reglab/statecodes huggingface dataset:
Nebraska Administrative Code › Topic - HEALTH AND HUMAN SERVICES SYSTEM › Title 471 - NEBRASKA MEDICAL ASSISTANCE PROGRAM SERVICES › Chapter 32 - CHILDREN'S MENTAL HEALTH AND SUBSTANCE USE TREATMENT SERVICES › Section 471-32-008 - Inpatient Psychiatric Services for Individuals Under Age 19 in Psychiatric Residential Treatment Facilities

Current through June 17, 2024
008.01 Psychiatric Residential Treatment
  Facilities (PRTFs) for Children/Adolescents
A Psychiatric Residential Treatment Facility (PRTF) is a facility,
	 other than a hospital, that provides inpatient psychiatric services to
	 individuals under the age of 19. A PRTF must provide the inpatient psychiatric
	 services under the direction of a physician, must be accredited and must comply
	 with all the requirements of applicable state and federal
	 regulations.
008.02 Prior
  Authorization
In order for an admission to a PRTF to be reimbursed by Medicaid, the
	 individual must meet the Certification of Need for Services requirements set
	 forth in 32-008.03 and be prior authorized by Medicaid or its designee. Prior
	 authorization applies to all admissions described in
	 32-008.04.
008.03
  Certification of Need for Services
A team specified in Section 32-008.04 must certify, prior to admission,
	 that:
1. Ambulatory care resources
  available in the community do not meet the treatment needs of the
  individual;
2. Proper treatment of
  the individual's psychiatric condition requires services on an inpatient basis
  under the direction of a physician; and
3. The services can reasonably be expected to
  improve the individual's condition or prevent further regression so that the
  services will no longer be needed.
Nebraska Administrative Code › Topic - HEALTH AND HUMAN SERVICES SYSTEM › Title 471 - NEBRASKA MEDICAL ASSISTANCE PROGRAM SERVICES › Chapter 33 - HEALTH CHECK (EARLY PERIODIC SCREENING, DIAGNOSIS AND TREATMENT [EPSDT]) SERVICES › Section 471-33-001 - 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
	 68-901
	 et seq.
Nebraska Administrative Code › Topic - HEALTH AND HUMAN SERVICES SYSTEM › Title 471 - NEBRASKA MEDICAL ASSISTANCE PROGRAM SERVICES › Chapter 33 - HEALTH CHECK (EARLY PERIODIC SCREENING, DIAGNOSIS AND TREATMENT [EPSDT]) SERVICES › Section 471-33-002 - DEFINITIONS

Current through June 17, 2024
The following definitions apply:
002.01
CONTINUING
  CARE.
The provision of HEALTH CHECK preventive, acute, and chronic
  care services by a single provider, who coordinates care, maintains a
  consolidated medical record of the child, and is the child's regular source of
  health care.
002.02
DIAGNOSTIC.
The determination of the nature or cause
  of a physical or mental disease or abnormality.
002.03
EARLY.
The
  practice of assessing and identifying problems as soon as an individual's or a
  family's eligibility for assistance has been established; or, in the case of a
  family already receiving assistance, as early as possible in the individual's
  life. This includes informing Medicaid-eligible pregnant women so that
  prevention begins prenatally.
002.04
ENVIRONMENTAL LEAD
  INVESTIGATION.
An assessment of the child's home or primary
  residence by a health professional certified as a lead inspector using a
  portable x-ray fluorescence (XRF) analyzer.
002,05
EARLY PERIODIC SCREENING,
  DIAGNOSIS AND TREATMENT (EPSDT),
Federally mandated program for
  children under age 21 that requires states to provide comprehensive services
  and furnish all Medicaid coverable, appropriate, and medically necessary
  services needed to correct and ameliorate health conditions, based on certain
  federal guidelines.
002.06
PERIODIC.
Checking children's health at
  age-appropriate intervals established for examination or screening to ensure
  continued health and to detect conditions requiring treatment.
002.07
SCREENING
  SERVICES.
Regularly scheduled periodic child health assessments to
  examine and evaluate the general physical and mental health, growth,
  development, and nutritional status of eligible children. The screenings are
  performed to identify individuals who may require diagnosis, further
  examination, and treatment.
Nebraska Administrative Code › Topic - HEALTH AND HUMAN SERVICES SYSTEM › Title 471 - NEBRASKA MEDICAL ASSISTANCE PROGRAM SERVICES › Chapter 33 - HEALTH CHECK (EARLY PERIODIC SCREENING, DIAGNOSIS AND TREATMENT [EPSDT]) SERVICES › Section 471-33-004 - SERVICE REQUIREMENTS

Current through June 17, 2024
004.01
GENERAL SERVICE REQUIREMENTS.
HEALTH CHECK, the
  Nebraska Early and Periodic Screening, Diagnosis, and Treatment (EPSDT)
  Program, is a service available to all individuals age 20 and younger eligible
  for medical assistance. The HEALTH CHECK Program ensures the availability and
  accessibility of required health care resources and aids Nebraska
  Medicaid-eligible children and their parents or caretakers effectively use
  them.
004.01(A)
PRIOR
  AUTHORIZATION.
Unless otherwise outlined, all services not covered
  by the Department must be prior authorized by the Department. The provider must
  submit requests for prior authorization using the standard electronic Health
  Care Services Review - Request for Review and Response transaction (ASC X12N
  278) or by completing and submitting a written request. The plan of care may be
  submitted on Form EPSDT-5: Plan of Care or as a statement by the screening
  practitioner. If the initial request is denied, additional information may be
  sent for reconsideration. A request for prior authorization must include:
(i) A copy of the screening exam form or the
  name of the screening practitioner and the date of the screening exam that
  identified the condition; and
(ii)
  A plan of care that includes:
(1) History of
  the condition;
(2) Physical
  findings and other signs and symptoms, including appropriate laboratory
  data;
(3) Recommended service or
  procedure, including the potential provider of service or where the services
  will be obtained;
(4) Estimated
  cost, if available; and
(5)
  Expected outcome(s).
Nebraska Administrative Code › Topic - HEALTH AND HUMAN SERVICES SYSTEM › Title 471 - NEBRASKA MEDICAL ASSISTANCE PROGRAM SERVICES › Chapter 33 - HEALTH CHECK (EARLY PERIODIC SCREENING, DIAGNOSIS AND TREATMENT [EPSDT]) SERVICES › Section 471-33-005 - BILLING AND PAYMENT FOR HEALTH CHECK SERVICES

Current through June 17, 2024
005.01
BILLING.
005.01(A)
GENERAL BILLING REQUIREMENTS.
Providers must comply
  with all applicable billing requirements codified in 471 NAC 3. In the event
  that individual billing requirements in 471 NAG 3 conflict with billing
  requirements outlined in this 471 NAC 33, the individual billing requirements
  in 471 NAC 33 will govern.
005.01(B)
SPECIFIC BILLING
  REQUIREMENTS.
Providers must bill the Department using Form
  CMS-1500 or the standard electronic Health Care Claim: Professional transaction
  (ASC X12N 837) for HEALTH CHECK exams, HEALTH CHECK-associated services, and
  other comparable exams. The physician or the physician's authorized agent must
  submit the physician's usual and customary charge for each procedure code
  listed on or in the claim.
005.01(B)(i)
PROCEDURE CODES.
Physicians must use Healthcare Common
  Procedure Coding System (HCPCS) procedure codes when submitting claims or
  encounter data to the Department. Healthcare Common Procedure Coding System
  (HCPCS) and Current Procedural Terminology (CPT) procedure codes used by
  Medicaid are listed in the Nebraska Medicaid Practitioner Fee
  Schedule.
005.01(B)(ii)
VACCINE FOR CHILDREN PROGRAM (VFC) PROGRAM.
When a
  physician uses federal-purchased vaccine for immunizations, the physician must
  bill the Department only for the administration. The physician must use the
  modifier "SL" with the vaccine code when billing for the administration. Billed
  charges for the administration of Vaccine for Children Program (VFC) vaccines
  cannot exceed the state maximum as determined by the federal Vaccine for
  Children Program (VFC) program. Contact the Nebraska Vaccine for Children
  Program (VFC) program with questions regarding the Nebraska
  maximum.
Nebraska Administrative Code › Topic - HEALTH AND HUMAN SERVICES SYSTEM › Title 471 - NEBRASKA MEDICAL ASSISTANCE PROGRAM SERVICES › Chapter 34 - RURAL HEALTH CLINICS (RHC's) › Section 471-34-001 - Standards for Participation

Current through June 17, 2024
To participate in the Nebraska Medical Assistance Program (NMAP), a
	 Rural Health Clinic must be certified by the Centers for Medicare and Medicaid
	 Services (CMS) for participation in the Medicare program.
Nebraska Administrative Code › Topic - HEALTH AND HUMAN SERVICES SYSTEM › Title 471 - NEBRASKA MEDICAL ASSISTANCE PROGRAM SERVICES › Chapter 34 - RURAL HEALTH CLINICS (RHC's) › Section 471-34-002 - Services Provided for Clients Enrolled in the Nebraska Health Connection (NHC)

Current through June 17, 2024
Certain NMAP clients are required to participate in the Nebraska
	 Medicaid Managed Care Program known as the Nebraska Health Connection (NHC).
	 See 471-000-122 for a listing of the NHC plans.
002.01 Health Maintenance Organization (HMO)
  Plans
The NHC HMO plans are required to provide, at a minimum, coverage of
	 services as described in this Chapter. The prior authorization requirements,
	 payment limitations, and billing instructions outlined in this Chapter do not
	 apply to services provided to clients enrolled in an NHC HMO plan with the
	 following exceptions:
1.
Medical Transplants
: As defined under 471 NAC
  18-004.40, transplants continue to require prior authorization by NMAP and are
  reimbursed on a fee-for-service basis, outside the HMO's capitation
  payment;
2.
Abortions
: As currently defined, abortions continue to
  require prior authorization by NMAP and are included in the capitation fee for
  the HMO; and
3.
Family
  Planning Services
: Family planning services do not require a
  referral from a primary care physician (PCP). As defined in 471 NAC 18-004.26,
  the client must be able to obtain family planning services upon request and
  from a provider of choice who is enrolled in NMAP. Family planning services are
  reimbursed according to the Nebraska Medicaid Practitioner Fee Schedule.
Services provided to clients enrolled in an NHC HMO plan are not billed
	 to NMAP. The provider must provide services only under arrangement with the
	 HMO.
Nebraska Administrative Code › Topic - HEALTH AND HUMAN SERVICES SYSTEM › Title 471 - NEBRASKA MEDICAL ASSISTANCE PROGRAM SERVICES › Chapter 34 - RURAL HEALTH CLINICS (RHC's) › Section 471-34-003 - Covered RHC Services

Current through June 17, 2024
NMAP covers services provided by RHC's on or after July 1, 1990, under
	 this chapter. NMAP defines covered Rural Health Clinic services as the
	 following services provided by a Certified Rural Health Clinic:
1. Services provided by a physician within
  the scope of practice under state law, if the physician performs the services
  in the clinic or the services are provided away from the clinic and the
  physician has an agreement with the clinic provided that s/he will be paid by
  the clinic for the services;
2.
  Services provided by a physician assistant, nurse practitioner, nurse midwife,
  or other specialized nurse practitioner if the services are provided in
  accordance with Medicare requirements;
3. Services and supplies that are provided as
  an incident to professional services provided by a physician, physician
  assistant, nurse practitioner, nurse midwife, or other specialized nurse
  practitioner;
4. Part-time or
  intermittent visiting nurse care and related medical supplies (other than drugs
  and biologicals) if -
a. The clinic is
  located in an area in which the Centers for Medicare and Medicaid Services has
  determined that there is a shortage of home health agencies;
b. The services are provided by a registered
  nurse or licensed practical nurse or a licensed vocational nurse who is
  employed by, or otherwise compensated for services by the clinic;
c. The services are provided under a written
  plan of treatment that is established and reviewed at least every 60 days by a
  physician, physician assistant, nurse practitioner, nurse midwife, or other
  specialized nurse practitioner and review and approved at least every 60 days
  by a supervising physician of the clinic; and
d. The services are provided to a "homebound"
  client. For the purposes of visiting nurse care, a "homebound" client is one
  who is permanently or temporarily confined to his/her place of residence
  because of a medical or health condition. The client may be considered
  homebound if the client leaves the place of residence infrequently. For this
  purpose, "place of residence" does not include a hospital or skilled nursing
  facility.
Nebraska Administrative Code › Topic - HEALTH AND HUMAN SERVICES SYSTEM › Title 471 - NEBRASKA MEDICAL ASSISTANCE PROGRAM SERVICES › Chapter 34 - RURAL HEALTH CLINICS (RHC's) › Section 471-34-004 - Payment for Rural Health Clinic Services

Current through June 17, 2024
NMAP will pay for services provided by Rural Health Clinics in
	 compliance with Section 1902 (bb) of the Social Security Act. The Department
	 assures that payments to all RHCs will result in a payment to the clinic in the
	 amount which is at least equal to the Prospective Payment System.
004.01 Definitions
Definitions means the following definitions apply within this
	 chapter:
Encounter
means a face-to-face visit between
	 a Medicaid-eligible patient and a physician, physician assistant, nurse
	 practitioner, nurse midwife, specialized nurse practitioner, visiting nurse,
	 clinical psychologist, or clinical social worker during which an FQHC service
	 is rendered. Encounters with more than one health professional and multiple
	 encounters with the same health professional which take place on the same day
	 and at a single location constitute a single visit, except for cases in which
	 the patient, subsequent to the first encounter, suffers an illness or injury
	 requiring additional diagnosis or treatment.
Encounter Payments
means PPS rate paid to the
	 RHC by the Department multiplied by the number of encounters billed.
Encounter Rate
means the all-inclusive PPS
	 rate that the Department reimburses the RHC for an encounter.
Independent Rural Health Clinic
means A
	 clinic that is free standing with no association to a hospital, nursing
	 facility, or home health agency.
Medicare Cost Report
means the report filed
	 by each RHC provider with its Medicare intermediary as required by Chapter 9 of
	 the Medicare Rural Health Clinic and Federal Qualified Health Center
	 Manual.
Prospective Payment System (PPS)
means the
	 payment system where in a reimbursement rate is paid for services
	 provided.
Provider-Based Rural Health Clinic
means a
	 rural health clinic that is an integral part of a hospital, nursing facility,
	 or home health agency that is participating in Medicare and is licensed,
	 governed and supervised by the facility.
Nebraska Administrative Code › Topic - HEALTH AND HUMAN SERVICES SYSTEM › Title 471 - NEBRASKA MEDICAL ASSISTANCE PROGRAM SERVICES › Chapter 34 - RURAL HEALTH CLINICS (RHC's) › Section 471-34-005 - Prospective Payment System

Current through June 17, 2024
005.01 Payment for Services Provided by
  Provider-Based Rural Health Clinics Associated with Hospitals Having 50 Beds or
  Greater
The Department will compute the Prospective Payment System (PPS) base
	 rate as follows:
1. Combine reasonable
  costs from the RHC fiscal year 1999 and 2000 cost reports; then
2. Divide the cost by the combined Total
  Adjusted Visits from the two fiscal year cost reports (Form CMS- 222-92
  Worksheet C, Part 1, Line 6; or Form CMS- 2552-96 Worksheet M-3, Line 6).
Effective October 1, 2001, the Department will update the PPS base rate
	 annually using the Medicare Economic Index (MEI).
Nebraska Administrative Code › Topic - HEALTH AND HUMAN SERVICES SYSTEM › Title 471 - NEBRASKA MEDICAL ASSISTANCE PROGRAM SERVICES › Chapter 34 - RURAL HEALTH CLINICS (RHC's) › Section 471-34-006 - Payment for Non-RHC Services

Current through June 17, 2024
For those non-RHC services, NMAP makes payment according to the
	 Nebraska Medicaid Practitioners Fee Schedule.
Nebraska Administrative Code › Topic - HEALTH AND HUMAN SERVICES SYSTEM › Title 471 - NEBRASKA MEDICAL ASSISTANCE PROGRAM SERVICES › Chapter 34 - RURAL HEALTH CLINICS (RHC's) › Section 471-34-007 - Payment for Telehealth Services

Current through June 17, 2024
Payment for telehealth services will be the Medicaid rate for the
	 comparable in-person service. RHC core services provided via telehealth
	 technologies are not covered under the encounter rate.
007.01 Payment for Telehealth Transmission
  Costs
Payment for telehealth transmission costs related to non-core services
	 will be the lower of:
1. The
  provider's submitted charge; or
2.
  The maximum allowable amount.
The Department will pay for transmission costs for line charges when
	 directly related to a covered telehealth service. The provider must be in
	 compliance with the standards for real time, two way interactive audiovisual
	 transmissions (see 471 NAC
	 1-006).
Nebraska Administrative Code › Topic - HEALTH AND HUMAN SERVICES SYSTEM › Title 471 - NEBRASKA MEDICAL ASSISTANCE PROGRAM SERVICES › Chapter 34 - RURAL HEALTH CLINICS (RHC's) › Section 471-34-008 - Cost Reports

Current through June 17, 2024
Providers participating with NMAP as RHCs must submit an annual cost
	 report to the Department. The RHC must report and supply the Department with
	 necessary documentation regarding, cost reports, and any other documentation
	 when requested.
The Medicare cost report form CMS- 222-92 can be found in the Provider
	 Reimbursement Manual-Part 2 ( Pub. 15-2 ), Chapter 29 located at
http://www.cms.gov/maunals/PBM/list.asp
on the CMS website.
Hospital-based RHCs associated with hospitals of 50 beds or greater
	 must complete Worksheet M of Form CMS- 2552-96. Hospital and Hospital Complex
	 Cost Report Found in provider reimbursement manual-Part 2 ( Pub. 15-2 ),
	 Chapter 36, located at
http://www.cms.hhs.gov/Manuals/PBM/list.asp
on the CMS website.
Nebraska Administrative Code › Topic - HEALTH AND HUMAN SERVICES SYSTEM › Title 471 - NEBRASKA MEDICAL ASSISTANCE PROGRAM SERVICES › Chapter 34 - RURAL HEALTH CLINICS (RHC's) › Section 471-34-009 - Billing for RHC Services

Current through June 17, 2024
All RHCs must bill for Rural Health Services as defined in 471 NAC
	 34-003 on Form CMS-1450 or the
	 standard electronic Health Care Claim: Institutional transaction (ASC X12N
	 837). RHCs will use the appropriate HCPCS/CPT procedure codes and revenue codes
	 when billing for all services.
IRHCs must use Form CMS-1500 (see 471-000-58) or the standard
	 electronic Health Care Claim: Professional transaction (ASC X12N 837) to bill
	 NMAP for clinical radiology/laboratory services using the non-Rural Health
	 Clinic provider number.
All Provider-Based RHCs must use Form CMS-1450 or the standard
	 electronic Health Care Claim: Institutional transaction (ASC X12N 837) to bill
	 NMAP for clinical laboratory services and radiology services using the hospital
	 provider number.
Nebraska Administrative Code › Topic - HEALTH AND HUMAN SERVICES SYSTEM › Title 471 - NEBRASKA MEDICAL ASSISTANCE PROGRAM SERVICES › Chapter 35 - REHABILITATIVE PSYCHIATRIC SERVICES › Section 471-35-002 - Provider Participation

Current through June 17, 2024
To participate in NMAP as a provider of rehabilitative psychiatric
	 services, a program must be certified by the Department of Health and Human
	 Services under the applicable rules and regulations described in 204 NAC. The
	 provider shall agree to contract with the Department of Health and Human
	 Services for the provision of rehabilitative psychiatric services, and
	 demonstrate the capacity to fulfill all the contractual requirements contained
	 therein. The provider must also complete and sign Form MC-19 or Form MC-20,
	 "Medical Assistance Provider Agreement," and be approved for enrollment in
	 NMAP. In addition, eligible providers must also provide other documentation
	 requested.
Nebraska Administrative Code › Topic - HEALTH AND HUMAN SERVICES SYSTEM › Title 471 - NEBRASKA MEDICAL ASSISTANCE PROGRAM SERVICES › Chapter 35 - REHABILITATIVE PSYCHIATRIC SERVICES › Section 471-35-003 - Nebraska Health Connection Services

Current through June 17, 2024
Certain Medicaid clients are required to participate in the Nebraska
	 Medicaid Managed Care Program (known as the Nebraska Health Connection). The
	 Department developed the NHC to improve the health and wellness of Nebraska's
	 Medicaid clients by increasing their access to comprehensive health services in
	 a way that is cost effective to the State. The NHC was implemented on July 1,
	 1995. Enrollment in the NHC is mandatory for certain clients in designated
	 geographic areas of the state. NHC clients will receive a Nebraska Medicaid
	 Identification Card. Participation in NHC can be verified by accessing the
	 Department Internet Access for Enrolled Providers (
www.dhhs.ne.gov/med/internetaccess.htm
):
	 the Nebraska Medicaid Eligibility System (NMES) at 800-642 -6092 (in Lincoln,
	 471-9580) (see 471-000-124); the Medicaid Inquiry Line at 877-255 -3092 (in
	 Lincoln 471-9128); or electronically using the standard Health Care Eligibility
	 Benefit Inquiry and Response transaction (ASC X12N 270/271).
The NHC utilizes two models of managed care plans to provide the basic
	 benefits package; these models are health maintenance organizations (HMO's) and
	 primary care case management (PCCM) networks. The NHC also provides a mental
	 health and substance abuse benefits package on a statewide basis available to
	 all clients who are required to participate in NHC.
If a client is required to participate in the NHC, all services
	 contained in the benefits package (MH/SA or medical) must be provided under the
	 management of the managed care plan.
Nebraska Administrative Code › Topic - HEALTH AND HUMAN SERVICES SYSTEM › Title 471 - NEBRASKA MEDICAL ASSISTANCE PROGRAM SERVICES › Chapter 35 - REHABILITATIVE PSYCHIATRIC SERVICES › Section 471-35-005 - Referrals for Rehabilitative Psychiatric Services

Current through June 17, 2024
Referrals for Rehabilitative Psychiatric Services will be directed to
	 the Department or its designee. The referral must include documentation that
	 establishes:
1. The client's Medicaid
  eligibility; and
2. How the client
  meets the definition of serious and persistent mental illness specified in 471
  NAC 35-001.01.
Nebraska Administrative Code › Topic - HEALTH AND HUMAN SERVICES SYSTEM › Title 471 - NEBRASKA MEDICAL ASSISTANCE PROGRAM SERVICES › Chapter 35 - REHABILITATIVE PSYCHIATRIC SERVICES › Section 471-35-006 - Eligibility for Rehabilitative Psychiatric Services

Current through June 17, 2024
To be eligible for Rehabilitative Psychiatric Services, the client
	 must be eligible for Medicaid, meet the definition of severe and persistent
	 mental illness, and be authorized by the Department or its designee for
	 specific services.
Nebraska Administrative Code › Topic - HEALTH AND HUMAN SERVICES SYSTEM › Title 471 - NEBRASKA MEDICAL ASSISTANCE PROGRAM SERVICES › Chapter 35 - REHABILITATIVE PSYCHIATRIC SERVICES › Section 471-35-007 - Service Needs Assessment and Rehabilitative Psychiatric Service Recommendations

Current through June 17, 2024
All clients determined eligible for rehabilitative psychiatric
	 services must be assessed and have rehabilitative psychiatric service
	 recommendations developed by a referring provider according to specified
	 protocols.
Nebraska Administrative Code › Topic - HEALTH AND HUMAN SERVICES SYSTEM › Title 471 - NEBRASKA MEDICAL ASSISTANCE PROGRAM SERVICES › Chapter 35 - REHABILITATIVE PSYCHIATRIC SERVICES › Section 471-35-008 - Service Authorization

Current through June 17, 2024
The completed assessment and rehabilitative psychiatric service
	 recommendations must be reviewed by the Department or its designee. A
	 determination will be made to -
1.
  Approve the client for a specified level and duration of one or more
  rehabilitative psychiatric services;
2. Request additional information from the
  assessor; or
3. Deny the request
  for rehabilitative psychiatric services.
Nebraska Administrative Code › Topic - HEALTH AND HUMAN SERVICES SYSTEM › Title 471 - NEBRASKA MEDICAL ASSISTANCE PROGRAM SERVICES › Chapter 35 - REHABILITATIVE PSYCHIATRIC SERVICES › Section 471-35-009 - Plan Development

Current through June 17, 2024
Clients authorized for one or more of the rehabilitative psychiatric
	 services (Community Support, Day Rehabilitation, Residential Rehabilitation)
	 will be referred by the Department or its designee to the appropriate
	 rehabilitative psychiatric services provider(s), consistent with client choice.
	 Rehabilitative psychiatric service providers will be responsible for working
	 with the client to -
1. Complete an
  assessment of the client's strengths and needs in that service domain according
  to the requirements of 204 NAC 5
  004.05G and 204
  NAC 5
  004.05H
  2.
2. Develop, in conjunction with
  the client, an Individual Service Plan (ISP) for their respective service
  areas, according to the requirements of 204 NAC 5
  004.05I.
3. Participate in developing, along with the
  client, the client's family members and/or significant others (as appropriate
  and with client consent), and other relevant community service providers, the
  client's Individual Program Plan (IPP) according to Department of Health and
  Human Services specified protocols.
The Community Support program will be assigned responsibility for IPP
	 development and coordination unless otherwise determined by the Department or
	 its designee.
Nebraska Administrative Code › Topic - HEALTH AND HUMAN SERVICES SYSTEM › Title 471 - NEBRASKA MEDICAL ASSISTANCE PROGRAM SERVICES › Chapter 35 - REHABILITATIVE PSYCHIATRIC SERVICES › Section 471-35-010 - Utilization Management

Current through June 17, 2024
The Department or its designee will provide utilization management for
	 all rehabilitative psychiatric services. This will include the service
	 authorization/service intensity functions identified in 471 NAC
	 35-008. In addition, the Department
	 or its designee will authorize client IPP's and provide ongoing utilization
	 review of the client's progress in relation to the IPP's. At least annually,
	 clients in rehabilitative psychiatric services will be reassessed and new
	 service recommendations will be reviewed and approved by the Department or its
	 designee as described in 471 NAC
	 35-008.
Nebraska Administrative Code › Topic - HEALTH AND HUMAN SERVICES SYSTEM › Title 471 - NEBRASKA MEDICAL ASSISTANCE PROGRAM SERVICES › Chapter 35 - REHABILITATIVE PSYCHIATRIC SERVICES › Section 471-35-011 - Payment for Rehabilitative Psychiatric Services

Current through June 17, 2024
For services provided on or after April 1, 1995, NMAP pays for
	 rehabilitative psychiatric services at established rates. Rates will not exceed
	 the actual cost of providing rehabilitative psychiatric
	 services.
Nebraska Administrative Code › Topic - HEALTH AND HUMAN SERVICES SYSTEM › Title 471 - NEBRASKA MEDICAL ASSISTANCE PROGRAM SERVICES › Chapter 35 - REHABILITATIVE PSYCHIATRIC SERVICES › Section 471-35-012 - Appeals and Fair Hearings

Current through June 17, 2024
A client has the right to appeal under 465 NAC 2-001.02 and 42 CFR
	 431, Subpart E. A provider has the right to appeal under 471 NAC
	 2-003. Hearings are conducted
	 according to 465 NAC 6-000 and 42 CFR 431, Subpart E.
The Department is primarily responsible for the administrative duties
	 of this function.
Nebraska Administrative Code › Topic - HEALTH AND HUMAN SERVICES SYSTEM › Title 471 - NEBRASKA MEDICAL ASSISTANCE PROGRAM SERVICES › Chapter 35 - REHABILITATIVE PSYCHIATRIC SERVICES › Section 471-35-017 - Community Support

Current through June 17, 2024
Substance Abuse Community Support is a rehabilitative and supportive
	 service for individuals with primary Axis I Diagnosis of Substance Dependence.
	 Community Support Interventions provide direct rehabilitation and support
	 services to individuals in the community to assist the individual in
	 maintaining abstinence, stabilizing community living, and preventing
	 exacerbation of symptoms and admissions to more restrictive levels of care.
	 This service is not available for individuals who are also receiving level III
	 or greater substance abuse treatment services. Services are based upon medical
	 necessity as identified in the client's treatment and recovery plan and shall
	 be provided in 15-minute increments.
017.01 Program Components
The Community Support Program shall:
1. Facilitate communication and coordination
  among all health care professionals providing services to the client;
2. Ensure completion of a strength-based
  needs assessment completion within 30 days of admission by the rehabilitation
  team or team member;
3. Develop and
  implement strategies to encourage the individual to become engaged and remain
  engaged in necessary substance use/abuse and mental health treatment services
  as recommended and included in the treatment/recovery plan;
4. Have access to the comprehensive substance
  abuse assessment including a biopsychosocial assessment conducted by a fully
  licensed practitioner practicing within his/her scope updated within 30 days of
  admission into the program;
5.
  Participate with and report to the treatment and recovery team on the
  individual's progress and response to community support intervention in areas
  of relapse prevention of substance use/abuse and application of education and
  skills in the recovery environment;
6. Review and update the treatment and
  recovery plan and discharge plan with the individual and other approved family
  supports every 90 days or more often as clinically necessary;
7. Coordinate with the providers of mental
  health when the client has a co-occurring diagnosis and receiving mental health
  services by a licensed practitioner either located in the agency or in a
  separate program;
8. Assist in
  facilitating the transfer to and the transition to other levels of treatment
  service;
9. Assist in the
  development, evaluation, and update in a crisis and relapse plan with the
  client;
10. Provide contact as
  needed with other providers, client family members and other significant
  individuals in the client's life to facilitate communication necessary to
  support the individual in maintaining community living;
11. When prescribed, monitor medication
  compliance and report compliance issues as necessary;
12. Assist the client with all health
  insurance issues; and
13. Assist in
  the discharge plan for the client and support development of community-based
  resources.
Nebraska Administrative Code › Topic - HEALTH AND HUMAN SERVICES SYSTEM › Title 471 - NEBRASKA MEDICAL ASSISTANCE PROGRAM SERVICES › Chapter 36 - HOSPICE SERVICES › Section 471-36-001 - SCOPE AND AUTHORITY

Current through June 17, 2024
These regulations govern services provided under the Medical Assistance
	 Act, Nebraska Revised Statute (Neb. Rev. Stat.) §§
									68-901 et seq.
Nebraska Administrative Code › Topic - HEALTH AND HUMAN SERVICES SYSTEM › Title 471 - NEBRASKA MEDICAL ASSISTANCE PROGRAM SERVICES › Chapter 36 - HOSPICE SERVICES › Section 471-36-002 - DEFINITIONS

Current through June 17, 2024
The following definitions apply:
002.01
ADVANCED
  DIRECTIVE.
A legal document, including, but not limited to, a
  living will, signed by a competent person, to provide guidance for medical and
  health-care decisions in the event the client becomes incapable to make such
  decisions.
002.02
ASSISTED LIVING FACILITY.
A facility licensed as an
  assisted living facility by the Department of Health and Human Services,
  Division of Public Health.
002.03
ATTENDING PHYSICIAN.
A doctor of medicine or
  osteopathy who is legally authorized to practice medicine or surgery by the
  state in which they perform that function, and is identified by the client, at
  the time they elect to receive hospice care, as having the most significant
  role in the determination and delivery of the client's medical care.
002.04
BENEFIT
  PERIOD.
The dates that the certification or recertification
  request covers.
002.05
BEREAVEMENT COUNSELING.
Emotional, psychosocial, and
  spiritual support and services provided before and after the death of the
  client to assist with issues related to grief, loss, and adjustment.
002.06
CAREGIVER.
A
  friend, family member, or legal guardian who provides ongoing care for a client
  who is unable to care for themself.
002.07
CENTER FOR THE
  DEVELOPMENTAL DISABILITIES (CDD).
A facility, including a group
  home, where shelter, food, care, advice, counseling, diagnosis, treatment, or
  related services are provided for a period of more than twenty-four consecutive
  hours to four or more persons residing at such facility who have developmental
  disabilities.
002.08
CLIENT.
A Medicaid client who is:
(A) Diagnosed as terminally ill;
  and
(B) Admitted into a hospice
  service, after giving informed consent.
Nebraska Administrative Code › Topic - HEALTH AND HUMAN SERVICES SYSTEM › Title 471 - NEBRASKA MEDICAL ASSISTANCE PROGRAM SERVICES › Chapter 36 - HOSPICE SERVICES › Section 471-36-004 - SERVICE REQUIREMENTS

Current through June 17, 2024
004.01
GENERAL REQUIREMENTS.
004.01(A)
CLIENT
  ELIGIBILITY.
The Medicaid hospice benefit is available to clients
  who meet the following criteria:
(i) The
  client is currently eligible for Medicaid;
(ii) The client is diagnosed as terminally
  ill by the hospice medical director or the physician member of the hospice
  interdisciplinary group (IDG), and the attending physician, if any;
  and
(iii) The client is an adult
  and has elected to receive palliative or comfort care to manage symptoms of
  terminal illness, and has chosen not to receive curative treatment or disease
  management; or
(iv) The client is a
  child and his or her parent or guardian has elected to receive palliative or
  comfort care to manage symptoms of terminal illness. Such election by a child's
  parent or guardian must not constitute a waiver of any rights of the child to
  be provided with, or receive Medicaid payment for, concurrent services related
  to the treatment of the child's condition for which a diagnosis of terminal
  illness has been made.
Nebraska Administrative Code › Topic - HEALTH AND HUMAN SERVICES SYSTEM › Title 471 - NEBRASKA MEDICAL ASSISTANCE PROGRAM SERVICES › Chapter 36 - HOSPICE SERVICES › Section 471-36-005 - BILLING AND PAYMENT FOR HOSPICE SERVICES

Current through June 17, 2024
005.01
BILLING.
005.01(A)
GENERAL BILLING REQUIREMENTS.
Providers must comply
  with all applicable billing requirements in 471 NAC 3. In the event that
  billing requirements in 471 NAC 3 conflict with billing requirements outlined
  in this chapter, the billing requirements in this chapter will
  govern.
005.01(B)
SPECIFIC BILLING REQUIREMENTS.
The hospice provider
  must bill for services provided using Form CMS-1450 or the standard electronic
  health care claim. Healthcare Common Procedure Coding System (HCPCS) and
  Current Procedural Terminology (CPT) procedure codes used by Medicaid are
  listed in the Nebraska Medicaid Fee Schedule.
Nebraska Administrative Code › Topic - HEALTH AND HUMAN SERVICES SYSTEM › Title 471 - NEBRASKA MEDICAL ASSISTANCE PROGRAM SERVICES › Chapter 37 - PROGRAM OF ALL-INCLUSIVE CARE FOR THE ELDERLY › Section 471-37-001 - INTRODUCTION

Current through June 17, 2024
This chapter regulates Nebraska's Program of All-Inclusive Care for the
	 Elderly (PACE) provided under Nebraska Medicaid.
001.01 Definitions
Appeal
: The process by which a participant
	 may seek and obtain a review and reversal with respect to enrollment denial;
	 involuntary disenrollment; or non-coverage of, or nonpayment for, a service
	 including denials, reductions, or termination of services.
External appeal:
The State Administering
	 Agency's or Medicare's formal appeal processes.
Grievance
: A complaint, either written or
	 oral, by participants, their family members, and/or representatives expressing
	 dissatisfaction with service delivery or the quality of care furnished.
Internal appeal:
A PACE organization's appeal
	 process.
PACE organization
: An entity that has a PACE
	 program agreement in effect to operate a PACE program.
PACE program
: A program of all-inclusive care
	 for the elderly that is operated by an approved PACE organization and that
	 provides comprehensive healthcare services to PACE participants in accordance
	 with a PACE program agreement.
PACE program agreement
: An agreement between
	 a PACE organization, CMS, and the State Administering Agency for the operation
	 of a PACE program.
Participant
: An individual who is enrolled in
	 a PACE program.
Premium
: The monthly amount that a PACE
	 organization charges a participant as determined by the participant's
	 eligibility status for Medicare and Medicaid pursuant to
	 42
	 CFR 460.186.
State Administering Agency (SAA)
: The State
	 agency responsible for administering the PACE program agreement. In Nebraska
	 the SAA is the Nebraska Department of Health and Human Services, Division of
	 Medicaid and Long-Term Care.
001.02 Legal Basis
PACE is authorized by Sections 1894 and 1934 of the federal Social
	 Security Act. Federal PACE regulations are located at 42 CFR, Part
	 460.
Nebraska Administrative Code › Topic - HEALTH AND HUMAN SERVICES SYSTEM › Title 471 - NEBRASKA MEDICAL ASSISTANCE PROGRAM SERVICES › Chapter 37 - PROGRAM OF ALL-INCLUSIVE CARE FOR THE ELDERLY › Section 471-37-002 - PARTICIPANT ELIGIBILITY

Current through June 17, 2024
002.01 Eligibility Criteria
Participation in PACE is voluntary. PACE eligibility criteria include
	 the following:
1. Be 55 years of age
  or older;
2. Meet the nursing
  facility level of care (NF LOC) criteria (See 471 NAC 12);
3. Live in the service area of the PACE
  organization; and
4. Be able to
  safely live in a community setting, at the time of enrollment, with PACE
  services.
Nebraska Administrative Code › Topic - HEALTH AND HUMAN SERVICES SYSTEM › Title 471 - NEBRASKA MEDICAL ASSISTANCE PROGRAM SERVICES › Chapter 37 - PROGRAM OF ALL-INCLUSIVE CARE FOR THE ELDERLY › Section 471-37-003 - PARTICIPANT ENROLLMENT

Current through June 17, 2024
003.01 Participant Enrollment
A PACE organization shall receive direct inquiries from potential
	 participants. The PACE organization shall verify that the potential participant
	 meets all eligibility criteria as set forth in section
	 37-002 of this
	 chapter.
003.02 Duration of
  Enrollment
Enrollment continues until the PACE participant's death, regardless of
	 changes in health status, unless the participant voluntarily disenrolls or is
	 involuntarily disenrolled by the PACE organization under section 37-006.01 or
	 37-006.02 of this chapter.
Nebraska Administrative Code › Topic - HEALTH AND HUMAN SERVICES SYSTEM › Title 471 - NEBRASKA MEDICAL ASSISTANCE PROGRAM SERVICES › Chapter 37 - PROGRAM OF ALL-INCLUSIVE CARE FOR THE ELDERLY › Section 471-37-004 - PACE BENEFITS

Current through June 17, 2024
004.01 Benefits
The PACE benefit package for all participants, regardless of source of
	 payment, shall include the following:
1. All Medicare-covered items and
  services;
2. All Medicaid-covered
  items and services as specified in Nebraska's approved Medicaid State Plan;
  and
3. Other services determined
  necessary by the PACE organization's interdisciplinary team to improve and
  maintain the participant's overall health status.
Nebraska Administrative Code › Topic - HEALTH AND HUMAN SERVICES SYSTEM › Title 471 - NEBRASKA MEDICAL ASSISTANCE PROGRAM SERVICES › Chapter 37 - PROGRAM OF ALL-INCLUSIVE CARE FOR THE ELDERLY › Section 471-37-005 - PARTICIPANT RIGHTS

Current through June 17, 2024
005.01 Written Explanation
Upon enrollment, a PACE participant shall be informed, in writing, of
	 his/her rights and responsibilities and all rules and regulations governing
	 participation according to
	 42 CFR 460.110 and
	 460.112.
005.02 Grievance Process
Upon enrollment and at least annually thereafter, the PACE organization
	 supply participants written information about its grievance process. In the
	 event of a grievance, the PACE organization shall:
1. Discuss with and provide to the
  participant in writing the specific steps, including timeframes for response,
  that will be taken to resolve the participant's grievance;
2. Continue to furnish all required services
  to the participant during the grievance process.
Nebraska Administrative Code › Topic - HEALTH AND HUMAN SERVICES SYSTEM › Title 471 - NEBRASKA MEDICAL ASSISTANCE PROGRAM SERVICES › Chapter 37 - PROGRAM OF ALL-INCLUSIVE CARE FOR THE ELDERLY › Section 471-37-006 - PARTICIPANT DISENROLLMENT

Current through June 17, 2024
Reasons for disenrollment, either voluntary or involuntary, shall be
	 documented by the PACE organization.
006.01 Voluntary Disenrollment
A participant may voluntarily disenroll from the program without cause
	 at any time, including if he/she no longer meets NF LOC
	 criteria.
006.02 Involuntary
  Disenrollment
A PACE organization may involuntarily disenroll a participant for any
	 of the following reasons:
1. The
  participant fails to pay, or make satisfactory arrangements to pay, any premium
  due the PACE organization after a 30-day grace period.
2. The participant engages in disruptive or
  threatening behavior. Disruptive or threatening behavior is either of the
  following:
a. Behavior that jeopardizes a
  participant's health or safety or the safety of others; or
b. Consistent refusal to comply with an
  individual plan of care or the terms of the PACE enrollment agreement while
  having decision-making capacity.
3. The participant moves out of the PACE
  program service area or is out of the service area for more than 30 consecutive
  days, unless the PACE organization agrees to a longer absence due to
  extenuating circumstances.
4. The
  participant is determined to no longer meet nursing facility level of care and
  is not deemed eligible under section 37-002.06 of this chapter.
5. The PACE organization's agreement with CMS
  and the SAA is not renewed or is terminated.
6. The PACE organization is unable to offer
  required services because of the loss of State licenses or outside provider
  contracts.
37-006.02A
SAA Review and Final Determination
: Before an
  involuntary disenrollment is effective, it shall be reviewed by the SAA and a
  determination made that acceptable grounds for disenrollment have been
  documented by the PACE organization.
37-006.02B
Reinstatement in
  PACE
: A previously disenrolled PACE participant may re-enroll but
  shall do so as a new applicant.
A participant scheduled to be disenrolled for failure to pay his/her
	 premium may be reinstated with no break in coverage if payment is made prior to
	 the effective date of disenrollment. If payment is received after the effective
	 date of disenrollment, the participant shall re-enroll as a new
	 applicant.
Nebraska Administrative Code › Topic - HEALTH AND HUMAN SERVICES SYSTEM › Title 471 - NEBRASKA MEDICAL ASSISTANCE PROGRAM SERVICES › Chapter 37 - PROGRAM OF ALL-INCLUSIVE CARE FOR THE ELDERLY › Section 471-37-007 - PACE ORGANIZATIONS

Current through June 17, 2024
007.01 Agreement
PACE organizations shall have an agreement with CMS and the SAA for the
	 operation of a PACE program. The agreement specifies the prospective monthly
	 capitated Medicaid payment amount as negotiated by the PACE organization and
	 the SAA. The monthly capitated payment may be renegotiated on an annual basis
	 as pursuant to
	 42 CFR
	 460.182.
007.02 Licenses or Credentials
PACE organizations must hold appropriate licenses or credentials as
	 required under state licensing laws.
007.03 Federal Requirements
In addition to the requirements in this chapter, PACE organizations
	 must also meet all applicable federal requirements, including those set forth
	 in 42 CFR, Part 460.
Nebraska Administrative Code › Topic - HEALTH AND HUMAN SERVICES SYSTEM › Title 471 - NEBRASKA MEDICAL ASSISTANCE PROGRAM SERVICES › Chapter 38 - ESTATE RECOVERY › Section 471-38-001 - SCOPE AND AUTHORITY

Current through June 17, 2024
Medicaid estate recovery is mandated by §1917(b) of the Social
	 Security Act and Neb. Rev. Stat. §
									68-919.
Nebraska Administrative Code › Topic - HEALTH AND HUMAN SERVICES SYSTEM › Title 471 - NEBRASKA MEDICAL ASSISTANCE PROGRAM SERVICES › Chapter 38 - ESTATE RECOVERY › Section 471-38-004 - UNDUE HARDSHIP WAIVER

Current through June 17, 2024
004.01 PURPOSE.
  Waivers granted by the Department based on undue hardship are a rare and
  extraordinary remedy intended to prevent the impoverishment of the deceased
  recipient's family if the Department were to pursue an estate-recovery claim.
  Anticipating or expecting an inheritance, or being inconvenienced economically
  by the lack of an inheritance, is not a valid basis for an undue-hardship
  waiver.
004.02 HEIR. Any person who
  could be considered an heir of the now-deceased Medicaid recipient under the
  Probate Code may apply for an undue-hardship waiver.
004.03 CRITERIA. Any of the following
  circumstances may constitute an undue hardship that results in a complete or
  partial waiver of claim:
(A) An heir of the
  recipient resided in the recipient's home for two years prior to the
  recipient's entry into a nursing home and during that time provided the type
  and quantity of unreimbursed care that delayed the recipient's entry into a
  nursing home;
(B) An heir of the
  recipient resided in the recipient's home for two years prior to the
  recipient's receipt of recoverable medical services and during that time
  provided the type and quantity of unreimbursed care that delayed the
  recipient's receipt of those services;
(C) Payment of the Department's claim would
  cause an heir of the deceased recipient to become eligible for public
  assistance;
(D) Waiver of the
  Department's claim would allow an heir to discontinue eligibility for public
  assistance for a substantial time period; or
(E) Other situations that the Department, in
  its discretion and on a case-by-case basis upon consideration of all facts and
  circumstances, determines constitutes an undue hardship.
Nebraska Administrative Code › Topic - HEALTH AND HUMAN SERVICES SYSTEM › Title 471 - NEBRASKA MEDICAL ASSISTANCE PROGRAM SERVICES › Chapter 38 - ESTATE RECOVERY › Section 471-38-005 - LONG-TERM CARE PARTNERSHIP PROGRAM

Current through June 17, 2024
Neb. Rev. Stat. §
									68-1095.01
	 established Nebraska's Long-Term Care Partnership Program
Resources equal to the amount of benefits paid out by a long-term care
	 partnership policy are disregarded for an individual applying for Medicaid if
	 the policy was issued on July 1, 2006 or later and the individual is otherwise
	 Medicaid eligible. The amount of the resource disregard is also excluded from
	 estate recovery.
The Department accepts the Department of Insurance's approval of the
	 policy.
005.01 RECIPROCITY WITH OTHER
  STATES. The Department will accept partnership policies issued in other states
  with Qualified Long-Term Care Partnership Programs that meet the criteria
  established in §1917(b)(1)(C) of the Social Security Act.
Nebraska Administrative Code › Topic - HEALTH AND HUMAN SERVICES SYSTEM › Title 471 - NEBRASKA MEDICAL ASSISTANCE PROGRAM SERVICES › Chapter 39 - NEBRASKA ALTERNATIVE BENEFIT PLANS (ABP) › Section 471-39-001 - 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.
Nebraska Administrative Code › Topic - HEALTH AND HUMAN SERVICES SYSTEM › Title 471 - NEBRASKA MEDICAL ASSISTANCE PROGRAM SERVICES › Chapter 39 - NEBRASKA ALTERNATIVE BENEFIT PLANS (ABP) › Section 471-39-002 - OVERVIEW

Current through June 17, 2024
This chapter details the benefit plans and services offered to
	 eligible adults aged 19 through 64 enrolled in the Heritage Health Adult (HHA)
	 program as described in 477 NAC 29. This benefit plans begins October 1,
	 2021.