C.M.R. 10, 144, ch. 101, ch. III, 144-101-III-67, subsec. 144-101-III-67-38

Current through 2024-51, December 18, 2024

Subsection 144-101-III-67-38 - INTENSIVE REHABILITATION NF SERVICES FOR INDIVIDUALS WITH ACQUIRED BRAIN INJURY (ABI)

It has been determined that the reasonable cost of comprehensive rehabilitative services of acquired brain injury is an allowable cost. This requires that the facility possess characteristics, both in terms of staffing and physical design, which meet the requirements of providing comprehensive rehabilitative ABI services. The Department will require that the facility obtain prior approval of its staffing pattern for the nursing and clinical staff associated with the ABI unit from the Office of MaineCare Services. In the event a facility believes that the needs of the residents it serves have increased or decreased, the facility must request prior approval from the Office of MaineCare Services authorizing such a change to its staffing pattern/reimbursement rate.

The Department will recognize NF-ABI services when they are a distinct part of a dual licensed nursing facility. The facility will be reimbursed for the average annual per diem cost for ABI rehabilitative services, for individuals classified as eligible for ABI services in accordance with Chapter II, Section 67 of the MaineCare Benefits Manual. There can be no duplication of services with other providers if clinical and therapy services are included in the facility's staffing/reimbursement rate.

38.1Principle. A nursing facility which has a recognized ABI unit will be reimbursed for services provided to members covered under MaineCare based upon the actual cost of services provided. The Department will establish the rate and determine that the cost is reasonable and adequate to be an efficiently and economically operated facility in order to provide care and services in conformity with applicable state and federal laws, regulations and quality and safety standards.

38.2Cost. The Department's payments made for allowable ABI services provided will be based on the actual cost of services provided. The allowable per diem cost for ABI services will include a direct care price, a routine service component, a rehabilitative ancillary service component, and a fixed cost component.

38.2.1 The direct care price will be determined by the Office of MaineCare Services. It will be increased annually by the rate of inflation, as defined in Principle 31, at the beginning of a facility's fiscal year. This direct care price is not subject to audit. The Direct Care price times the number of Acquired Brain Injury days of service will be removed from the total Direct Care Cost in determining the allowable cost for the NF level of care.

38.2.2 The Routine Cost component rate will be increased annually by the rate of inflation, as defined in Principle 31, at the beginning of a facility's fiscal year.

These routine costs will be cost settled on an annual basis at the end of the facility's fiscal year. They will be based on actual costs allocated to Acquired Brain Injury services in accordance with the allocations defined in Principle 7.10 of these Principles.

38.2.3 Rehabilitative ancillary services included in the care of an individual with brain injured residing in a recognized ABI unit shall be considered an allowable cost.

Covered ancillary services must meet the requirements and definitions under Medicare regulations. These rehabilitative costs will be increased annually by the rate of inflation, as defined in Principle 31, at the beginning of a facility's fiscal year. These costs will be cost settled on an annual basis at the end of the facility's fiscal year. They will be based on actual costs allocated to Brain Injury services in accordance will the allocations defined in Principle 7.10 of these Principles.

38.2.4Fixed Costs. Fixed Costs are an allowable cost as defined in Principle 18 of these Principles. These costs will be cost settled on an annual basis at the end of the facility's fiscal year. They will be based on actual costs allocated to Acquired Brain Injury services in accordance will the allocations defined in Principle 7.10 of these Principles.

38.3Rehabilitative ancillary services are not subject to the routine service cost limitations.

Rehabilitative ancillary services include:

-Physical Therapy Services

-Occupational Therapy Services

-Speech Pathology Services

-Respiratory Therapy Services

-Recreational Therapy Services

-Physiatry Evaluation and Consultation Services -Neuropsychology Evaluation and Consultation Services -Psychology Evaluation and Consultation Services

38.4Cost Reporting. Costs will be reported on forms provided by the Department that will segregate NF-ABI routine costs and ABI ancillary costs from standard NF costs.

For the purpose of calculating a separate NF-ABI rate, whether interim or final, a facility that has been granted a special NF-ABI rate for a distinct part shall allocate its costs to the distinct part as the distinct part were licensed as a separate level of care. All other principles pertaining to that allowability, recording and reporting of costs shall apply.

C.M.R. 10, 144, ch. 101, ch. III, 144-101-III-67, subsec. 144-101-III-67-38