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 II - Specific Policies By Service › Section 144-101-II-67 - Nursing Facility Services › Subsection 144-101-II-67.04 - STANDARDS OF CARE

Current through 2024-29, July 17, 2024
All nursing facilities must meet the following standards
						to qualify for MaineCare reimbursement:
67.04-1
General Regulatory
					 Compliance
A. In order to qualify for
					 reimbursement under this Section, NFs, including those operated by the State of
					 Maine, must meet the requirements contained in the Regulations Governing the
					 Licensing and Functioning of Skilled Nursing Facilities and Nursing Facilities
					 as are currently in effect. NFs must also comply with the Principles of
					 Reimbursement for Nursing Facilities; and all requirements of Title XIX of the
					 Social Security Act and the CFR, Subpart B, Requirements for Long Term Care
					 Facilities, 42 CFR 483 issued pursuant thereto, as are most currently in
					 effect. These standards are incorporated into this Section by reference as if
					 set out fully herein.
B. All NFs
					 including those operated by the State of Maine, must obtain a license from the
					 Department of Health and Human Services in order to qualify for Title XIX
					 reimbursement. However, the license shall not be considered valid evidence that
					 the facility meets all requirements for certification under MaineCare
					 regulations if the Secretary of Health and Human Services has established, on
					 the basis of an on-site monitoring survey or other federal review, that the
					 Department's certification agency has failed to properly apply Federal
					 certification standards or procedures.
C. Each NF must obtain Medicare certification
					 for a minimum of twenty percent (20%) of its licensed bed capacity.
					 Additionally, any NF that participates in the MaineCare program must follow
					 required Federal procedures for certification and become certified following
					 the Department's recommendation for certification; submit an annual application
					 for Medicare participation at the same time applications for licenses and
					 MaineCare certification are due; and participate in the Medicare program by
					 billing Medicare for care provided to eligible members prior to billing
					 MaineCare.
D. Sanctions. Failure to
					 comply with any of the provisions in Section 67.04-1(C) may result in the
					 imposition of a penalty of one hundred dollars ($100) per bed. This penalty
					 must be imposed for each day a NF fails to comply with the requirement that the
					 NF participate in the Medicare program by billing Medicare for care provided to
					 eligible members prior to billing MaineCare. A repeated failure to comply with
					 any provision in Section 67.04-1(C) will result in fines of two hundred dollars
					 ($200) per bed. The imposition and collection of these sanctions are governed
					 by 22 M.R.S.A. §7946.
E. In
					 order to qualify for reimbursement for laboratory services by nursing
					 facilities, those laboratory services must be in compliance with the rules
					 implementing the Clinical Laboratory Improvement Amendments (CLIA) of 1988, and
					 any amendments thereto, or otherwise have a waiver. CLIA regulations are
					 located at following website:http://www.phppo.cdc.gov/clia/regs/toc.aspx [File
					 Link Not Available].