C.M.R. 10, 144, ch. 110, att. A
The items and services that will be covered by the daily rate at this Facility are based on the Resident's medical needs and depend in part on how the Resident will be paying for his or her care. The chart below summarizes what items and services are currently covered by the daily rate for the different payment sources. An "X" means that the item or service is covered by the Facility's daily rate. These items and services may change from time to time based on changes in Federal or State law and regulation.
This Facility is required to complete this chart for all three payment sources.The Facility should also be able to supply a list of fees charged for any service or item that is listed below but not covered by the Facility's daily rate.
Item or Service: | Payment Source: | ||
Medicaid | Medicare | Private | |
1. Medical Supplies and Durable Medical Equipment, including but not limited to: | |||
Alcohol | X | ||
Alternating pressure pads, air mattresses, "Egg Crate" mattresses, gel mattresses | X | ||
Applicators | X | ||
Bandages, including bandaids and gauze bandages | X | ||
Basins | X | ||
Beds (standard hospital type) and bed rails | X | ||
Bed pans | X | ||
Blood pressure equipment | X | ||
Bottles (water) | X | ||
Canes | X | ||
Catheters and catheter trays (disposable) | X | ||
Chairs (standard, geriatric) | X | ||
Commodes | X | ||
Corner chair | X | ||
Cotton | X | ||
Crutches | X | ||
Cushions (e.g., comfort rings) | X | ||
Disinfectants | X | ||
Douche trays (disposable) | X | ||
Dressings | X | ||
Enema equipment | X | ||
Glucometer | X | ||
General services such as administration of oxygen and related medications, hand feeding, incontinency care, tray service and enemas | X | ||
Gloves (sterile and unsterile) | X | ||
Gowns | X | ||
Ice bags | X | ||
Incontinent supplies (including Chux, Attends, Pampers, plastic pants, liners, etc., all sizes) | X | ||
Irrigation trays | X | ||
Non-prescription medications, including analgesics, Antacids, artificial tears, calcium supplements, cough syrups and expectorants, dietary supplements (including special dietary supplements), hemorrhoid preparations, iron supplements, laxatives, lotions, lubricants, ointments including petroleum jelly, powders (medicated and baby), sunscreen, suppositories, vitamins and non-prescription supplies for decubiti | X | ||
Oxygen, for emergency and as necessary | X | ||
Parenteral/enteral feedings | X | ||
Pillows | X | ||
Pitchers (water) | X | ||
Prone boards | X | ||
Rectal medicated wipes | X | ||
Restraints (posey, thoracic chest supports, tilt in space, Wedge pillows, etc.) | X | ||
Sheepskin | X | ||
Shower chairs and tub seats | X | ||
Specimen containers | X | ||
Sterile I.V. or irrigation solutions | X | ||
Stethoscope | X | ||
Suture sets | X | ||
Swabs, medicated or unmedicated | X | ||
Syringes and needles | X | ||
Tapes | X | ||
Testing materials to be used by staff of Facility | X | ||
Thermometers | X | ||
Tongue depressors | X | ||
Traction equipment | X | ||
Trapezes | X | ||
Tubes (gavage, lavage, etc.) | X | ||
Underpads | X | ||
Urinals | X | ||
Urinary drainage equipment and supplies (disposable) | X | ||
Walkers | X | ||
Wheelchairs (standard, pediatric, "hemi" chairs, reclining wheelchairs) | X | ||
2. Routine personal hygiene items and services as required to meet the needs of the Resident, including but not limited to: | |||
Bathing services | X | ||
Bath soap | X | ||
Brush | X | ||
Comb | X | ||
Cotton balls | X | ||
Cotton swabs | X | ||
Dental floss | X | ||
Denture adhesive | X | ||
Denture cleaner | X | ||
Deodorant | X | ||
Disinfecting soaps or specialized cleansing agents when indicated to treat special skin problems or fight infection | X | ||
Moisturizing lotion | X | ||
Mouthwash | X | ||
Razor | X | ||
Routine hair hygiene services | X | ||
Routine nail hygiene services | X | ||
Sanitary napkins and related supplies | X | ||
Shampoo | X | ||
Shaving cream | X | ||
Soap | X | ||
Tissues | X | ||
Toothbrush | X | ||
Toothpaste | X | ||
Towels | X | ||
Washcloths | X | ||
3. Basic personal laundry services | X | ||
4. Room/bed maintenance services | X | ||
5. Routine activities programs that are required to be provided by the Facility to meet the interests and physical, mental and psychosocial well-being of the Resident | X | ||
6. Routine transportation of the Resident or laboratory specimens to hospital or doctors' offices | X | ||
7. Other personal items and services | |||
Barber and beautician services | |||
Personal clothing other than gowns | |||
Telephone | |||
Television | |||
OTHER | |||
C.M.R. 10, 144, ch. 110, att. A