La. Admin. Code tit. 50 § II-10149

Current through Register Vol. 50, No. 11, November 20, 2024

Section II-10149 - Services and Supplies

A. Regulations pertaining to this subsection are incorporated under the state plan for the Medicaid program and included in the Medicaid Eligibility Manual (MEM).

B. Services and Supplies Included. The nursing facility shall be responsible for providing the following services, supplies, and equipment to Medicaid residents:

1. room, board, and therapeutic diets; and

2. food supplements or food replacements, including at least one brand of each type (i.e., regular, high fiber, diabetic, high nitrogen).

NOTE: This does not include enteral/parenteral nutrients, accessories and/or supplies.

3. General services as listed below:

a. professional nursing services;

b. an activities program with daily supervision of such activities;

c. medically-related social services; and

d. other services provided by required staff in accordance with the plan of care.

4. Personal Care Need. The facility shall provide personal hygiene items and services when needed by residents to include:

a. hair hygiene supplies;

b. comb;

c. brush;

d. bath soap;

e. disinfecting soaps or specialized cleansing agents when indicated to treat special skin problems or to fight infection;

f. razors;

g. shaving cream;

h. toothbrush;

i. toothpaste;

j. denture adhesive;

k. denture cleaner;

l. dental floss;

m. moisturizing lotion;

n. tissues;

o. cotton balls;

p. cotton swabs;

q. deodorant;

r. incontinence supplies;

s. sanitary napkins and related supplies;

t. towels;

u. washcloths;

v. hospital gowns;

w. hair and nail hygiene services;

x. bathing;

y. basic personal laundry;

z. incontinence care.

NOTE: Special hair cuts, permanent waves, and other such services, which are provided by a licensed barber or beautician at the request of the resident shall be paid directly by residents from their personal funds, or by their legal representative or sponsors, unless provided as a free service by the facility.

5. Drugs

a. Over the counter drugs are part of pharmaceutical services that the nursing facility is responsible for providing when it is specified in the resident's plan of care. If the prescribing physician does not specify a particular brand in the written order, a generic equivalent is acceptable. If the physician specified a particular brand, the nursing facility would have to incur the cost of providing that drug. If the physician does not specify a particular brand, but the resident insists on receiving a particular brand, the nursing facility is not required to provide the requested drug. However, if the facility honors the resident's request, it may, after giving appropriate notice, make a charge to the resident's funds for the difference between the cost of the requested item and the cost of the generic.

b. Presceiption drugs prescribed by the attending physician shall be filled by the Pharmacy. Reimbursement shall be made as follows.

i. The pharmacy shall submit claims to the state Medicaid program for drugs covered under the program.

ii. The resident is financially responsible for prescription drugs not covered under the Medicaid program. The limit of the liability is from the resident's resources. A legal representative or sponsor cannot legally be held personally liable for the resident's debt; such person can only be required to pay the resident's debts from the resident's funds. Prior to charging a resident, for a medication, the prescribing physician should be notified that it is not covered by the Medicaid program and asked if an equivalent alternative that is covered can be prescribed. A resident should not be denied a needed medication simply because of inability to pay.

6. Wheelchairs

a. Standard Wheelchair. Standard wheelchairs shall be provided in adequate numbers to meet the temporary mobility or general transporation needs of residents.

b. Customized Wheelchairs. Customized wheelchairs may be obtained for Medicaid recipients with prior authorization through the DME program of Medicaid. If this is not an option for the resident, the nursing facility shall attempt to arrange for the provision of customized wheelchairs as needed through family, community resources, etc. Customized wheelchairs purchased by the nursing facility shall be allowable in the cost report.

Repairs to a wheelchair owned by a resident are not the responsibility of the facility. For residents who are unable to pay for such repairs, the facility shall assist them in finding alternative funding sources.

7. Other. The facility shall also provide an adequate number of the following items:

a. standard, adjustable walkers;

b. crutches;

c. over-bed tables;

d. bedside commodes;

e. lifts;

f. restraints;

g. sheepskins or similar decubitus prevention and treatment devices;

h. mechanical supports such as Posey vest-type;

i. suction machines for general use (DME Program will purchase, with prior approval, suction machines and other related equipment for those residents meeting the DME program need requirements);

j. glucometers and diabetic supplies;

k. blood pressure cuffs;

l. stethoscopes;

m. other such items which are generally a part of nursing facility treatment.

NOTE: A facility is not required to provide clothing except in emergency situations. If provided, it shall be of reasonable fit.

C. Medical Supplies. The facility shall provide the following apparatus:

1. all types of syringes and needles;

2. I-V set-ups;

3. tubing and bags of all kinds except those provided through other funding sources;

4. gauze;

5. bandages;

6. thin film wound dressings (Tegraderm, Duoderm, and similar products); and

7. non-adhering dressings (Telfa or similar products).

D. Incontinent Care and Supplies. The facility must provide incontinent supplies as needed to meet the needs of residents. The cost shall not be passed on to the resident or resident's legal representative or sponsor as it is included in the reimbursement rate. Neither shall such items be billed to other payment sources when reimbursement is being made by Medicaid through the rate as this constitutes a duplication of billing. If, however, the family or resident elects to purchase supplies other than what is provided by the facility, the facility is not obligated to pay for such supplies.

E. Catheters. The facility shall provide all supplies needed to perform intermittent catheterization.

EXCEPTION: Facilities are not required to provide supplies used for inserting indwelling catheters. These indwelling catheters and catheter trays may be purchased through the Medicaid Pharmacy Program or through Medicare if the resident is eligible for Medicare Part B.

F. Laundry. The facility shall provide laundry services, including personal laundry, for residents.

EXCEPTION: Dry cleaning and/or laundering of hand-washable garments is not a provision of this service.

G. Oxygen. The facility shall provide oxygen for use on a temporary or emergency basis. The facility shall also be responsible for arranging for oxygen required on a long term basis. With prior approval and when the resident's condition requires, based on specific criteria of blood gases at room air, the Medicaid program will purchase or rent an oxygen concentrator.

H. Services and Supplies Excluded. Listed below are general categories and examples of items and services that the facility may charge to residents if they are requested:

1. telephone;

2. television/radio for personal use;

3. personal comfort items, including smoking materials, notions and novelties, and confections;

4. cosmetic and grooming items and services in excess of those for which payment is made under Medicaid or Medicare;

5. personal clothing;

6. personal reading matter;

7. gifts purchased on behalf of a resident;

8. flowers and plants;

9. non-covered special care services such as privately hired nurses or aides;

10. private room, except when therapeutically required (for example, isolation for infection control); and

11. specially prepared food requested instead of the food generally prepared by the facility.

I. Requests For Items and Services

1. The facility shall not charge a resident (or his or her representative) for any item or service not requested by the resident.

2. The facility shall not require a resident (or his or her representative) to request any item or service as a condition of admission or continued stay.

3. The facility shall inform the resident (or his or her representative) requesting an item or service for which a charge will be made, that there will be a charge for the item or service and what the charge will be.

4. A facility's general accommodations are rooms shared by two or more residents. Private rooms are not included in the vendor payments.

J. Ventilator Equipment

1. The Louisiana Medicaid Program will cover ventilator equipment required by dually eligible Medicare and Medicaid recipients in nursing facilities as this is not a covered service under Medicare. Medicaid cannot provide this equipment to individuals in a skilled nursing facility until after 20 days have elapsed from the nursing facility admit date.

2. Department of Health and Hospitals encourages the nursing facility staff to work with families in returning life-saving equipment (such as ventilators) to the nursing facility for use by other Medicaid residents.

K. Multiple Billing and Arrangements For Services Not Included in The Vendor Payment. The facility shall not bill the resident or responsible party for services or supplies included in the vendor payment.

1. All Medicaid benefits available must be utilized before residents or responsible parties can be charged for services in the facility. This includes payment for reserving beds.

a. The nursing facility may bill residents or their responsible parties for reserving beds after the Medicaid Program limits at the Medicaid rate are exceeded.

b. Facilities shall not impose policies regarding bed reservations which are more restrictive than BHSF regulations.

L. Oxygen Concentrator. The facility may request authorization for payment of an oxygen concentrator from the Durable Medical Equipment Program.

1. The medical criteria used to determine need follows the same requirements established by Medicare.

2. The medical criteria used is available in written form from the Health Standard Regional Office upon request.

NOTE: Items purchased through the Medicaid Durable Medical Equipment (DME) Program shall not be included in the facility's cost report.

M. Colostomy Bags and Colostomy Equipment. These items may be purchased with prior authorization from the Medicaid Program or through Medicare if the patient is eligible for Medicare Part B.

N. Payor of Last Resort. Medicaid is the payor of last resort. Charges shall not be made to the Medicaid Program for any benefits for which the resident is eligible under Title XVIII (Medicare) or other third party insurance coverage.

O. Sitters. A facility shall neither expect nor require a resident to have a sitter. The use of sitters shall be entirely at the discretion of the resident or his legal representative or sponsor. Family members may also elect to use sitters unless the resident or his/her legal representative or sponsor expresses a contrary intent.

1. The facility shall not be responsible for paying the sitter.

2. A sitter shall be expected to abide by the facility's rules and regulations, including health standards and professional ethics. The facility shall provide written notice of violations to the resident, his/her legal representative or sponsor any family member who hired the sitter and to the BHSF-HSS Regional Office.

3. Prescence of a sitter does not absolve the facility of its full responsibility for the resident's care.

4. Office of Secretary to furnish the Bureau of Health Services Financing-Health Standards Section with an initial cost report from the date of purchase or lease to the new fiscal year end selected by the new legal entity. Thereafter, the facility shall file a cost report annually on the purchaser's designated year end.

P. Cost Report. Facilities shall be required to submit cost reports within 90 days from their fiscal year end. A separate report must be completed and submitted for all related:

a) home office,

b) central office and/or,

c) management company costs included in the nursing home cost report. Facilities may select any annual period of cost reporting purposes. However, once a facility has made a selection and reported accordingly, the cost report is to be submitted on the same due date unless a change in the reporting period is approved by the BHSF.

La. Admin. Code tit. 50, § II-10149

Promulgated by the Department of Health and Hospitals, Office of the Secretary, Bureau of Health Services Financing, LR 22:34 (January 1996).

AUTHORITY NOTE: Promulgated in accordance with R.S. 46:153.