Section 144-115-17 - COST RELATED TO CARE OF MEMBERS17.1Principle Reimbursement for specified room and board costs shall be proided on a "reasonable cost-related basis" rather than by simply reimbursing the provider's costs. In determining what is a reasonable cost-related basis, all payments must relate to the care of the member and be based on the "reasonable cost." Reasonable costs include all allowable, necessary, and proper costs incurred in rendering room and board to members who are receiving Medical and Remedial Services under the MaineCare program, subject to the Principles relating to specific items of revenue and cost. Costs may not be shifted from Medical and Remedial Services to room and board.
17.1.1 Costs must be ordinary and necessary and related to member services. They must be of the nature and magnitude that prudent and cost conscious management would pay for a specific item or service.17.1.2 Costs must not be of the type conceived for the purpose of circumventing the regulations. Such costs will be disallowed under the principle that the substance of any transaction will prevail over form.17.1.3 Costs that relate to inefficient, unnecessary or luxurious care of facilities (as defined by the Medicare Provider Reimbursement Manual, HIM-15), and to activities not common and accepted in the residential care field are not allowable.17.1.4 Compensation, to be allowable, must be reasonable and for services that are necessary, and pertinent to the operation of the facility. The services must actually be performed and must be paid in full. The compensation must be reported to all appropriate state and federal tax authorities to the extent required by law for income tax, social security, and unemployment insurance purposes. Reimbursement may not be claimed for personal expenses of the provider not related to member care. Bonuses that are part of a written policy of the provider and that require some measurable and attainable employee job performance expectations are allowable. Bonuses based solely on the availability of any anticipated savings are not allowable.
17.1.5 Costs incurred for room and board that are rendered in common to eligible members, as well as to ineligible members, will be allowed on a pro rata basis, unless there is a specific allocation defined elsewhere in these Principles.17.1.6 Effective November 1, 2017, costs incurred by a residential care facility to comply with changes in federal or state laws, regulations, and rules or local ordinances and not otherwise specified in rules adopted by the Department are considered reasonable and necessary costs. Reimbursement for these additional regulatory costs will be paid via a supplemental payment that is added to the per diem rate until the Department adjusts for the routine limit, as applicable, to fairly and properly reimburse facilities for these costs. Requests for rate adjustments must be made in writing and addressed to:
Director of Rate-Setting
11 State House Station
Augusta, ME 04333
The Department may deny or modify the adjustment request based on documentation provided and will provide written notification of adjustment request determination.
17.2Room and Board Reimbursement Rate17.2.1 The reimbursement rate will consist of a rate for routine services, and fixed/capital costs as defined in Principles 20 through 33. It will be offset by the program allowance received by the facility in accordance with the Principles of Reimbursement, Chapter III, Section 97, Appendices C and F.17.2.2 The facility must account for and report all costs. To comply with the MaineCare requirements, the facility must segregate room and board costs from costs related to providing direct services in accordance with the Principles of Reimbursement, Chapter III, Section 97, Appendix C and F.17.2.3 The Department will set interim per diem daily rates as follows: Interim daily rates for Appendix C medical and remedial service facilities, and funded by DHHS, are set by the Office of Rate-Setting, DHHS.
Interim daily rates for Appendix F non-case mixed medical and remedial service facilities, funded by DHHS- Office of Aging and Disability Services, are set by the DHHS, Office of Rate-Setting.
10- 144 C.M.R. ch. 115, § 17