost report, if
					 the Department's share of the allowable fixed costs actually incurred by the
					 facility is greater than the amount paid by the Department (the fixed cost
					 component of the final prospective rate multiplied by the number of days of
					 care provided to MaineCare beneficiaries), the difference will be paid to the
					 facility by the Department. If, the Department's appropriate share of the
					 allowable fixed costs actually incurred by a facility is less than the amount
					 paid by the Department, the difference will be paid to the Department by the
					 facility.
26.2 Federal regulations
					 state that during the first year of implementing the nursing home reform
					 requirements, the new costs that a facility must incur to comply with these
					 requirements will be treated as a fixed cost. The facility must maintain the
					 appropriate documentation in order for these costs to be identified at the time
					 of the facility's final audit.
The cost associated with meeting the Nursing Home Reform
						Act of 1987 requirements will continue to be treated as a fixed cost through
						the facility's first full fiscal year after September 30, 1991 and will not be
						included in the determination of incentive payments which the facility might be
						entitled to receive as a result of its performance during that year.
						Thereafter, the cost associated with implementing the Nursing Home Reform Act
						of 1987 will be considered in the appropriate cost component and will be added
						to the facility's final prospective rate.
Upon final audit of a facility's cost report, if the
						Department's share of the allowable OBRA costs actually incurred by the
						facility is greater than the amount paid by the Department, the Department will
						pay the facility the difference. If on the other hand, the Department's
						appropriate share of the allowable OBRA costs actually incurred by a facility
						is less than the amount paid by the Department, the difference will be paid to
						the Department by the facility.
Code of Maine Rules › 10 - DEPARTMENT OF HEALTH AND HUMAN SERVICES › 144 - DEPARTMENT OF HEALTH AND HUMAN SERVICES - GENERAL › Chapter 101 - MAINECARE BENEFITS MANUAL (FORMERLY MAINE MEDICAL ASSISTANCE MANUAL) › Chapter III - Allowances for Services › Section 144-101-III-67 - Principles of Reimbursement for Nursing Facilities › Subsection 144-101-III-67-27 - ESTABLISHMENT OF PEER GROUP

Current through 2024-29, July 17, 2024
27.1
Establishment of Peer Group
. All Nursing care facilities will be
					 included in one (1) of three (3) peer groups. Hospital based nursing facilities
					 (excluding governmental institutions) will comprise one (1) peer group,
					 non-hospital based facilities with sixty (60) or fewer beds will compose a
					 second peer group, and non-hospital based facilities with more than sixty (60)
					 beds will compose the third peer group. Please refer to Principle 1.4 for a
					 description of a hospital-affiliated nursing facility. For determining the
					 Medicare upper limit, it should be noted that the establishment of these three
					 (3) peer groups in developing a payment model is not an accepted model in
					 determining the upper limits as established by Federal Statute. The Federal
					 Statute recognizes free standing nursing facilities in determining the upper
					 limit. The upper limit for hospital-based facilities is based on one-half the
					 routine costs of freestanding facilities and one-half the costs of hospital
					 based facilities. Therefore, the appropriate Medicare upper limit test will be
					 applied to all nursing facilities.
Code of Maine Rules › 10 - DEPARTMENT OF HEALTH AND HUMAN SERVICES › 144 - DEPARTMENT OF HEALTH AND HUMAN SERVICES - GENERAL › Chapter 101 - MAINECARE BENEFITS MANUAL (FORMERLY MAINE MEDICAL ASSISTANCE MANUAL) › Chapter III - Allowances for Services › Section 144-101-III-67 - Principles of Reimbursement for Nursing Facilities › Subsection 144-101-III-67-28 - CALCULATION OF OVERPAYMENTS OR UNDERPAYMENTS

Current through 2024-29, July 17, 2024
Upon determination of the final rate as outlined in
						Principle 25 above, the Department will calculate the net amount of any
						overpayments or underpayments made to the facility.
If the Department determines that it has underpaid a
						facility, the Department will calculate the exact amount due and forward the
						result to the facility within thirty (30) days. If the Department determines
						that it has overpaid a facility, the Department will so notify the facility.
						Facilities will pay the total overpayment within sixty (60) days of the notice
						of overpayment or request the Department to reduce facility payments during the
						balance of its fiscal year by the amount of the overpayment. Facilities that do
						not notify the Department of the method by which they intend to repay the
						overpayment will, beginning sixty (60) days after their receipt of the notice
						of overpayment, have their subsequent payments from the Department reduced by
						the amount of overpayment.
If a facility appeals a determination of overpayment, the
						facility must repay within sixty (60) days of the notice of overpayment all
						portions of the determined overpayment except those that are expressly disputed
						and for which specific dollar values are identified. Repayment of each such
						specifically disputed portion and identified amount shall be stayed pending
						resolution of the dispute with respect thereto. The amount of money in dispute
						must be identified in the manner outlined in Principle 36.
The net amount of any over or underpayment made to the
						facility will be based on 1) the calculation of actual fixed expenses incurred
						in the prior year and 2) the estimated difference in amount due or paid based
						on the interim versus final prospective rate.
Code of Maine Rules › 10 - DEPARTMENT OF HEALTH AND HUMAN SERVICES › 144 - DEPARTMENT OF HEALTH AND HUMAN SERVICES - GENERAL › Chapter 101 - MAINECARE BENEFITS MANUAL (FORMERLY MAINE MEDICAL ASSISTANCE MANUAL) › Chapter III - Allowances for Services › Section 144-101-III-67 - Principles of Reimbursement for Nursing Facilities › Subsection 144-101-III-67-29 - BEDBANKING OF NURSING FACILITY BEDS

Current through 2024-29, July 17, 2024
29.1 Any
					 bed-banking request must be submitted to the Department for review by the
					 Office of Elder Services and the Office of MaineCare Services. Nursing
					 facilities are permitted to bank nursing facility beds, according to the
					 guidelines contained in Title 22, Chapter 103A, Section
					 333, providing the space left
					 vacant in the facility is not used for the creation of private rooms. In
					 addition to those guidelines, a floor plan must be submitted to the Office of
					 Aging and Disability Services that describes the intended use of the banked bed
					 spaces. This floor plan will be reviewed by the Department. Reimbursement of
					 costs associated with the banked beds will be allowed to the extent that such
					 costs have been approved by the Department. Reasons that the Department may
					 deny the space as reimbursable under these Principles includes, but is not
					 limited to, the following:
29.1.1 the use of
					 the space is not reimbursable under the criteria contained in these
					 Principles,
29.1.2 the proposed
					 purpose of the use of the space has already been designated by other space
					 within the facility and this would constitute duplication of use,
29.1.3 the proposed use of the space is not
					 deemed to be in the best interest of the physical, emotional, and safety needs
					 of the residents (In this case, a recommendation by the Department may be made
					 for an alternative use of the space).
Code of Maine Rules › 10 - DEPARTMENT OF HEALTH AND HUMAN SERVICES › 144 - DEPARTMENT OF HEALTH AND HUMAN SERVICES - GENERAL › Chapter 101 - MAINECARE BENEFITS MANUAL (FORMERLY MAINE MEDICAL ASSISTANCE MANUAL) › Chapter III - Allowances for Services › Section 144-101-III-67 - Principles of Reimbursement for Nursing Facilities › Subsection 144-101-III-67-30 - DECERTIFICATION/DELICENSING OF NURSING FACILITY BEDS

Current through 2024-29, July 17, 2024
30.1 Any
					 request for delicensing/decertification of nursing facility beds must be
					 submitted to the Department for review by Office of MaineCare Services. In
					 addition to those guidelines, a floor plan must be submitted to the Office of
					 MaineCare Services that describes the intended use, if any, of the space that
					 the beds previously occupied. This floor plan will be reviewed by the
					 Department. Reasons that the Department may deny the space as reimbursable
					 under these Principles includes, but is not limited to, the following:
30.1.1 the use of the space is not
					 reimbursable under the criteria contained in these Principles,
30.1.2 the proposed purpose of the use of the
					 space has already been designated by other space within the facility and this
					 would constitute duplication of use,
30.1.3 the proposed use of the space is not
					 deemed to be in the best interest of the physical, emotional, and safety needs
					 of the residents (In this case, a recommendation by the Department may be made
					 for an alternative use of the space).
Code of Maine Rules › 10 - DEPARTMENT OF HEALTH AND HUMAN SERVICES › 144 - DEPARTMENT OF HEALTH AND HUMAN SERVICES - GENERAL › Chapter 101 - MAINECARE BENEFITS MANUAL (FORMERLY MAINE MEDICAL ASSISTANCE MANUAL) › Chapter III - Allowances for Services › Section 144-101-III-67 - Principles of Reimbursement for Nursing Facilities › Subsection 144-101-III-67-32 - REGIONS

Current through 2024-29, July 17, 2024
The regions, for DHS analysis purposes, are:
Region I
- Cumberland County, Knox County,
						Lincoln County, Sagadahoc County, and York County.
Region II
- Androscoggin County, Franklin
						County, Kennebec County, Oxford County, and Somerset County.
Region III
- Penobscot County, Piscataquis
						County, Waldo County, Hancock County, and Washington County.
Region IV
- Aroostook
						County
Code of Maine Rules › 10 - DEPARTMENT OF HEALTH AND HUMAN SERVICES › 144 - DEPARTMENT OF HEALTH AND HUMAN SERVICES - GENERAL › Chapter 101 - MAINECARE BENEFITS MANUAL (FORMERLY MAINE MEDICAL ASSISTANCE MANUAL) › Chapter III - Allowances for Services › Section 144-101-III-67 - Principles of Reimbursement for Nursing Facilities › Subsection 144-101-III-67-33 - DAYS WAITING PLACEMENT

Current through 2024-29, July 17, 2024
Reimbursement to nursing facilities for days waiting
						placement are governed by the regulations specified in the Principles of
						Reimbursement for Residential Care Facilities.
Code of Maine Rules › 10 - DEPARTMENT OF HEALTH AND HUMAN SERVICES › 144 - DEPARTMENT OF HEALTH AND HUMAN SERVICES - GENERAL › Chapter 101 - MAINECARE BENEFITS MANUAL (FORMERLY MAINE MEDICAL ASSISTANCE MANUAL) › Chapter III - Allowances for Services › Section 144-101-III-67 - Principles of Reimbursement for Nursing Facilities › Subsection 144-101-III-67-34 - EXTRAORDINARY CIRCUMSTANCE ALLOWANCE

Current through 2024-29, July 17, 2024
Facilities which experience unforeseen and uncontrollable
						events during a year that result in unforeseen or uncontrollable increases in
						expenses may request an adjustment to a prospective rate in the form of an
						extraordinary circumstance allowance. Extraordinary circumstances include, but
						are not limited to:
* events of a catastrophic nature (fire, flood,
						etc.)
* unforeseen increase in minimum wage, Social Security,
						or employee retirement contribution expenses in lieu of social security
						expenses
* changes in the number of licensed beds
* changes in licensure or accreditation
						requirements
If the Department concludes that an extraordinary
						circumstance existed, an adjustment will be made by the Department in the form
						of a supplemental allowance.
The Department will determine from the nature of the
						extraordinary circumstance whether it would have a continuing impact and
						therefore whether the allowance should be included in the computation of the
						base rate for the succeeding year.
Code of Maine Rules › 10 - DEPARTMENT OF HEALTH AND HUMAN SERVICES › 144 - DEPARTMENT OF HEALTH AND HUMAN SERVICES - GENERAL › Chapter 101 - MAINECARE BENEFITS MANUAL (FORMERLY MAINE MEDICAL ASSISTANCE MANUAL) › Chapter III - Allowances for Services › Section 144-101-III-67 - Principles of Reimbursement for Nursing Facilities › Subsection 144-101-III-67-35 - ADJUSTMENTS

Current through 2024-29, July 17, 2024
35.1 Adjustment for Unrestricted Grants or
					 Gifts. Unrestricted Federal or State grants or gifts received by a facility and
					 which have been deducted from operating costs for purposes of reimbursement
					 will be added back to the direct resident care and routine cost component for
					 purposes of calculating a base rate.
35.2 Adjustment for Appeal Decisions. The
					 Department will adjust any interim or final prospective rate to reflect appeal
					 decisions made subsequent to the establishment of those rates.
35.3 Adjustments for Capital Costs. The
					 Department will adjust the fixed cost component of an interim or final
					 prospective rate to reflect increases or decreases in capital costs. For
					 example costs which have been approved under the Maine Certificate of Need Act
					 or refinancing.
Code of Maine Rules › 10 - DEPARTMENT OF HEALTH AND HUMAN SERVICES › 144 - DEPARTMENT OF HEALTH AND HUMAN SERVICES - GENERAL › Chapter 101 - MAINECARE BENEFITS MANUAL (FORMERLY MAINE MEDICAL ASSISTANCE MANUAL) › Chapter III - Allowances for Services › Section 144-101-III-67 - Principles of Reimbursement for Nursing Facilities › Subsection 144-101-III-67-36 - APPEAL PROCEDURES-START UP COSTS-DEFICIENCY RATE - RATE LIMITATION

Current through 2024-29, July 17, 2024
36.1
Appeal Procedures
36.1.1 A facility may administratively appeal
					 any of the following types of Division of Audit determinations:
(1) Audit Adjustment
(2) Calculation of final prospective
					 rate
(3) Adjustment of final
					 prospective rate or a refusal to make such an adjustment pursuant to these
					 Principles.
Code of Maine Rules › 10 - DEPARTMENT OF HEALTH AND HUMAN SERVICES › 144 - DEPARTMENT OF HEALTH AND HUMAN SERVICES - GENERAL › Chapter 101 - MAINECARE BENEFITS MANUAL (FORMERLY MAINE MEDICAL ASSISTANCE MANUAL) › Chapter III - Allowances for Services › Section 144-101-III-67 - Principles of Reimbursement for Nursing Facilities › Subsection 144-101-III-67-37 - DEFICIENCY PER DIEM RATE

Current through 2024-29, July 17, 2024
When a facility is found not to have provided the quality
						of service or level of care required, reimbursement will be made on ninety
						percent (90%) of the provider's per diem rate, unless otherwise specified. This
						"deficiency rate" will be applied following written notification to the
						facility of the effective date of the reduced rate for any of the following
						service deficiencies:
37.1 Staffing
					 over a period of two (2) weeks or more does not meet the Federal Certification
					 and State Licensing requirements, except where there is written documentation
					 of a good faith effort to employ licensed nurses to meet the licensed nurse
					 requirements over and above the full time director of nursing;
37.2 Food service does not meet the Federal
					 Certification and State Licensing requirements;
37.3 Specific, documented evidence that the
					 care provided does not meet the Federal Certification and State Licensing
					 requirements. Such penalty to be effective no sooner than thirty (30) days from
					 written notification that such deficiencies exist;
37.4 Failure to correct, within the time
					 frames of an accepted Plan of Correction, deficiencies in meeting the Federal
					 Certification and State Licensing requirements, which cause a threat to the
					 health and safety of residents in a facility or the surrounding
					 community;
37.5 Failure to submit a
					 cost report, financial statements, and other schedules as requested by the
					 Division of Audit and to maintain auditable records as required by these
					 Principles and other relevant regulations may result in application of the
					 deficiency per diem rate. The deficiency per diem rate for these items will go
					 into effect immediately upon receipt of written notification from the
					 Department.
Failures to correct MDS, as requested in writing, and
						submit within the specified time outlined in Principle 16.2.1 of these
						Principles of Reimbursement. A reduction in rate because of deficiencies shall
						remain in effect until the deficiencies have been corrected, as verified by
						representatives of the Department, following written notification by the
						provider that the deficiencies no longer exist. No retroactive adjustments to
						the full rate shall be made for the period that the deficiency rate is in
						effect unless the provider demonstrates to the satisfaction of the Department
						that there was no just cause for the reduction in payment.
Code of Maine Rules › 10 - DEPARTMENT OF HEALTH AND HUMAN SERVICES › 144 - DEPARTMENT OF HEALTH AND HUMAN SERVICES - GENERAL › Chapter 101 - MAINECARE BENEFITS MANUAL (FORMERLY MAINE MEDICAL ASSISTANCE MANUAL) › Chapter III - Allowances for Services › Section 144-101-III-67 - Principles of Reimbursement for Nursing Facilities › Subsection 144-101-III-67-40 - PUBLICLY OWNED NURSING FACILITIES

Current through 2024-29, July 17, 2024
40.1 For
					 publicly owned nursing facilities, as defined in Principle 1.4, the total
					 MaineCare per diem funds must not exceed the lesser of the facility's Medicaid
					 allowable costs as reflected on the Medicare cost report or the Medicare rate
					 of reimbursement. Such designated publicly owned nursing facilities shall be
					 subject to the provisions of the rules contained in the Principles of
					 Reimbursement for Nursing Facilities.
Code of Maine Rules › 10 - DEPARTMENT OF HEALTH AND HUMAN SERVICES › 144 - DEPARTMENT OF HEALTH AND HUMAN SERVICES - GENERAL › Chapter 101 - MAINECARE BENEFITS MANUAL (FORMERLY MAINE MEDICAL ASSISTANCE MANUAL) › Chapter III - Allowances for Services › Section 144-101-III-67 - Principles of Reimbursement for Nursing Facilities › Subsection 144-101-III-67-41 - REMOTE ISLAND NURSING FACILITIES

Current through 2024-29, July 17, 2024
41.1 *In
					 order to qualify as a remote island nursing facility, a nursing facility must
					 meet all of the following criteria:
1. The
					 nursing facility must be located on an island, and
2. must have less than 30 licensed NF beds,
					 and
3. must not be physically
					 located within a hospital, and
4.
					 must not have any licensed residential care beds.
*The Department shall submit to CMS and anticipates
						approval for a State Plan Amendment related to this
						provision.
Code of Maine Rules › 10 - DEPARTMENT OF HEALTH AND HUMAN SERVICES › 144 - DEPARTMENT OF HEALTH AND HUMAN SERVICES - GENERAL › Chapter 101 - MAINECARE BENEFITS MANUAL (FORMERLY MAINE MEDICAL ASSISTANCE MANUAL) › Chapter III - Allowances for Services › Section 144-101-III-67 - Principles of Reimbursement for Nursing Facilities › Subsection 144-101-III-67-42 - VENTILATOR CARE SERVICES

Current through 2024-29, July 17, 2024
In order for a nursing facility to receive additional
						reimbursement for ventilator care, a nursing facility must meet all of the
						following criteria:
1. The nursing
					 facility must supply their own ventilators; and
2. The nursing facility must employ or
					 contract with a pulmonologist or other health care professional trained in
					 respiratory therapy; and
3. The
					 nursing facility must have the required additional staffing to meet the needs
					 of ventilator dependent members.
Principle
. A nursing facility with
						qualifying ventilator care services under this section will be reimbursed for
						the additional care associated with members receiving ventilator care through a
						prior authorization from the Department using CPT code 94004. Prior
						authorization for these services will state what is included in the custom
						reimbursement rate.
Rate setting
. Qualified providers must
						receive a prior authorization from the Department to bill for Ventilator
						Services.
Audit.
The additional ventilator care add-on
						will be considered an ancillary service. All costs including general &
						administrative costs associated with the provision of ventilator care services
						will be considered ancillary costs and will not be cost settled. Any capital
						costs that are incurred as a result of the development of a vent unit or due to
						the admission of a vent patient will also be considered ancillary costs that
						are not reimbursable during cost settlement.
Code of Maine Rules › 10 - DEPARTMENT OF HEALTH AND HUMAN SERVICES › 144 - DEPARTMENT OF HEALTH AND HUMAN SERVICES - GENERAL › Chapter 101 - MAINECARE BENEFITS MANUAL (FORMERLY MAINE MEDICAL ASSISTANCE MANUAL) › Chapter III - Allowances for Services › Section 144-101-III-67 - Principles of Reimbursement for Nursing Facilities › Subsection 144-101-III-67-43 - SPECIAL WAGE ALLOWANCE FOR FISCAL YEAR 2018-19

Current through 2024-29, July 17, 2024
For the state fiscal year ending June 30, 2019, a special
						wage allowance shall be made to provide for increases in wages and wage-related
						benefits in both the direct care cost component and routine care cost component
						as follows. The allocated amount, equal to ten percent (10%), of all allowable
						wages and associated benefits and taxes, does not include contract labor, as
						reported on each facility's cost report for its fiscal year ending in calendar
						year 2016 and shall be added to the cost per resident day in calculating each
						facility's prospective rate, notwithstanding any otherwise applicable caps or
						limits on reimbursement. This special wage allowance shall be allowed and paid
						at final audit to the full extent that it does not cause reimbursement to
						exceed the facility's allowable costs in that fiscal year.
Providers must ensure that the increase in reimbursement
						rates effective August 2, 2018 is applied in full to wages and benefits for
						employees who provide direct services. Providers must document compliance with
						this requirement in their financial records and provide such documentation to
						the Department upon request.
Code of Maine Rules › 10 - DEPARTMENT OF HEALTH AND HUMAN SERVICES › 144 - DEPARTMENT OF HEALTH AND HUMAN SERVICES - GENERAL › Chapter 101 - MAINECARE BENEFITS MANUAL (FORMERLY MAINE MEDICAL ASSISTANCE MANUAL) › Chapter III - Allowances for Services › Section 144-101-III-67 - Principles of Reimbursement for Nursing Facilities › Subsection 144-101-III-67-44 - SPECIAL WAGE ALLOWANCES FOR JANUARY 1, 2020 - JUNE 30, 2021 AND JANUARY 1, 2022 - JUNE 30, 2022

Current through 2024-29, July 17, 2024
44.1 A special wage
					 allowance shall be made to provide for increases in wages and wage-related
					 benefits in both the direct care cost component and routine care cost component
					 as follows:
The allocated amount, up to ten percent (10%), of all
						allowable wages and associated benefits and taxes, not including contract
						labor, as reported on each facility's cost report for its fiscal year ending in
						calendar year 2016 for the period of January 1, 2020-June 30, 2021, and the
						facility's cost report for its fiscal year ending in calendar year 2020 for the
						period of January 1, 2022-June 30, 2022, and shall be added to the cost per
						resident day in calculating each facility's prospective rate, notwithstanding
						any otherwise applicable caps or limits on reimbursement. This special wage
						allowance shall be allowed and paid at final audit to the full extent that it
						does not cause reimbursement to exceed the facility's allowable costs in that
						fiscal year.
44.2 A special
					 wage allowance shall be made to provide for increases in contract labor in both
					 the direct care cost component and routine care cost component as follows. The
					 allocated amount, up to ten percent (10%), of all allowable contract labor as
					 reported on each facility's cost report for its fiscal year ending in calendar
					 year 2017 and shall be added to the cost per resident day in calculating each
					 facility's prospective rate, notwithstanding any otherwise applicable caps or
					 limits on reimbursement. This special wage allowance shall be allowed and paid
					 at final audit to the full extent that it does not cause reimbursement to
					 exceed the facility's allowable costs in that fiscal year.
44.3
January 1 through June 30,
					 2022
: The Special Wage Allowance for the period January 1 through
					 June 30, 2022 is authorized for reimbursement under Principle 34 (Extraordinary
					 Circumstance Allowance).
Code of Maine Rules › 10 - DEPARTMENT OF HEALTH AND HUMAN SERVICES › 144 - DEPARTMENT OF HEALTH AND HUMAN SERVICES - GENERAL › Chapter 101 - MAINECARE BENEFITS MANUAL (FORMERLY MAINE MEDICAL ASSISTANCE MANUAL) › Chapter III - Allowances for Services › Section 144-101-III-91 - Health Home Services

Current through 2024-29, July 17, 2024
Community Care Teams
Community Care Teams will be reimbursed at a rate of
					 $129.50 per member per Billing Month.
Home Outreach and Member Engagement Providers (HOME
					 Providers)
HOME Providers will be reimbursed at the following
					 rates:
Intensive Tier: $835.53 per member per Billing
						Month
										Stabilization Tier: $484.30 per member per Billing
						Month
										Maintenance Tier: $260.11 per member per Billing
						Month
Code of Maine Rules › 10 - DEPARTMENT OF HEALTH AND HUMAN SERVICES › 144 - DEPARTMENT OF HEALTH AND HUMAN SERVICES - GENERAL › Chapter 101 - MAINECARE BENEFITS MANUAL (FORMERLY MAINE MEDICAL ASSISTANCE MANUAL) › Chapter III - Allowances for Services › Section 144-101-III-97 - Private Non-Medical Institution Services › Subsection 144-101-III-97-1000 - PURPOSE

Current through 2024-29, July 17, 2024
The purpose of these regulations is to define which
						items of expense will be taken into account and which will be excluded in the
						calculation of reasonable costs for Private Non-Medical Institutions. These
						Principles of Reimbursement for Private Non-Medical Institutions identify which
						costs are reimbursed under Chapter II, Section 97 - Private Non-Medical
						Institution (herein after, PNMI) Services of the
MaineCare Benefits
						Manual
. The Department will consider allowable costs identified by
						these Principles for reimbursement of services in a children's residential care
						facility, substance use disorder treatment facility, and community residences
						for persons with mental illness (for those facilities covered under Appendices
						B, D, and E) on the first day of the provider's fiscal year beginning on or
						after July 1, 2001. The Department will consider allowable costs identified by
						these Principles of Reimbursement for Private Non-Medical Institution medical
						and remedial facility services (under Appendices C and F) rendered on or after
						July 1, 2001. Prior to July 1, 2001, PNMI services rendered in a medical and
						remedial facility and non-case mixed medical and remedial facility shall follow
						the applicable appendix in effect prior to July 1, 2001, and the Principles of
						Reimbursement for Residential Care Facilities- Room and Board Costs.
Code of Maine Rules › 10 - DEPARTMENT OF HEALTH AND HUMAN SERVICES › 144 - DEPARTMENT OF HEALTH AND HUMAN SERVICES - GENERAL › Chapter 101 - MAINECARE BENEFITS MANUAL (FORMERLY MAINE MEDICAL ASSISTANCE MANUAL) › Chapter III - Allowances for Services › Section 144-101-III-97 - Private Non-Medical Institution Services › Subsection 144-101-III-97-1100 - SCOPE/AUTHORITY

Current through 2024-29, July 17, 2024
These Principles define scope and authority within the
						specific Appendix applicable to that type of Private Non-Medical Institution.
						These Principles define Department and member/resident in Section 10000 of this
						policy. These Principles define facility in each specific Appendix.
Code of Maine Rules › 10 - DEPARTMENT OF HEALTH AND HUMAN SERVICES › 144 - DEPARTMENT OF HEALTH AND HUMAN SERVICES - GENERAL › Chapter 101 - MAINECARE BENEFITS MANUAL (FORMERLY MAINE MEDICAL ASSISTANCE MANUAL) › Chapter III - Allowances for Services › Section 144-101-III-97 - Private Non-Medical Institution Services › Subsection 144-101-III-97-1300 - ADULT FAMILY CARE HOMES

Current through 2024-29, July 17, 2024
1300.1 The
					 Department does not use these PNMI Principles in the determination of
					 reimbursable amount paid to Adult Family Care Homes.
Code of Maine Rules › 10 - DEPARTMENT OF HEALTH AND HUMAN SERVICES › 144 - DEPARTMENT OF HEALTH AND HUMAN SERVICES - GENERAL › Chapter 101 - MAINECARE BENEFITS MANUAL (FORMERLY MAINE MEDICAL ASSISTANCE MANUAL) › Chapter III - Allowances for Services › Section 144-101-III-97 - Private Non-Medical Institution Services › Subsection 144-101-III-97-1400 - REQUIREMENTS FOR MAINECARE REIMBURSEMENT

Current through 2024-29, July 17, 2024
1400.1 In
					 order to be reimbursed, all PNMIs identified as children's residential care,
					 substance use treatment, community residences for persons with mental illness,
					 and Appendix F scattered site PNMIs for people for intellectual disabilities
					 must be licensed as applicable, in accordance with the Mental Health Agency
					 Licensing Standards and Rights of Recipients of Mental Health Services,
					 Regulations for Licensing and Certification of Alcohol and Drug treatment
					 Services, or Rules for the Licensure of Residential Child Care
					 Facilities/Rights of Recipients of Mental Health Services Who are Children in
					 Need of Treatment. In order to be reimbursed, medical and remedial service
					 PNMIs and non-case mixed must be licensed by the Division of Licensing and
					 Certification in the Department of Health and Human Services (See 10-149 C.M.R.
					 , Ch. 113). Appendix F, scattered site PNMIs for persons with intellectual
					 disabilities, may be licensed as either a residential care facility or as a
					 mental health provider in accordance with the Mental Health Agency Licensing
					 Standards and Rights of Recipients of Mental Health Services, Regulations for
					 Licensing and Certification of Alcohol and Drug treatment services.
1400.2 All PNMIs must obtain licensure and a
					 signed Provider/Supplier Enrollment Agreement with the Department of Health and
					 Human Services, Office of MaineCare Services (OMS). Providers must submit a
					 copy of the license accompanying the Provider/Supplier Enrollment Agreement to
					 the Department.
1400.3 Types of
					 PNMIs considered for MaineCare reimbursement, subject to the availability of
					 funds, include:
1400.3.1 Facilities providing
					 Private Non-Medical Institution services to members with significant mental or
					 physical disability requiring structured, individualized habilitative or
					 rehabilitative in-home programming as outlined in the provider agreement with
					 the PNMI.
1400.3.2 Facilities with
					 licensed Private Non-Medical Institution beds at scattered locations serving a
					 minimum of four eligible members, as long as the service provided consistently
					 fits within the definition of the applicable appendix stated below.
Appendix B Substance Use Treatment Facilities
Appendix D Children's Residential Care Facilities
Appendix F Non-Case Mixed Medical and Remedial
						PNMIs
Code of Maine Rules › 10 - DEPARTMENT OF HEALTH AND HUMAN SERVICES › 144 - DEPARTMENT OF HEALTH AND HUMAN SERVICES - GENERAL › Chapter 101 - MAINECARE BENEFITS MANUAL (FORMERLY MAINE MEDICAL ASSISTANCE MANUAL) › Chapter III - Allowances for Services › Section 144-101-III-97 - Private Non-Medical Institution Services › Subsection 144-101-III-97-1500 - RESPONSIBILITIES OF OWNERS OR OPERATORS

Current through 2024-29, July 17, 2024
The owners or operators of a Private Non-Medical
						Institution must prudently manage and operate a PNMI of adequate quality to
						meet its residents' needs. Neither the issuance of a per diem rate, nor final
						orders made by the Commissioner, nor a duly authorized representative may in
						any way relieve the owner or operator of a PNMI from full responsibility for
						compliance with the requirements and standards of the Department or Federal
						requirements and standards.