Current through Register Vol. 48, No. 38, September 20, 2024
a) Residential providers are responsible for
ensuring the provision of a continuous program of active treatment services for
each resident (
42 CFR
483.410(d) and
42 CFR
483.440) . The Department (DPA) will
reimburse SNF, ICF and ICF/MR facilities (including ICF/MR-15 Specialized
Living Centers (SLC), and ICF/MR-SNF/PED) through a separate component of the
per diem for DT services provided to residents who have developmental
disabilities. Such individuals would be identified as needing DT by the
facility's interdisciplinary team. The facilities may contract for these
services from community providers whose programs are certified by the
Department of Mental Health and Developmental Disabilities (DMHDD) or may
provide their own (DT) if the DT Program is certified by the (DMHDD) and
conducted by staff of the DT program. The DT program is defined as the distinct
part of a long term care or residential facility, and/or independent business
entity certified by DMHDD to provide DT services.
b) Billing by the facility and payment by the
Department for each month of active treatment services provided by the facility
includes DT services.
c) Timely
Billing Flow-Through for DT Services
1) Claims
for reimbursement for DT services must be received by the Department no later
than the close of business on the 16th day of the
month following the previous month of DT services. If the
16th day of the month falls on a weekend, billing
must be received by the Department no later than the close of business of the
Friday before that weekend.
2) If
the billing for DT services is not received by the Department as specified in
subsection (c)(1) above, a hold will be placed on the processing of the
facility's claims for reimbursement and subsequent payment for services. The
hold on processing of facility billing and payment for services will be lifted
once the DT billing has been received.
3) The turnaround of DT attendance records
from the DT provider to the facility must also be timely. These records are
utilized by the facility to complete billing forms for DT services. DT
attendance records should be received by the facility by the
7th day of the month following the previous month of
DT services. The facility must notify the Department five (5) working days
before the 16th day of the month if the attendance
records regarding DT services have not been returned to the facility. When DT
billing is late due to a delay by the DT agency in submitting attendance
records, no hold will be placed on facility billings or payments.
d) Timely Payment Flow-Through for
DT Services
1) The facility must flow-through
payments to the DT agency for DT services no later than ten (10) working days
after facility receipt of the payment from the Department, unless the facility
itself operates the DT program. The expected time frame for the DT agency to
receive its flow-through payment is twenty (20) calendar days (5 days in the
mail from the Department to the facility, no more than 10 days to issue
payment, and 5 days in the mail from the facility to the DT agency). Facilities
may incur penalties under Sections
140.16
and
140.17
for violations of this requirement.
2) When the Department is notified that
reimbursement for DT services has not been received by the DT agency within the
specified time frame, Department staff will contact the residential provider
and request a copy of the cancelled check which was issued for DT services. If
the facility is unable to demonstrate to the Department that the DT payment has
been received by the DT agency, the Department will take the actions provided
in subsection (d)(3) below.
3) If
the DT payment has not been received by the DT agency within twenty (20)
calendar days following Department release of the payment to the facility, a
hold will be placed on the processing of facility billing and payment for
facility services. The hold on facility billing and payment will be lifted when
the DT agency has received the outstanding payment for services.
e) Change of Ownership/Operator
1) Billing and payment for DT services must
be processed and either paid in full or incurred as a debt whenever there is a
change in ownership or licensed operator of a Medicaid funded residential
facility. The transaction to change a licensed operator or transfer ownership
must include a recognition of all debts of unprocessed and/or unpaid
billings.
2) The Department will
not enter into a provider agreement with a residential provider unless:
A) payment is made in full for all DT
services by the previous owner/operator; or
B) the amount is incurred as a debt to be
paid in full by the new owner/operator within forty-five (45) calendar days
after becoming the new owner/operator when the Department has paid the facility
in full prior to the change in ownership or licensed operator for all DT
services provided under the previous owner; or
C) the amount is incurred as a debt to be
paid in full by the new owner/operator within ten (10) working days after
facility receipt of the payment from the Department, when such payment reaches
the facility on or after the effective date of the change in ownership or
licensed operator.
3) If
the new owner/operator does not pay the full amount due the DT agency by the
end of the forty-five (45) day period as specified in subsection (e)(2)(B)
above, or by the end of the ten (10) day period as specified in subsection
(e)(2)(C) above, a hold on the reimbursements will be implemented. The hold on
facility billings and payment will be lifted after the DT agency has been paid
in full for the indebted amount.
f) Providers of DT program services will be
responsible for providing any required transportation between the program and
the facility. Reimbursement for transportation costs is included in the DT
program monthly rate as established in Section
140.648.
The DT Program contracting with a long term care or residential facility may
not elect to discontinue the provision of transportation.
g) The term Mentally Retarded and related
conditions, as used in rules contained in Sections
140.646
-
140.652
refers to individuals meeting the definition of Mental Retardation or related
conditions as described in
42 CFR
435.1009(1989).
h) The term "facility" which is used in rules
contained in Sections
140.646
-
140.652
is understood to refer to long term care facilities (ICF and SNF) and
residential facilities (ICF/MR, including ICF/MR-15 and SLC, and
ICF/MR-SNF/PED).
i) Persons with
developmental disabilities who are residents of facilities, and whose public
school special education services have been terminated, are deemed eligible for
DT services.
j) DT programs shall
be subject to review as part of the Department's evaluation of recipient care
under its utilization and medical reviews of long term care and residential
facilities (Section
140.512
).
k) Payment may be approved for
DT services, during a DT participant's hospitalization, for a period not to
exceed 10 days. Such payments:
1) are limited
to individuals who will be returning to the same facility,
2) are a daily rate at 75% of the
individual's current DT per diem rate.
