Code of Maine Rules › 10 - DEPARTMENT OF HEALTH AND HUMAN SERVICES › 144 - DEPARTMENT OF HEALTH AND HUMAN SERVICES - GENERAL › Chapter 115 - PRINCIPLES OF REIMBURSEMENT FOR RESIDENTIAL CARE FACILITIES - ROOM AND BOARD COSTS › Section 144-115-17 - COST RELATED TO CARE OF MEMBERS

Current through 2024-29, July 17, 2024
17.1
Principle
Reimbursement for specified room and board costs shall be
				  proided on a "reasonable cost-related basis" rather than by simply reimbursing
				  the provider's costs. In determining what is a reasonable cost-related basis,
				  all payments must relate to the care of the member and be based on the
				  "reasonable cost." Reasonable costs include all allowable, necessary, and
				  proper costs incurred in rendering room and board to members who are receiving
				  Medical and Remedial Services under the MaineCare program, subject to the
				  Principles relating to specific items of revenue and cost. Costs may not be
				  shifted from Medical and Remedial Services to room and board.
17.1.1 Costs must be ordinary and necessary
				and related to member services. They must be of the nature and magnitude that
				prudent and cost conscious management would pay for a specific item or
				service.
17.1.2 Costs must not be
				of the type conceived for the purpose of circumventing the regulations. Such
				costs will be disallowed under the principle that the substance of any
				transaction will prevail over form.
17.1.3 Costs that relate to inefficient,
				unnecessary or luxurious care of facilities (as defined by the
Medicare
				Provider Reimbursement Manual
, HIM-15), and to activities not common
				and accepted in the residential care field are not allowable.
17.1.4 Compensation, to be allowable, must be
				reasonable and for services that are necessary, and pertinent to the operation
				of the facility. The services must actually be performed and must be paid in
				full. The compensation must be reported to all appropriate state and federal
				tax authorities to the extent required by law for income tax, social security,
				and unemployment insurance purposes.
Reimbursement may not be claimed for personal expenses of
				  the provider not related to member care. Bonuses that are part of a written
				  policy of the provider and that require some measurable and attainable employee
				  job performance expectations are allowable. Bonuses based solely on the
				  availability of any anticipated savings are not allowable.
17.1.5 Costs incurred for room and board that
				are rendered in common to eligible members, as well as to ineligible members,
				will be allowed on a pro rata basis, unless there is a specific allocation
				defined elsewhere in these Principles.
17.1.6 Effective November 1, 2017, costs
				incurred by a residential care facility to comply with changes in federal or
				state laws, regulations, and rules or local ordinances and not otherwise
				specified in rules adopted by the Department are considered reasonable and
				necessary costs. Reimbursement for these additional regulatory costs will be
				paid via a supplemental payment that is added to the per diem rate until the
				Department adjusts for the routine limit, as applicable, to fairly and properly
				reimburse facilities for these costs.
Requests for rate adjustments must be made in writing and
				  addressed to:
Director of Rate-Setting
11 State House Station
Augusta, ME 04333
The Department may deny or modify the adjustment request
				  based on documentation provided and will provide written notification of
				  adjustment request determination.