Iowa Administrative Code › Agency 441 - Human Services Department › Title VIII - Medical Assistance › Chapter 81 - Nursing Facilities › Rule 441-81.10 - Payment Procedures

Current through Register Vol. 47, No. 3, July 24, 2024
(1)
Method of payment.
Except for Medicaid accountability measures
				payment established in paragraph 81.6(16)
"g,"
facilities shall
				be reimbursed under a modified price-based vendor payment program. A per diem
				rate shall be established based on information submitted according to rule
				441-81.6 (249A). Effective July
				1, 2002, the per diem rate shall include an amount for Medicaid accountability
				measures.
(2)
Authorization
				of payment.
The department shall authorize payment for care in a
				facility. The authorization shall be obtained prior to admission of the
				resident, whenever possible. For a nursing facility to be eligible for Medicaid
				payment for a resident, the facility must, when applicable, exhaust all
				Medicare benefits.
(3) Rescinded
				IAB 8/9/89, effective 10/1/89.
(4)
Periods authorized for payment.
a. Payment shall be made on a per diem basis
				for the portion of the month the resident is in the facility.
b. Payment will be authorized as long as the
				resident is certified as needing care in a nursing facility.
c. Payment will be approved for the day of
				admission but not the day of discharge or death.
d. Payment will be approved for periods the
				resident is absent overnight for purpose of visitation or vacation. The
				facility will be paid to hold the bed for a period not to exceed 18 days in any
				calendar year. Additional days shall be based upon a recommendation by the
				resident's physician in the plan of care that additional days would be
				rehabilitative.
e. Payment will be
				approved for a period not to exceed 10 days in any calendar month when the
				resident is absent due to hospitalization. Medicaid payment to the facility may
				not be initiated while a resident is on reserve bed days unless the person was
				residing in the facility as a private pay resident prior to the hospitalization
				and returns to the facility as a resident.
f. Payment for periods when residents are
				absent for a visit, vacation, or hospitalization shall be made at zero percent
				of the nursing facility's rate, except for special population facilities and
				state-operated nursing facilities, which shall be paid for such periods at 42
				percent of the facility's rate.
g.
				Payment for residents determined by utilization review to require the
				residential level of care shall be made at the maximum state supplementary
				assistance rate. This rate is effective as of the date of final notice by
				utilization review that the lower level of care is required.
h. Ventilator patients.
(1) Definition. For purposes of this
				paragraph only, "ventilator patients" means Medicaid-eligible patients who, as
				determined by the quality improvement organization, require a ventilator at
				least six hours every day, are inappropriate for home care, and have medical
				needs that require skilled care.
(2) Reimbursement. In-state nursing
				facilities shall receive reimbursement for care of ventilator patients equal to
				the sum of the Medicare-certified hospital-based nursing facility rate plus the
				Medicare-certified hospital-based nursing facility non-direct care rate
				component as defined in subparagraph 81.6(16)
"f"
(3).
				Facilities may continue to receive this reimbursement at this rate for 30 days
				after a ventilator patient is weaned from a ventilator if, during the 30 days,
				the patient continues to reside in the facility and continues to meet skilled
				care criteria.
i.
				Payment for residents of a special population facility licensed by the
				department of inspections and appeals as an intermediate care facility for
				persons with mental illness will be made only when the resident is aged 65 or
				over. If a resident under the age of 65 is admitted with a payment source other
				than Medicaid, the facility shall notify the resident, or when applicable the
				resident's guardian or legal representative, that Iowa Medicaid may neither
				make payment to the facility nor make payment for any other services rendered
				by any provider while the person resides in the facility, until the resident
				attains the age of 65.
j.
				Nonpayment for provider-preventable conditions. Reimbursement will not be made
				for patient days attributable to preventable conditions identified pursuant to
				this rule that develop in a nursing facility. Any patient days attributable to
				a provider-preventable condition must be billed as noncovered days. A
				provider-preventable condition is one in which any of the following occur:
(1) The wrong surgical or other invasive
				procedure is performed on a resident; or
(2) A surgical or other invasive procedure is
				performed on the wrong body part; or
(3) A surgical or other invasive procedure is
				performed on the wrong resident.