Hawaii Administrative Rules
Title 17 - DEPARTMENT OF HUMAN SERVICES
Department of Human Services
Chapter 1739.2 - AUTHORIZATION, PAYMENT, AND CLAIMS IN THE FEE-FOR-SERVICE MEDICAL ASSISTANCE PROGRAM - LONG TERM CARE PROSPECTIVE PAYMENT SYSTEM
Section 17-1739.2-4 - Services included in the basic PPS rate

Universal Citation: HI Admin Rules 17-1739.2-4

Current through August, 2024

(a) The reasonable and necessary costs of providing the following items and services shall be included in the basic PPS rate and shall not be separately reimbursable, unless specifically excluded under subsection (b):

(1) Room and board;

(2) Administration of medication and treatment and all nursing services;

(3) Development, management, and evaluation of the written patient care plan based on physician orders that necessitate the involvement of skilled technical or professional personnel to meet the recipient's care needs, promote recovery, and ensure the recipient's health and safety;

(4) Observation and assessment of the recipient's unstable condition that requires the skills and knowledge of skilled technical or professional personnel to identify and evaluate the recipient's need for possible medical intervention, modification of treatment, or both, to stabilize the recipient's condition;

(5) Health education services, such as gait training and training in the administration of medications, provided by skilled technical or professional personnel to teach the recipient self-care;

(6) Provision of therapeutic diet and dietary supplements as ordered by the attending physician;

(7) Laundry services, including items of recipient's washable personal clothing;

(8) Basic nursing and treatment supplies, such as soap, skin lotion, alcohol, powder, bandages, applicators, tongue depressors, cotton balls, gauze, adhesive tape, incontinent pads, V-pads, thermometers, blood pressure apparatus, plastic or rubber sheets, enema equipment, and douche equipment;

(9) Non-customized durable medical equipment and supplies used by individual recipients, but which are reusable. Examples include items such as ice bags, hot water bottles, urinals, bedpans, commodes, canes, crutches, walkers, wheelchairs, and side-rail and traction equipment;

(10) Activities of the patient's choice (including religious activities) that are designed to provide normal pursuits for physical and psychosocial well being;

(11) Social services provided by qualified personnel;

(12) Maintenance therapy; provided, however, that only the costs that would have been incurred if nursing staff had provided the maintenance therapy will be included in calculating the basic PPS rates;

(13) A review of the drug regimen of each resident at least once a month, by a licensed pharmacist, as required for a nursing facility to participate in Medicaid.

(14) Provision of and payment for, through contractual agreements with appropriate skilled technical or professional personnel, other medical and remedial services ordered by the attending physician which are not regularly provided by the provider. The contractual agreement shall stipulate the responsibilities, functions, objectives, services fee, and other terms agreed to by the provider and the person or entity that contracts to provide the service; and

(15) Recurring, reasonable and incremental costs incurred to comply with OBRA 87.

(b) The costs of providing the following items and services shall be specifically excluded from reimbursement under this chapter, and shall be billed separately to the department by the providers:

(1) Physician services, except those of the medical director and quality assurance or

(2) drug use review board, or all three;

(3) Drugs that are provided to residents in accordance with Title XIX policy;

(4) Laboratory, x-ray, and EKG;

(5) Ambulance and any other transportation for medical reasons that is not provided by the provider and not included in the costs used to calculate the basic PPS rates;

(5) Optical;

(6) Audiology;

(7) Podiatry;

(8) Physical therapy, excluding maintenance therapy;

(9) Occupational therapy, excluding maintenance therapy;

(10) Speech, hearing, and respiratory therapies;

(11) Customized durable medical equipment and such other equipment or items that are designed to meet special needs of a resident and are authorized by the department; and

(12) Charges for ancillary services are not included in calculating the basic PPS rates and shall be paid as follows:

(A) Providers that have the capability shall bill the department separately for ancillary services;

(B) The department shall make an ancillaries payment to providers that it designates as incapable of billing for ancillary services on an itemized basis;

(C) In order to receive an ancillaries payment, the provider must make assurances satisfactory to the department that it is committed to acquiring the ability to bill on an itemized basis for ancillaries, and is pursuing that goal with all deliberate speed;

(D) As part of the FY 98 rebasing, the department shall identify ancillary services for which a provider lacks the ability to bill separately and calculate a per diem amounts as an ancillaries payment ;

(E) No provider that receives an ancillaries payment shall otherwise bill the department separately on behalf of a Title XIX resident for any type of ancillary service that is included in calculating its ancillaries payment. A provider that receives an ancillaries payment must also implement procedures and assure the department that no other person or entity will bill separately for any type of ancillary service that is included in calculating the ancillaries payment;

(F) The provider shall provide to the department upon request the progress that it is making in its efforts to acquire the ability to bill separately for ancillary services. If and when the provider acquires that ability, then it shall promptly notify the department in writing;

(G) Once the department determines that a provider is capable of billing for some or all ancillary services on an itemized basis, then it shall provide advance written notice to that provider of a date upon which it will either cease making or reduce the ancillaries payment. If the provider acquires the capability of billing for some (but not all) ancillary services that were included in calculating its ancillaries payment, then the department shall reduce the ancillaries payment accordingly; and

(H) The department shall make available all necessary data to ensure the appropriate accounting for ancillary services.

(c) The personal funds of medical assistance recipients may not be charged any costs for routine personal hygiene items and services provided by the provider.

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