Code of Maine Rules
10 - DEPARTMENT OF HEALTH AND HUMAN SERVICES
144 - DEPARTMENT OF HEALTH AND HUMAN SERVICES - GENERAL
Chapter 115 - PRINCIPLES OF REIMBURSEMENT FOR RESIDENTIAL CARE FACILITIES - ROOM AND BOARD COSTS
Section 144-115-14 - REIMBURSEMENT METHOD

Universal Citation: 10 ME Code Rules ยง 144-115-14

Current through 2024-38, September 18, 2024

14.1 All facilities must be appropriately licensed by the Division of Licensing and Certification and have signed a Provider/Supplier Agreement with DHHS, Office of MaineCare Services, in order to be reimbursed.

14.2 Subject to the availability of funds, the Department will reimburse Appendix C and F, Level III and Level IV Private Non-Medical Institutions (PNMI) facilities defined under the MBM, Chapter III, Section 97, Appendix C and F for allowable room and board costs as defined in this Chapter.

14.3 Residential care facilities will be reimbursed for allowable room and board costs provided to eligible members based on an interim rate established by the Department. The Department will establish an interim rate based on what it determines is reasonable and adequate to meet the costs which must be incurred by an efficiently and economically operated facility in conformity with applicable State and Federal laws, regulations and quality and safety standards.

14.3.1 The Department will furnish blank cost reports to the facilities for their use. The facility's financial statements will be the basis for completing the cost report and establishing an interim rate of reimbursement.

14.3.2 Facilities are required to submit annual cost reports as stated in Section 18.4.

14.3.3 Written requests for interpretation of these Principles will be responded to in writing by the Department, and copies of these interpretation letters will be available to all interested parties.

14.3.4 In facilities licensed for nursing and residential care, the cost finding method contained in Section 18.3 of these Principles applies. All other Principles pertaining to the treatment of costs in these rules will also apply. Multi-level facilities must use the nursing facility cost report form.

14.3.5 The Department reserves the right to take legal action against, and/or terminate the MaineCare Provider/Supplier Agreement of a facility which fails to comply with these Principles, or which submits or causes to be submitted false information for the purpose of obtaining greater compensation than that to which the provider is legally entitled.

14.3.6 The failure of the Department to insist upon the performance of any of the terms or conditions of these Principles, or to exercise any right under these Principles, or to disapprove of any practice, accounting procedure or item of account in any audit, shall not be construed as a waiver of future performance of the right. The obligation of the Provider with respect to future performance shall continue, and the Department shall not be prevented from requiring such future performance.

14.3.7 No final audit shall be reopened, or any hearing allowed, concerning matters contained in any final audit if three (3) years following the date of the final audit settlement have passed. This limitation does not apply in the event of fraud or misrepresentation.

14.4 Allowability of Costs

If these Principles do not set forth a determination of whether or not a cost is allowable or sufficiently define a term used, reference will be made first, to the Medicare Provider Reimbursement Manual (HIM-15) guidelines followed by the Internal Revenue Service Guidelines in effect at the time of such determination if the HIM-15 is silent on the issues.

14.5 Remote Island Supplemental Payment

An Appendix C PNMI that qualifies as a "remote island facility" under this section will receive a fifteen (15) percent supplemental payment in addition to their MaineCare Room and Board rate. This increase will apply only to facilities located on an island not connected to the mainland by a bridge.

Disclaimer: These regulations may not be the most recent version. Maine may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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