Code of Maine Rules
10 - DEPARTMENT OF HEALTH AND HUMAN SERVICES
144 - DEPARTMENT OF HEALTH AND HUMAN SERVICES - GENERAL
Chapter 101 - MAINECARE BENEFITS MANUAL (FORMERLY MAINE MEDICAL ASSISTANCE MANUAL)
Chapter III - Allowances for Services
Section 144-101-III-50 - Principles of Reimbursement for Intermediate Care Facilities for the Mentally Retarded
Subsection 144-101-III-50-8000 - APPEAL PROCEDURES - DEFICIENCY RATE - RATE LIMITATION
Current through 2024-38, September 18, 2024
8010 Procedures
Only issues presented in the informal review will be considered at the administrative hearing. A request for an administrative hearing must be made, in writing, within sixty (60) days of receipt of the decision made as a result of the informal review.
8020 [Reserved]
8030 [Reserved]
8040 Deficiency per diem rate. When a facility is found not to have provided the quality of service or level of care required, reimbursement will be made on ninety (90%) of the provider's per diem rate. This "deficiency rate" will be applied following written notification to the facility of the effective date of the reduced rate for any of the following service deficiencies:
8041 Staffing over a period of two (2) weeks or more does not meet the Federal Certification and State Licensing requirements, except where there is written documentation of a good faith effort to employ licensed nurses to meet the licensed nurse requirements over and above the full time director of nursing;
8042 Food service does not meet the Federal Certification and State Licensing requirements;
8043 Specific, documented evidence that the care provided does not meet the Federal Certification and State Licensing requirements. Such penalty to be effective no sooner than thirty (30) days from written notification that such deficiencies exist;
8044 Failure to correct, within the time frames of an accepted Plan of Correction, deficiencies in meeting the Federal Certification and State Licensing requirements, which cause a threat to the health and safety of members in a facility or the surrounding community;
8045 Failure to submit acceptable cost reports and maintain auditable records as required. A reduction in rate because of service deficiencies shall remain in effect until the deficiencies have been corrected, as verified by representatives of the Department of Health and Human Services, following written notification by the provider that the deficiencies no longer exist. No retroactive adjustments to the full rate shall be made for the period that the deficiency rate is in effect.
8050 Limitation
8051 In no case may payment exceed the facility's customary charges to the general public for such services. This determination will be based on the Principles described in the Medicare Provider Reimbursement Manual (CMS Pub15) in effect at the time of such determination.
