reglab/statecodes huggingface dataset:
Nebraska Administrative Code › Topic - HEALTH AND HUMAN SERVICES SYSTEM › Title 471 - NEBRASKA MEDICAL ASSISTANCE PROGRAM SERVICES › Chapter 39 - NEBRASKA ALTERNATIVE BENEFIT PLANS (ABP) › Section 471-39-003 - BENEFIT PLAN AND SERVICES

Current through June 17, 2024
003.01
NEBRASKA ALTERNATIVE BENEFIT PLAN.
The Nebraska
  Alternative Benefit Plan offers all services as described in the Title XIX Plan
  and listed in 471 NAC 1.
003.01(A)
NEBRASKA ALTERNATIVE BENEFIT PLAN SERVICES.
For the purposes of the Nebraska Alternative Benefit Plan, these
	 services are grouped as follows;
(i)
  Ambulatory patient services as set forth in 471 NAC 5, 9, 10, 18, 26, 36, and
  34;
(ii) Emergency services as set
  forth in 471 NAC 4 and 10;
(iii)
  Hospitalization as set forth in 471 NAC 10;
(iv) Maternity and newborn care as set forth
  in 471 NAC 9, 10, 18, 26, 34, 36, and 42;
(v) Mental health and substance use disorder
  services as set forth in 471 NAC 9, 10, 18, 20, 26, 34, 35, and 36;
(vi) Prescription drugs/pharmacy as set forth
  in 471 NAC 16;
(vii) Rehabilitative
  and habilitative services and devices as set forth in 471 NAC 7, 9, 14, 21, and
  23;
(viii) Laboratory services as
  set forth in 471 NAC 10;
(ix)
  Preventative and wellness services and chronic disease management as set forth
  in 471 NAC 10, 18, and 33;
(x)
  Early periodic screening, diagnosis, and treatment (EPSDT) as set forth in 471
  NAC 33;
(xi) Other services as
  follows;
(1) Rural Health Clinic as set forth
  in 471 NAC 34;
(2) Federally
  Qualified Health Center (FQHC) as set forth in 471 NAC 29;
(3) Certified pediatric & family nurse
  practitioner services as set forth in 471 NAC 10;
(4) Podiatrists' services as set forth in 471
  NAC 19;
(5) Case management as set
  forth in 477 NAC 4;
(6) Inpatient
  psychiatric services under age 21 as set forth in 471 NAC 20;
(7) Telehealth as set forth in Title 471
  NAC;
(8) Non-emergency
  transportation as set forth in 471 NAC 27;
(9) Respiratory care services as set forth in
  471 NAC 22;
(10) Abortion services
  as set forth in 471 NAC 10 and 18;
(11) Family planning services and supplies as
  set forth in 471 NAC 10 and 18;
(12) Critical care hospital as set forth in
  471 NAC 10;
(13) Intermediate care
  facility services as set forth in 471 NAC 12;
(14) Program or All-Inclusive Care (PACE)
  services as set forth in 471 NAC 37;
(15) Long term nursing facility services as
  set forth in 471 NAC 12;
(16) 915
  (C) Home and Community Based Services (HCBS) waivers as set forth in Title 480
  NAC;
(17) Personal assistance
  services as set forth in 471 NAC 15;
(18) Private duty nursing services as set
  forth in 471 NAC 13;
(19)
  Medically-monitored inpatient withdraw management as set forth in 471 NAC
  20;
(20) Opioid treatment program
  as set forth in 471 NAC 20;
(21)
  Dental services as set forth in 471 NAC 6;
(22) Dentures as set forth in 471 NAC
  6;
(23) Optometrists' services as
  set forth in 471 NAC 24;
(24)
  Eyeglasses as set forth in 471 NAC 24; and
(25) Over-the-counter (OTC) pharmacy services
  as set forth in 471 NAC 16.
Nebraska Administrative Code › Topic - HEALTH AND HUMAN SERVICES SYSTEM › Title 471 - NEBRASKA MEDICAL ASSISTANCE PROGRAM SERVICES › Chapter 39 - NEBRASKA ALTERNATIVE BENEFIT PLANS (ABP) › Section 471-39-004 - PARTICIPATION IN THE HEALTH INSURANCE PREMIUM PAYMENT (HIPP) PROGRAM

Current through June 17, 2024
Clients eligible to receive benefits under the Heritage Health Adult
	 (HHA) program may voluntarily participate in the Health Insurance Premium
	 Payment (HIPP) program as described in 471 NAC 30.
Nebraska Administrative Code › Topic - HEALTH AND HUMAN SERVICES SYSTEM › Title 471 - NEBRASKA MEDICAL ASSISTANCE PROGRAM SERVICES › Chapter 39 - NEBRASKA ALTERNATIVE BENEFIT PLANS (ABP) › Section 471-39-005 - COPAYMENTS

Current through June 17, 2024
Clients receiving services through the Heritage Health Adult (HHA)
	 program will be subject to copayment requirements as described in 471 NAC
	 3-008.01.
Nebraska Administrative Code › Topic - HEALTH AND HUMAN SERVICES SYSTEM › Title 471 - NEBRASKA MEDICAL ASSISTANCE PROGRAM SERVICES › Chapter 42 - FREESTANDING BIRTH CENTERS › Section 471-42-001 - STANDARDS FOR PARTICIPATION

Current through June 17, 2024
Medicaid covers facility services provided by non-hospital freestanding
	 birth centers. To participate in Medicaid, a freestanding birth center
	 must:
1. Be licensed by the Department
  of Health and Human Services, Division of Public Health, as a facility
  providing labor and delivery services and not licensed as another type of
  health care facility and maintain standards of care required by the Department
  of Health and Human Services, Division of Public Health for
  licensure.
2. The center must have
  a written agreement for emergency care with a hospital that provides
  obstetrical services or each medical practitioner practicing at the facility
  must have admitting privileges at a transferring hospital.
3. Admissions to the facility must be
  restricted to uncomplicated (low-risk) patients. Planned caesarean section
  procedures are prohibited.
4. Each
  mother and newborn must be discharged within 24 hours after admission, in a
  condition which will allow or not endanger the well-being of either. If the
  condition of mother or newborn does not allow discharge within 24 hours, then
  transfer to a hospital must occur.
5. The birth center must be enrolled and
  approved by the Department or its designee for participation in
  Medicaid.
6. The birth attendant
  must be licensed at the time and place the services are provided and must be
  enrolled and approved by the Department or its designee for participation in
  Medicaid.
001.01 Definition of a
  Freestanding Birth Center
A Freestanding Birth Center means a health facility-
1. That is not a hospital;
2. Where childbirth is planned to occur away
  from the pregnant woman's residence;
3. That is licensed or otherwise approved by
  the State to provide prenatal labor and delivery or postpartum care and other
  ambulatory services; and
4. That
  complies with such other requirements relating to the health and safety of
  individuals furnished services by the facility as the State shall
  establish.
Nebraska Administrative Code › Topic - HEALTH AND HUMAN SERVICES SYSTEM › Title 471 - NEBRASKA MEDICAL ASSISTANCE PROGRAM SERVICES › Chapter 42 - FREESTANDING BIRTH CENTERS › Section 471-42-002 - COVERED BIRTH CENTER FACILITY SERVICES

Current through June 17, 2024
Coverage of birth center facility services is limited to certain birth
	 services provided by the center and determined by the birth attendant to be
	 necessary for the care of the mother and live newborn child following the
	 mother's normal, uncomplicated pregnancy. Reimbursable services are limited to
	 facility services provided during the labor and delivery. These items and
	 services are those that would otherwise be covered by Medicaid if provided on
	 an inpatient or outpatient basis in a hospital in connection with the services
	 provided by the center. Birth center facility services furnished prior to or
	 after the above described period are not considered birth center facility
	 services and are not covered or reimbursed.
Services provided by the birth attendant are not considered to be birth
	 center facility services. The fee for the birth center facility services does
	 not include payment for medical or other health services such as the birth
	 attendant's services.
Nebraska Administrative Code › Topic - HEALTH AND HUMAN SERVICES SYSTEM › Title 471 - NEBRASKA MEDICAL ASSISTANCE PROGRAM SERVICES › Chapter 42 - FREESTANDING BIRTH CENTERS › Section 471-42-004 - BILLING REQUIREMENTS

Current through June 17, 2024
004.01 Required Forms
When billing Medicaid, the Birth Center must submit using the paper
	 Form CMS-1500 or the standard electronic Health Care Claim: Professional
	 transaction (ASC X12N 837) (see Claim Submission Table at
	 471-000-49).
004.02
  Procedure Codes
To bill the Birth Center facility fee, the Birth Center must use the
	 appropriate HCPCS/CPT procedure codes. Birth Centers may only be reimbursed by
	 Medicaid for their facility labor and delivery services. Birth attendants'
	 services or other services not directly related to the labor and delivery
	 services, along with prenatal or family planning services in the birth center
	 setting must be submitted on separate claims. Claims for non-facility services
	 need to be submitted utilizing the appropriate HCPCS/CPT procedure codes on the
	 paper Form CMS-1500 or the standard electronic Health Care Claim: Professional
	 transaction (ASC X12N 837).
Nebraska Administrative Code › Topic - HEALTH AND HUMAN SERVICES SYSTEM › Title 471 - NEBRASKA MEDICAL ASSISTANCE PROGRAM SERVICES › Chapter 42 - FREESTANDING BIRTH CENTERS › Section 471-42-005 - PAYMENT FOR BIRTH CENTER SERVICES

Current through June 17, 2024
005.01 Fee for Birth Center Facility Services
Birth Centers may only be reimbursed for facility labor and delivery
	 services. The department will establish maximum reimbursement fees for birth
	 center services based upon the average of published rates from the State
	 Medicaid Programs of other states that have published rates for such services.
	 Rates may also be adjusted in accordance with legislative appropriations or
	 budget directives from the Nebraska Legislature, which may result in Medicaid
	 payment rate increases or decreases.
005.02 Payment for Services Not Included in
  the Birth Center Facility Services Fee
The fee for facility services does not include payment for birth
	 attendants' services or other services not directly related to the labor and
	 delivery services.
Nebraska Administrative Code › Topic - HEALTH AND HUMAN SERVICES SYSTEM › Title 471 - NEBRASKA MEDICAL ASSISTANCE PROGRAM SERVICES › Chapter 43 - NURSING FACILITY LEVEL OF CARE DETERMINATION FOR CHILDREN › Section 471-43-001 - SCOPE AND AUTHORITY

Current through June 17, 2024
The regulations govern the services provided under Nebraska's Medicaid
	 program as defined by Nebraska Revised Statute (Neb. Rev. Stat.) §§
									68-901
	 et seg. (the Medical Assistance Act).
Nebraska Administrative Code › Topic - HEALTH AND HUMAN SERVICES SYSTEM › Title 471 - NEBRASKA MEDICAL ASSISTANCE PROGRAM SERVICES › Chapter 44 - NURSING FACILITY LEVEL OF CARE DETERMINATION FOR ADULTS › Section 471-44-001 - SCOPE AND AUTHORITY

Current through June 17, 2024
The regulations govern the services provided under Nebraska's Medicaid
	 program as defined by Nebraska Revised Statute (Neb. Rev. Stat.) §
									68-901 et seq. (the Medical
	 Assistance Act).
Nebraska Administrative Code › Topic - HEALTH AND HUMAN SERVICES SYSTEM › Title 471 - NEBRASKA MEDICAL ASSISTANCE PROGRAM SERVICES › Chapter 45 - RATES FOR NURSING FACILITY SERVICES › Section 471-45-001 - SCOPE AND AUTHORITY

Current through June 17, 2024
The regulations govern the services provided under Nebraska's Medicaid
	 program as defined by Nebraska Revised Statute (Neb. Rev. Stat.) §§
									68-901 et seq. (the Medical
	 Assistance Act).
Nebraska Administrative Code › Topic - HEALTH AND HUMAN SERVICES SYSTEM › Title 471 - NEBRASKA MEDICAL ASSISTANCE PROGRAM SERVICES › Chapter 45 - RATES FOR NURSING FACILITY SERVICES › Section 471-45-003 - GENERAL INFORMATION

Current through June 17, 2024
Wherever applicable, the principles of reimbursement for provider's
	 cost and the related policies under which the Medicare extended care facility
	 program functions Medicare's Provider Reimbursement Manual, HIM-15, updated by
	 provider reimbursement manual revisions in effect as of the beginning of each
	 applicable cost report period are used in determining the cost for Nebraska
	 nursing facilities with exceptions noted in this section. Chapter 15, Change of
	 Ownership, of HIM-15 is excluded in its entirety. That portion of a provider's
	 allowable cost for the treatment of Medicaid patients is payable under Medicaid
	 except as limited in this section. The aggregate payments by the Department do
	 not exceed amounts which would be paid under Title XVIII principles of
	 reimbursement for extended care facilities. Except for Indian Health Services
	 nursing facility providers, a provider with 1,000 or fewer Medicaid inpatient
	 days during a complete fiscal year report period will not file a cost
	 report.
Nebraska Administrative Code › Topic - HEALTH AND HUMAN SERVICES SYSTEM › Title 471 - NEBRASKA MEDICAL ASSISTANCE PROGRAM SERVICES › Chapter 45 - RATES FOR NURSING FACILITY SERVICES › Section 471-45-004 - ALLOWABLE COSTS

Current through June 17, 2024
The following items are allowable costs under Medicaid:
004.01
COST OF MEETING LICENSURE
  AND CERTIFICATION STANDARDS.
Allowable costs for meeting licensure
  and certification standards are those costs incurred in order to:
(A) Meet the definition and requirements for
  a nursing facility of Title XIX of the Social Security Act, Section
  1919;
(B) Comply with the standards
  prescribed by the Secretary of the Federal Health and Human Services for
  nursing facilities in 42 Code of Federal Regulations (CFR) 442;
(C) Comply with requirements established by
  the Nebraska Department of Health and Human Services Division of Public Health
  standards, under 42 CFR
  431.610; and
(D) Comply with any other state law licensing
  requirements necessary for providing nursing facility services, as
  applicable.
Nebraska Administrative Code › Topic - HEALTH AND HUMAN SERVICES SYSTEM › Title 471 - NEBRASKA MEDICAL ASSISTANCE PROGRAM SERVICES › Chapter 45 - RATES FOR NURSING FACILITY SERVICES › Section 471-45-005 - UNALLOWABLE COSTS

Current through June 17, 2024
The following costs are specifically unallowable:
(A) Provisions for income tax;
(B) Fees paid board of directors;
(C) Non-working officers' salaries;
(D) Promotion expenses, except for promotion
  and advertising as allowed in HIM-15. Yellow Page display advertising is not
  allowable; one Yellow Page informational listing per local area telephone
  directory is allowable;
(E) Travel
  and entertainment, other than for professional meetings and direct operations
  of facility;
(F)
  Donations;
(G) Expenses of
  non-nursing home facilities and operations included in expenses;
(H) Insurance or annuity premiums on the life
  of the officer or owner;
(I) Bad
  debts, charity, and courtesy allowances;
(J) Costs and portions of costs which are
  determined by the Department not to be reasonably related to the efficient
  production of service because of either the nature or amount of the particular
  expenditure;
(K) Services provided
  by the clients' physicians, therapists or dentists, drugs, laboratory services,
  radiology services, or services provided by similar independent licensed
  providers, except services provided by state operated facilities. These
  exclusions are paid separately;
(L)
  Return on equity;
(M) Carry-over of
  costs lost due to any limitation in this system;
(N) Expenses for equipment, facilities, and
  programs provided to clients which are determined by the Department not to be
  reasonably related to the efficient production of service because of either the
  nature or amount of the particular service; and
(O) Revisit fees.
Nebraska Administrative Code › Topic - HEALTH AND HUMAN SERVICES SYSTEM › Title 471 - NEBRASKA MEDICAL ASSISTANCE PROGRAM SERVICES › Chapter 45 - RATES FOR NURSING FACILITY SERVICES › Section 471-45-006 - LIMITATIONS FOR RATE DETERMINATION

Current through June 17, 2024
The Department applies the following limitations for rate
	 determination.
006.01
EXPIRATION OR TERMINATION OF LICENSE OR CERTIFICATION.
The Department does not make payment for care provided 30 days after the date
  of expiration or termination of the provider's license or certificate to
  operate under Medicaid. The Department does not make payment for care provided
  to individuals who were admitted after the date of expiration or termination of
  the provider's license or certificate to operate under Medicaid.
006.02
TOTAL INPATIENT
  DAYS.
In computing the provider's allowable per diem rates, total
  inpatient days are used. Payment for holding beds for patients in acute
  hospitals or on therapeutic home visits is permitted if the policy of the
  facility is to hold beds for private patients and if the patient's bed is
  actually held. Bed holding is allowed for 15 days per hospitalization and for
  up to 18 days of therapeutic home visits per calendar year. Both bed hold days
  and therapeutic leave days for in-state nursing facilities are reimbursed equal
  to the resident's applicable level of care classification. Medicaid inpatient
  days are days for which claims or electronic Standard Health Care Claim:
  Institutional transaction, ASC X12N 837, from the provider have been processed
  by the Department. The Department will not consider days for which a claim has
  not been processed unless the provider can show justification to the
  Department's satisfaction. Days for which the client's Medicaid eligibility is
  in a spenddown category are considered Medicaid inpatient days in compiling
  inpatient days. A facility may not impose charges that exceed the payment rate
  established under this chapter for these days. An inpatient day is:
(A) A day on which a patient occupies a bed
  at midnight. When a client is admitted to a facility and dies before midnight
  on the same day, one day is counted and paid; or
(B) A day on which the bed is held for
  hospital leave or therapeutic home visits.
Nebraska Administrative Code › Topic - HEALTH AND HUMAN SERVICES SYSTEM › Title 471 - NEBRASKA MEDICAL ASSISTANCE PROGRAM SERVICES › Chapter 45 - RATES FOR NURSING FACILITY SERVICES › Section 471-45-010 - AUDITS

Current through June 17, 2024
The Department will perform at least one initial desk audit and may
	 perform subsequent desk audits or a periodic field audit of each cost report.
	 Selection of subsequent desk audits and field audits will be made as determined
	 necessary by the Department to maintain the integrity of the Nebraska Medical
	 Assistance Program. The Department may retain an outside independent public
	 accounting firm, licensed to do business in Nebraska or the state where the
	 financial records are maintained, to perform the audits. Audit reports must be
	 completed on all field audits and desk audits. All audit reports will be
	 retained by the Department for at least three years following the completion
	 and finalization of the audit. An initial desk audit will be completed on all
	 cost reports. Care classification maximums and average base rate components are
	 computed using audited data following the end of the Cost Report Period.
	 Subsequent desk and field audits will not result in a revision of care
	 classification maximums or average base rate components. All cost reports,
	 including those previously desk audited but excluding those previously field
	 audited, are subject to subsequent desk audits. The primary period or periods
	 and subject or subjects to be desk-audited are indicated in a notification
	 letter sent to the provider to initiate a subsequent desk audit. The provider
	 must deliver copies of schedules, summaries, or other records requested by the
	 Department as part of any desk audit. All cost reports, including those
	 previously desk-audited but excluding those previously field-audited, are
	 subject to field audit by the Department. The primary period or periods to be
	 field-audited are indicated in a confirmation letter, which is mailed to the
	 facility before the start of the field work. A field audit may be expanded to
	 include any period otherwise open for field audit. The scope of each field
	 audit will be determined by the Department. The provider must deliver to the
	 site of the field audit, or an alternative site agreed to by the provider and
	 the Department, any records requested by the Department as part of a field
	 audit.
Nebraska Administrative Code › Topic - HEALTH AND HUMAN SERVICES SYSTEM › Title 471 - NEBRASKA MEDICAL ASSISTANCE PROGRAM SERVICES › Chapter 45 - RATES FOR NURSING FACILITY SERVICES › Section 471-45-011 - SETTLEMENT AND RATE ADJUSTMENTS

Current through June 17, 2024
When an audit has been completed on a cost report, the Department will
	 determine if an adjustment to the rate is required; if necessary, a settlement
	 amount is determined. The facility will be notified of the settlement on a
	 remittance advice. Payment or arrangements for payment of the settlement
	 amount, by either the Department or the provider, must be made within 45 days
	 of the settlement notice unless an administrative appeal filed within the
	 appeal period is also filed within the 45-day repayment period. Administrative
	 appeals filed after the 45-day payment period will not stay repayment of the
	 settlement amount. The filing of an administrative appeal will not stay
	 repayments to the Department for audit adjustments not included in the appeal
	 request. The Department may adjust the interim rate for payments made after the
	 audit completion. The Department will determine a final adjustment to the rate
	 and settlement amount after the audit is final and all appeal options have been
	 exhausted. Payment for any final settlement must be made within 30 days. If
	 payment is not made, the Department will immediately begin recovery from future
	 facility payments until the amount due is fully recovered. The Department will
	 report an overpayment to the federal government on the appropriate form no
	 later than the second quarter following the quarter in which the overpayment
	 was found.
Nebraska Administrative Code › Topic - HEALTH AND HUMAN SERVICES SYSTEM › Title 471 - NEBRASKA MEDICAL ASSISTANCE PROGRAM SERVICES › Chapter 45 - RATES FOR NURSING FACILITY SERVICES › Section 471-45-012 - PENALTIES

Current through June 17, 2024
Under federal law, the penalty for making a false statement or
	 misrepresentation of a material fact in any application for Medicaid payments
	 and for soliciting, offering, or accepting kickbacks or bribes, including the
	 rebate of a portion of a fee or charge for a patient referral, is imprisonment
	 up to five years, a fine of $25,000, or both. Similarly, making a false
	 statement of material fact about conditions or operations of any institution is
	 a felony punishable by up to five years imprisonment, a fine of not more than
	 $25,000, or both.
Nebraska Administrative Code › Topic - HEALTH AND HUMAN SERVICES SYSTEM › Title 471 - NEBRASKA MEDICAL ASSISTANCE PROGRAM SERVICES › Chapter 45 - RATES FOR NURSING FACILITY SERVICES › Section 471-45-013 - APPEAL PROCESS

Current through June 17, 2024
Final administrative decision or inaction in the allowable cost
	 determination process is subject to administrative appeal. The provider may
	 request an appeal in writing from the Division Director. The request for an
	 appeal must include identification of the specific adjustments or
	 determinations being appealed and basis or explanation of each item, or both.
	 After the Division Director issues a determination in regard to the
	 administrative appeal, the Department will notify the facility of the final
	 settlement amount. Repayment of the settlement amount must be made within 30
	 days of the date of the letter of notification.
Nebraska Administrative Code › Topic - HEALTH AND HUMAN SERVICES SYSTEM › Title 471 - NEBRASKA MEDICAL ASSISTANCE PROGRAM SERVICES › Chapter 45 - RATES FOR NURSING FACILITY SERVICES › Section 471-45-014 - ADMINISTRATIVE FINALITY

Current through June 17, 2024
Administrative decision or inaction in the allowable cost determination
	 process for any provider, which is otherwise final, may be reopened by the
	 Department within three years of the date of notice of the decision or
	 inaction. Reopening means an action taken by the Division Director to reexamine
	 or question the correctness of a determination or decision which is otherwise
	 final. The Division Director is the sole authority in deciding whether to
	 reopen. The action may be taken on the initiative of the Department within the
	 three-year period; in response to a written request from a provider or other
	 entity within the three-year period. Whether the Division Director will reopen
	 a determination, which is otherwise final, depends on whether new and material
	 evidence has been submitted, a clear and obvious error has been made, or the
	 determination is found to be inconsistent with the law, regulations and
	 rulings, or general instructions; or anytime fraud or abuse is suspected. A
	 provider does not have the right to appeal a finding by the Division Director
	 that a reopening or correction of a determination or decision is not
	 warranted.
Nebraska Administrative Code › Topic - HEALTH AND HUMAN SERVICES SYSTEM › Title 471 - NEBRASKA MEDICAL ASSISTANCE PROGRAM SERVICES › Chapter 45 - RATES FOR NURSING FACILITY SERVICES › Section 471-45-015 - CHANGE OF HOLDER OF PROVIDER AGREEMENT

Current through June 17, 2024
A holder of a provider agreement receiving payments under 12-011 must
	 notify the Department 60 days before any change or termination regarding the
	 holder of the provider agreement. If any known settlement is due the Department
	 by that provider, payment must be made immediately. If the provider is subject
	 to recapture of depreciation on the anticipated sale or if an audit is in
	 process, the provider will be required to provide a guarantee of repayment of
	 the Department's estimated settlement either by payment of that amount to the
	 Department, providing evidence that another provider receiving payments under
	 this chapter has assumed liability, or by surety bond for payment. All
	 estimated or final amounts, regardless of appeal status, must be paid before
	 the transfer of ownership. The Department will not enter into a provider
	 agreement with a new provider if there is an unpaid settlement payable to the
	 Department by a prior provider of services at the same facility unless the new
	 provider has assumed liability for the unpaid amount. Parties to a facility
	 provider change may receive information about unpaid settlement amounts owed to
	 the Department by making a written request.
Nebraska Administrative Code › Topic - HEALTH AND HUMAN SERVICES SYSTEM › Title 471 - NEBRASKA MEDICAL ASSISTANCE PROGRAM SERVICES › Chapter 45 - RATES FOR NURSING FACILITY SERVICES › Section 471-45-017 - SPECIALIZED ADD-ON SERVICES PAYMENTS

Current through June 17, 2024
Specialized add-on services are paid to the provider or providers of
	 specialized add-on services. Payments to providers for medically necessary
	 services, including specialized add-on services in excess of limitations for
	 covered services identified elsewhere in the state plan, or not listed as
	 specialized add-on services according to the state plan, require
	 pre-authorization.
017.01
SPECIALIZED ADD-ON SERVICES.
Except as otherwise noted
  in the plan, fee schedule rates are the same for both governmental and private
  providers of specialized addon services provided in the nursing facility. The
  Medicaid agency's rates were set as of June 30, 2018, and are effective for
  dates of services provided on and after that date.
017.02
HABILITATIVE
  SERVICES.
Except as otherwise noted in the plan, fee schedule
  rates are the same for both governmental and private providers of habilitative
  services, provided to individuals residing in a nursing facility. The rates for
  these specialized add-on services were established using existing developmental
  disabilities waiver fee schedules. The rates were set as of June 30, 2018, and
  are effective for dates of service provided on and after that date, and updated
  as specified by the Department.
017.03
SUPERVISORY
  ACTIVITIES.
Payment excludes the supervisory activities rendered
  as a normal part of the employment support.
Nebraska Administrative Code › Topic - HEALTH AND HUMAN SERVICES SYSTEM › Title 471 - NEBRASKA MEDICAL ASSISTANCE PROGRAM SERVICES › Chapter 46 - RATES FOR HOSPITAL SERVICES › Section 471-46-001 - SCOPE AND AUTHORITY

Current through June 17, 2024
The regulations govern the services provided under Nebraska's Medicaid
	 program as defined by Nebraska Revised Statute (Neb. Rev. Stat.) §§
	 68 901 et seq. (the Medical Assistance Act).
Nebraska Administrative Code › Topic - HEALTH AND HUMAN SERVICES SYSTEM › Title 471 - NEBRASKA MEDICAL ASSISTANCE PROGRAM SERVICES › Chapter 46 - RATES FOR HOSPITAL SERVICES › Section 471-46-002 - DEFINITIONS

Current through June 17, 2024
The following definitions apply:
002.01
ALLOWABLE
  COSTS.
Those costs as provided in the Medicare statutes and
  regulations for routine service costs, inpatient ancillary costs,
  capital-related costs, medical education costs, and malpractice insurance
  cost.
002.02
ALL
  PATIENT REFINED-DIAGNOSIS RELATED GROUP ALL PATIENT REFINED DIAGNOSIS RELATED
  GROUP.
A diagnosis related group classification system.
002.03
BASE YEAR.
The period covered by the most recent settled Medicare cost report, which will
  be used for purposes of calculating prospective rates.
002.04
BUDGET
  NEUTRALITY.
Payment rates are adjusted for budget neutrality such
  that estimated expenditures for the current rate year are not greater than
  expenditures for the previous rate year, trended forward.
002.05
CAPITAL-RELATED
  COSTS.
Those costs, excluding tax-related costs, as provided in
  the Medicare regulations and statutes in effect for each facility's base
  year.
002.06
CASE-MIX
  INDEX.
An arithmetical index measuring the relative average
  resource use of discharges treated in a hospital compared to the statewide
  average.
002.07
COST
  OUTLIER.
Cases which have an extraordinarily high cost as
  established in this chapter so as to be eligible for additional payments above
  and beyond the initial diagnosis related group payment.
002.08
CRITICAL ACCESS
  HOSPITAL.
A hospital certified for participation by Medicare as a
  Critical Access Hospital.
002.09
DIAGNOSIS-RELATED GROUP.
A group of similar diagnoses
  combined based on patient age, procedure coding, comorbidity, and
  complications.
002.10
DIRECT MEDICAL EDUCATION COST PAYMENT.
An add-on to
  the operating cost payment amount to compensate for direct medical education
  costs associated with approved intern and resident programs. Costs associated
  with direct medical education are determined from the hospital base year cost
  reports, and are limited to the maximum per intern and resident amount allowed
  by Medicare in the base year.
002.11
DISPROPORTIONATE SHARE
  HOSPITAL.
A hospital located in Nebraska is deemed to be a
  disproportionate share hospital by having:
(A) A Medicaid inpatient utilization rate
  equal to or above the mean Medicaid inpatient utilization rate for hospitals
  receiving Medicaid payments in Nebraska; or
(B) A low-income utilization rate of 25
  percent or more.
Nebraska Administrative Code › Topic - HEALTH AND HUMAN SERVICES SYSTEM › Title 471 - NEBRASKA MEDICAL ASSISTANCE PROGRAM SERVICES › Chapter 46 - RATES FOR HOSPITAL SERVICES › Section 471-46-004 - NON-PAYMENT FOR HOSPITAL ACQUIRED CONDITIONS

Current through June 17, 2024
Medicaid will not make payment for conditions which are a result of
	 avoidable inpatient hospital complications and medical errors that are
	 identifiable, preventable, and serious in their consequences to patients. This
	 means that Medicaid will, at a minimum, identify as a hospital acquired
	 condition, those secondary diagnosis codes that have been identified as
	 Medicare hospital acquired conditions when not present on hospital
	 admission.
Nebraska Administrative Code › Topic - HEALTH AND HUMAN SERVICES SYSTEM › Title 471 - NEBRASKA MEDICAL ASSISTANCE PROGRAM SERVICES › Chapter 46 - RATES FOR HOSPITAL SERVICES › Section 471-46-005 - PAYMENTS FOR PSYCHIATRIC SERVICES

Current through June 17, 2024
Payments for psychiatric discharges are made on a prospective per diem.
	 Tiered rates will be used for all acute psychiatric inpatient services. This
	 includes services provided at a facility enrolled as a provider for psychiatric
	 services which is not a licensed psychiatric hospital or a Medicare-certified
	 distinct part unit. Payment for each discharge equals the applicable per diem
	 rate times the number of approved patient days for each tier. Payment is made
	 for the day of admission, but not the day of discharge. For payment of
	 inpatient hospital psychiatric services, effective July 1, 2014, the tiered per
	 diem rate will be: $ 715.32 for 1 and 2 days of service; $ 661.55 for 3 and 4
	 days of service; $ 631.18 for 5 and 6 days of service; and $ 601.14 for 7 and
	 greater days of service. For payment of inpatient hospital psychiatric
	 services, effective July 1, 2015, the tiered per diem rate will be: $ 731.41
	 for 1 and 2 days of service; $ 676.43 for 3 and 4 days of service; $ 645.38 for
	 5 and 6 days of service; and $ 614.67 for 7 and greater days of service. For
	 payment of inpatient hospital psychiatric services, effective July 1, 2016, the
	 tiered per diem rate will be: $ 747.87 for 1 and 2 days of service; $ 691.65
	 for 3 and 4 days of service; $ 659.90 for 5 and 6 days of service; and $ 628.50
	 for 7 and greater days of service. For payment of inpatient hospital
	 psychiatric services, effective July 31, 2019, the tiered per diem rate will
	 be: $ 777.79 for 1 and 2 days of service; $ 719.32 for 3 and 4 days of service;
	 $ 686.30 for 5 and 6 days of service; and $ 653.64 for 7 and greater days of
	 service. For payment of inpatient hospital psychiatric services, effective July
	 1, 2020, the tiered per diem rate will be: $ 809.00 for 1 and 2 days of
	 service; $ 748.00 for 3 and 4 days of service; $ 714.00 for 5 and 6 days of
	 service; and $ 680.00 for 7 and 8 days of service.
005.01
PAYMENT FOR PSYCHIATRIC
  ADULT INPATIENT SUBACUTE HOSPITAL SERVICES.
Payments for
  psychiatric adult inpatient subacute hospital services are made on a per diem
  basis. This rate may be reviewed annually. Effective April 12, 2008, the
  payment for psychiatric adult subacute inpatient hospital services identified
  in state regulations was $ 488.13. Beginning July 1, 2008, the per diem rate
  was $ 505.21 and on November 24, 2009 onward the rate is $ 512.79. Payments for
  psychiatric adult inpatient subacute hospital services may be adjusted annually
  as specified by the Department. The subacute inpatient hospital per diem rate
  is not a tiered rate. Payment will be an all-inclusive per diem, with the
  exception of physician services.
Nebraska Administrative Code › Topic - HEALTH AND HUMAN SERVICES SYSTEM › Title 471 - NEBRASKA MEDICAL ASSISTANCE PROGRAM SERVICES › Chapter 46 - RATES FOR HOSPITAL SERVICES › Section 471-46-006 - PAYMENTS FOR REHABILITATION SERVICES

Current through June 17, 2024
Payments for rehabilitation discharges are made on a prospective per
	 diem. All rehabilitation services, regardless of the type of hospital providing
	 the service, will be reimbursed on a per diem basis. This includes services
	 provided at a facility enrolled as a provider for rehabilitation services which
	 is not a licensed rehabilitation hospital or a Medicare-certified distinct part
	 unit. The per diem will be the sum of: the hospitalspecific base payment per
	 diem rate; the hospital-specific capital per diem rate; and the hospital's
	 direct medical education per diem rate, if applicable. Payment for each
	 discharge equals the per diem times the number of approved patient days.
	 Payment is made for the day of admission but not for the day of
	 discharge.
006.01
ADJUSTMENT OF HOSPITAL-SPECIFIC BASE PAYMENT AMOUNT.
The hospital sepcifc per diem rates may be adjusted annually as specified by
  the Department.
006.02
CALCULATION OF HOSPITAL-SPECIFIC CAPITAL PER DIEM
  RATE.
Capital-related cost payments for the building and fixtures
  portion of capital-related costs are paid on a per diem as described in this
  chapter.
Nebraska Administrative Code › Topic - HEALTH AND HUMAN SERVICES SYSTEM › Title 471 - NEBRASKA MEDICAL ASSISTANCE PROGRAM SERVICES › Chapter 46 - RATES FOR HOSPITAL SERVICES › Section 471-46-007 - PAYMENT FOR SERVICES FURNISHED BY A CRITICAL ACCESS HOSPITAL

Current through June 17, 2024
Effective for cost reporting periods beginning July 1, 2015, and after
	 payment for inpatient services of a critical access hospital is the reasonable
	 cost of providing the services, as determined under applicable Medicare
	 principles of reimbursement, except that the following principles do not apply:
	 the lesser of costs or charges rule, ceilings on hospital operating costs, and
	 the reasonable compensation equivalent limits for physician services to
	 providers. Subject to the 96-hour average on inpatient stays in critical access
	 hospitals, items and services that a critical access hospital provides to its
	 inpatients are covered if they are items and services of a type that would be
	 covered if furnished by a hospital to hospital inpatients.
Nebraska Administrative Code › Topic - HEALTH AND HUMAN SERVICES SYSTEM › Title 471 - NEBRASKA MEDICAL ASSISTANCE PROGRAM SERVICES › Chapter 46 - RATES FOR HOSPITAL SERVICES › Section 471-46-008 - RATES FOR STATE-OPERATED INSTITUTIONS OF MENTAL DISEASE

Current through June 17, 2024
Institutions for mental disease operated by the State of Nebraska will
	 be reimbursed for all reasonable and necessary costs of operation.
	 State-operated institutions of mental diseases will receive an interim per diem
	 payment rate, with an adjustment to actual costs following the cost reporting
	 period.
Nebraska Administrative Code › Topic - HEALTH AND HUMAN SERVICES SYSTEM › Title 471 - NEBRASKA MEDICAL ASSISTANCE PROGRAM SERVICES › Chapter 46 - RATES FOR HOSPITAL SERVICES › Section 471-46-009 - DISPROPORTIONATE SHARE HOSPITALS

Current through June 17, 2024
A hospital qualifies as a disproportionate share hospital if the
	 hospital meets the definition of a disproportionate share hospital and submits
	 the required information completed, dated and signed as follows with their
	 Medicare cost report:
(A) The names of
  at two obstetricians who have staff privileges at the hospital and who have
  agreed to provide obstetric services to individuals who are eligible for
  Medicaid. This requirement does not apply to a hospital:
(i) The inpatients of which are predominantly
  individuals under 18 years of age;
(ii) Which does not offer non-emergency
  obstetric services to the general population as of December 21, 1987;
  or
(iii) For a hospital located in
  a rural area, the term obstetrician includes any physician with staff
  privileges at the hospital to perform non-emergency obstetric
  procedures;
Nebraska Administrative Code › Topic - HEALTH AND HUMAN SERVICES SYSTEM › Title 471 - NEBRASKA MEDICAL ASSISTANCE PROGRAM SERVICES › Chapter 46 - RATES FOR HOSPITAL SERVICES › Section 471-46-010 - OUT-OF-STATE HOSPITAL RATES

Current through June 17, 2024
The Department pays out-of-state hospitals for hospital inpatient
	 services at the peer group rate for a like peer group of Nebraska hospitals.
	 The peer groups are: metro acute care hospitals, hospitals located in a
	 metropolitan statistical area as designated by Medicare; rural acute care
	 hospitals, all other acute care hospitals; psychiatric hospitals and distinct
	 part units in acute care hospitals, hospitals that are licensed as psychiatric
	 hospitals by the licensing agency of the state in which the hospital is located
	 and distinct parts as defined in this chapter; and rehabilitation hospitals and
	 distinct part units in acute care hospitals, hospitals that are licensed as
	 rehabilitation hospitals by the licensing agency of the state in which the
	 hospital is located and distinct parts as defined in this chapter. Operating
	 cost payment amounts are calculated based on the appropriate peer group base
	 payment amount. Capital-related cost payments are made based on the peer group
	 weighted median capital per diem rate. Effective September 1, 2003, capital
	 costs will be calculated as 96.85% of the peer group weighted median cost per
	 day. The cost-to-charge ratio is the peer group average. Payments for
	 psychiatric and rehabilitation services provided by out-of-state hospitals are
	 made on a prospective per diem. Hospitals are paid based on the peer group per
	 diem rate for the appropriate type of service. Operating cost payment amounts
	 are calculated based on the appropriate peer group per diem rate.
	 Capital-related cost payments are made based on the peer group weighted median
	 capital per diem rate. The Department may allow payments to out-of-state
	 hospitals for direct or indirect medical education costs at a negotiated per
	 discharge rate.
010.01
EXCEPTION.
The Administrator of the Medicaid Division
  may enter into an agreement with an out-of-state hospital for a rate that
  exceeds the rate or fee established in this chapter only when the Medical
  Director of the Department has determined that:
(A) The client requires specialized services
  that are not available in Nebraska; and
(B) No other source of the specialized
  services can be found to provide the services at the rate established in this
  chapter.
Nebraska Administrative Code › Topic - HEALTH AND HUMAN SERVICES SYSTEM › Title 471 - NEBRASKA MEDICAL ASSISTANCE PROGRAM SERVICES › Chapter 46 - RATES FOR HOSPITAL SERVICES › Section 471-46-011 - OUT-OF-PLAN SERVICES

Current through June 17, 2024
When enrollees in the Nebraska Health Connection are provided hospital
	 inpatient services by facilities not under contract with the Department's
	 prepaid health care organizations, the Department contracted prepaid health
	 care organizations are authorized, but are not required, to pay providers of
	 hospital inpatient services who care for individuals enrolled in the Nebraska
	 Health Connection at rates the Department would otherwise reimburse providers
	 under this chapter.
011.
FREE-STANDING PSYCHIATRIC HOSPITALS.
When a
  free-standing psychiatric hospital, in Nebraska or out of state, does not have
  ancillary services on-site, such as pharmacy or laboratory, the provider of the
  ancillary service shall bill Medicaid for the ancillary services provided to
  inpatients. The hospital shall not include these ancillary costs on its cost
  report. The hospital's rate is calculated according to this chapter. This is an
  exception to policies related to the elimination of combined billing in this
  chapter.
Nebraska Administrative Code › Topic - HEALTH AND HUMAN SERVICES SYSTEM › Title 471 - NEBRASKA MEDICAL ASSISTANCE PROGRAM SERVICES › Chapter 46 - RATES FOR HOSPITAL SERVICES › Section 471-46-012 - RATE-SETTING FOLLOWING A CHANGE IN OWNERSHIP

Current through June 17, 2024
The rate-setting process for facilities with a change in ownership will
	 be the same as the rate-setting process used prior to the change in ownership
	 as described in these regulations.
Nebraska Administrative Code › Topic - HEALTH AND HUMAN SERVICES SYSTEM › Title 471 - NEBRASKA MEDICAL ASSISTANCE PROGRAM SERVICES › Chapter 46 - RATES FOR HOSPITAL SERVICES › Section 471-46-013 - RATE-SETTING FOLLOWING A HOSPITAL MERGER

Current through June 17, 2024
Hospitals that have combined into a single entity shall be assigned a
	 single combined weighted average for each of the following: direct medical
	 education amount, if applicable, indirect medical education amount, if
	 applicable, cost-to-charge ratio, outpatient percentage, capital amount, and
	 any other applicable rates or add-ons. The weights shall equal each hospital's
	 base year Medicaid discharges as a proportion of total Medicaid discharges for
	 the merged hospitals, and shall be applied to the current fiscal year rates
	 which were calculated for each hospital.
Nebraska Administrative Code › Topic - HEALTH AND HUMAN SERVICES SYSTEM › Title 471 - NEBRASKA MEDICAL ASSISTANCE PROGRAM SERVICES › Chapter 46 - RATES FOR HOSPITAL SERVICES › Section 471-46-014 - RATE-SETTING FOR A NEW OPERATIONAL FACILITY

Current through June 17, 2024
The Department shall establish a prospective per discharge rate for a
	 new operational facility for Peer Groups 1-5. The rate will be the average peer
	 group rate for the respective peer group for the new facility. For critical
	 access hospitals, the rate will be determined individually for each hospital
	 based on reasonable cost. The peer groups are: Metro acute care hospitals,
	 hospitals located in a metropolitan statistical area as designated by Medicare;
	 Other urban acute care hospitals, hospitals that have been redesignated to an
	 metropolitan statistical area by Medicare for federal fiscal year 1995 or 1996
	 or hospitals designated by Medicare as a regional rural referral center; rural
	 acute care hospitals, all other acute care hospitals with 30 or more base year
	 Medicaid discharges; Psychiatric Hospitals and distinct part units in acute
	 care hospitals, hospitals that are licensed as psychiatric hospitals by the
	 Department and distinct parts as defined in these regulations; Rehabilitation
	 hospitals and distinct part units in acute care hospitals, hospitals that are
	 licensed as rehabilitation hospitals by the Department and distinct parts as
	 defined in these regulations; and critical access hospital, hospitals that are
	 certified as critical access hospitals by Medicare.
Nebraska Administrative Code › Topic - HEALTH AND HUMAN SERVICES SYSTEM › Title 471 - NEBRASKA MEDICAL ASSISTANCE PROGRAM SERVICES › Chapter 46 - RATES FOR HOSPITAL SERVICES › Section 471-46-015 - DEPRECIATION

Current through June 17, 2024
The Department recognizes depreciation as an allowable cost as reported
	 on each facility's Medicare cost report and as determined allowable by the
	 Medicare intermediary through application of Medicare principles of
	 reimbursement.
Nebraska Administrative Code › Topic - HEALTH AND HUMAN SERVICES SYSTEM › Title 471 - NEBRASKA MEDICAL ASSISTANCE PROGRAM SERVICES › Chapter 46 - RATES FOR HOSPITAL SERVICES › Section 471-46-016 - RECAPTURE OF DEPRECIATION

Current through June 17, 2024
A hospital which is sold for a profit and has received Medicaid
	 payments for depreciation, shall refund to the Department the lower of: the
	 amount of depreciation allowed and paid by the Department; or the product of
	 the ratio of Medicaid allowed inpatient days to total inpatient days; and the
	 amount of gain on the sale as determined by the Medicare intermediary. The year
	 or years for which depreciation is to be recaptured is determined by the
	 Medicare Intermediary according to Medicare principles of
	 reimbursement.
Nebraska Administrative Code › Topic - HEALTH AND HUMAN SERVICES SYSTEM › Title 471 - NEBRASKA MEDICAL ASSISTANCE PROGRAM SERVICES › Chapter 46 - RATES FOR HOSPITAL SERVICES › Section 471-46-017 - ADJUSTMENT TO RATE

Current through June 17, 2024
Changes to Medicaid total allowable costs as a result of error, audit,
	 or investigation may become the basis for adjusting current or prior
	 prospective rates. The adjustment will be made back to the initial date of
	 payment for the period affected based on the rate as determined by the
	 Department. Hospitals will receive written notice of any adjustment stating the
	 amount of the adjustment and the basis for the adjustment. If the rate
	 adjustment results in decreasing a hospital's rate, the hospital shall refund
	 the overpayment amount as determined by the Department to the Department. If
	 the rate adjustment results in increasing a hospital's rate, the Department
	 shall reimburse the underpayment amount as determined by the Department to the
	 hospital.