Current through Register Vol. 50, No. 9, September 20, 2024
A. Regulations
pertaining to this subsection are incorporated under the state plan for the
Medicaid program and included in the Medicaid Eligibility Manual
(MEM).
B. Services and Supplies
Included. The nursing facility shall be responsible for providing the following
services, supplies, and equipment to Medicaid residents:
1. room, board, and therapeutic diets;
and
2. food supplements or food
replacements, including at least one brand of each type (i.e., regular, high
fiber, diabetic, high nitrogen).
NOTE: This does not include enteral/parenteral nutrients,
accessories and/or supplies.
3. General services as listed below:
a. professional nursing services;
b. an activities program with daily
supervision of such activities;
c.
medically-related social services; and
d. other services provided by required staff
in accordance with the plan of care.
4. Personal Care Need. The facility shall
provide personal hygiene items and services when needed by residents to
include:
a. hair hygiene supplies;
b. comb;
c. brush;
d. bath soap;
e. disinfecting soaps or specialized
cleansing agents when indicated to treat special skin problems or to fight
infection;
f. razors;
g. shaving cream;
h. toothbrush;
i. toothpaste;
j. denture adhesive;
k. denture cleaner;
l. dental floss;
m. moisturizing lotion;
n. tissues;
o. cotton balls;
p. cotton swabs;
q. deodorant;
r. incontinence supplies;
s. sanitary napkins and related
supplies;
t. towels;
u. washcloths;
v. hospital gowns;
w. hair and nail hygiene services;
x. bathing;
y. basic personal laundry;
z. incontinence care.
NOTE: Special hair cuts, permanent waves, and other such
services, which are provided by a licensed barber or beautician at the request
of the resident shall be paid directly by residents from their personal funds,
or by their legal representative or sponsors, unless provided as a free service
by the facility.
5. Drugs
a.
Over the counter drugs are part of pharmaceutical services that the nursing
facility is responsible for providing when it is specified in the resident's
plan of care. If the prescribing physician does not specify a particular brand
in the written order, a generic equivalent is acceptable. If the physician
specified a particular brand, the nursing facility would have to incur the cost
of providing that drug. If the physician does not specify a particular brand,
but the resident insists on receiving a particular brand, the nursing facility
is not required to provide the requested drug. However, if the facility honors
the resident's request, it may, after giving appropriate notice, make a charge
to the resident's funds for the difference between the cost of the requested
item and the cost of the generic.
b. Presceiption drugs prescribed by the
attending physician shall be filled by the Pharmacy. Reimbursement shall be
made as follows.
i. The pharmacy shall submit
claims to the state Medicaid program for drugs covered under the
program.
ii. The resident is
financially responsible for prescription drugs not covered under the Medicaid
program. The limit of the liability is from the resident's resources. A legal
representative or sponsor cannot legally be held personally liable for the
resident's debt; such person can only be required to pay the resident's debts
from the resident's funds. Prior to charging a resident, for a medication, the
prescribing physician should be notified that it is not covered by the Medicaid
program and asked if an equivalent alternative that is covered can be
prescribed. A resident should not be denied a needed medication simply because
of inability to pay.
6. Wheelchairs
a. Standard Wheelchair. Standard wheelchairs
shall be provided in adequate numbers to meet the temporary mobility or general
transporation needs of residents.
b. Customized Wheelchairs. Customized
wheelchairs may be obtained for Medicaid recipients with prior authorization
through the DME program of Medicaid. If this is not an option for the resident,
the nursing facility shall attempt to arrange for the provision of customized
wheelchairs as needed through family, community resources, etc. Customized
wheelchairs purchased by the nursing facility shall be allowable in the cost
report.
Repairs to a wheelchair owned by a resident are not the
responsibility of the facility. For residents who are unable to pay for such
repairs, the facility shall assist them in finding alternative funding
sources.
7.
Other. The facility shall also provide an adequate number of the following
items:
a. standard, adjustable
walkers;
b. crutches;
c. over-bed tables;
d. bedside commodes;
e. lifts;
f. restraints;
g. sheepskins or similar decubitus prevention
and treatment devices;
h.
mechanical supports such as Posey vest-type;
i. suction machines for general use (DME
Program will purchase, with prior approval, suction machines and other related
equipment for those residents meeting the DME program need
requirements);
j. glucometers and
diabetic supplies;
k. blood
pressure cuffs;
l.
stethoscopes;
m. other such items
which are generally a part of nursing facility treatment.
NOTE: A facility is not required to provide clothing
except in emergency situations. If provided, it shall be of reasonable
fit.
C. Medical Supplies. The facility shall
provide the following apparatus:
1. all types
of syringes and needles;
2. I-V
set-ups;
3. tubing and bags of all
kinds except those provided through other funding sources;
4. gauze;
5. bandages;
6. thin film wound dressings (Tegraderm,
Duoderm, and similar products); and
7. non-adhering dressings (Telfa or similar
products).
D.
Incontinent Care and Supplies. The facility must provide incontinent supplies
as needed to meet the needs of residents. The cost shall not be passed on to
the resident or resident's legal representative or sponsor as it is included in
the reimbursement rate. Neither shall such items be billed to other payment
sources when reimbursement is being made by Medicaid through the rate as this
constitutes a duplication of billing. If, however, the family or resident
elects to purchase supplies other than what is provided by the facility, the
facility is not obligated to pay for such supplies.
E. Catheters. The facility shall provide all
supplies needed to perform intermittent catheterization.
EXCEPTION: Facilities are not required to provide
supplies used for inserting indwelling catheters. These indwelling catheters
and catheter trays may be purchased through the Medicaid Pharmacy Program or
through Medicare if the resident is eligible for Medicare Part B.
F. Laundry. The facility shall
provide laundry services, including personal laundry, for residents.
EXCEPTION: Dry cleaning and/or laundering of
hand-washable garments is not a provision of this service.
G. Oxygen. The facility shall provide oxygen
for use on a temporary or emergency basis. The facility shall also be
responsible for arranging for oxygen required on a long term basis. With prior
approval and when the resident's condition requires, based on specific criteria
of blood gases at room air, the Medicaid program will purchase or rent an
oxygen concentrator.
H. Services
and Supplies Excluded. Listed below are general categories and examples of
items and services that the facility may charge to residents if they are
requested:
1. telephone;
2. television/radio for personal
use;
3. personal comfort items,
including smoking materials, notions and novelties, and confections;
4. cosmetic and grooming items and services
in excess of those for which payment is made under Medicaid or
Medicare;
5. personal
clothing;
6. personal reading
matter;
7. gifts purchased on
behalf of a resident;
8. flowers
and plants;
9. non-covered special
care services such as privately hired nurses or aides;
10. private room, except when therapeutically
required (for example, isolation for infection control); and
11. specially prepared food requested instead
of the food generally prepared by the facility.
I. Requests For Items and Services
1. The facility shall not charge a resident
(or his or her representative) for any item or service not requested by the
resident.
2. The facility shall not
require a resident (or his or her representative) to request any item or
service as a condition of admission or continued stay.
3. The facility shall inform the resident (or
his or her representative) requesting an item or service for which a charge
will be made, that there will be a charge for the item or service and what the
charge will be.
4. A facility's
general accommodations are rooms shared by two or more residents. Private rooms
are not included in the vendor payments.
J. Ventilator Equipment
1. The Louisiana Medicaid Program will cover
ventilator equipment required by dually eligible Medicare and Medicaid
recipients in nursing facilities as this is not a covered service under
Medicare. Medicaid cannot provide this equipment to individuals in a skilled
nursing facility until after 20 days have elapsed from the nursing facility
admit date.
2. Department of Health
and Hospitals encourages the nursing facility staff to work with families in
returning life-saving equipment (such as ventilators) to the nursing facility
for use by other Medicaid residents.
K. Multiple Billing and Arrangements For
Services Not Included in The Vendor Payment. The facility shall not bill the
resident or responsible party for services or supplies included in the vendor
payment.
1. All Medicaid benefits available
must be utilized before residents or responsible parties can be charged for
services in the facility. This includes payment for reserving beds.
a. The nursing facility may bill residents or
their responsible parties for reserving beds after the Medicaid Program limits
at the Medicaid rate are exceeded.
b. Facilities shall not impose policies
regarding bed reservations which are more restrictive than BHSF
regulations.
L. Oxygen Concentrator. The facility may
request authorization for payment of an oxygen concentrator from the Durable
Medical Equipment Program.
1. The medical
criteria used to determine need follows the same requirements established by
Medicare.
2. The medical criteria
used is available in written form from the Health Standard Regional Office upon
request.
NOTE: Items purchased through the Medicaid Durable
Medical Equipment (DME) Program shall not be included in the facility's cost
report.
M.
Colostomy Bags and Colostomy Equipment. These items may be purchased with prior
authorization from the Medicaid Program or through Medicare if the patient is
eligible for Medicare Part B.
N.
Payor of Last Resort. Medicaid is the payor of last resort. Charges shall not
be made to the Medicaid Program for any benefits for which the resident is
eligible under Title XVIII (Medicare) or other third party insurance
coverage.
O. Sitters. A facility
shall neither expect nor require a resident to have a sitter. The use of
sitters shall be entirely at the discretion of the resident or his legal
representative or sponsor. Family members may also elect to use sitters unless
the resident or his/her legal representative or sponsor expresses a contrary
intent.
1. The facility shall not be
responsible for paying the sitter.
2. A sitter shall be expected to abide by the
facility's rules and regulations, including health standards and professional
ethics. The facility shall provide written notice of violations to the
resident, his/her legal representative or sponsor any family member who hired
the sitter and to the BHSF-HSS Regional Office.
3. Prescence of a sitter does not absolve the
facility of its full responsibility for the resident's care.
4. Office of Secretary to furnish the Bureau
of Health Services Financing-Health Standards Section with an initial cost
report from the date of purchase or lease to the new fiscal year end selected
by the new legal entity. Thereafter, the facility shall file a cost report
annually on the purchaser's designated year end.
P. Cost Report. Facilities shall be required
to submit cost reports within 90 days from their fiscal year end. A separate
report must be completed and submitted for all related:
a) home office,
b) central office and/or,
c) management company costs included in the nursing
home cost report. Facilities may select any annual period of cost reporting
purposes. However, once a facility has made a selection and reported
accordingly, the cost report is to be submitted on the same due date unless a
change in the reporting period is approved by the BHSF.
AUTHORITY NOTE:
Promulgated in accordance with
R.S.
46:153.
