17.1
Principle
Reimbursement for specified room and board costs shall be
proided on a "reasonable cost-related basis" rather than by simply reimbursing
the provider's costs. In determining what is a reasonable cost-related basis,
all payments must relate to the care of the member and be based on the
"reasonable cost." Reasonable costs include all allowable, necessary, and
proper costs incurred in rendering room and board to members who are receiving
Medical and Remedial Services under the MaineCare program, subject to the
Principles relating to specific items of revenue and cost. Costs may not be
shifted from Medical and Remedial Services to room and board.
17.1.1 Costs must be ordinary and necessary
and related to member services. They must be of the nature and magnitude that
prudent and cost conscious management would pay for a specific item or
service.
17.1.2 Costs must not be
of the type conceived for the purpose of circumventing the regulations. Such
costs will be disallowed under the principle that the substance of any
transaction will prevail over form.
17.1.3 Costs that relate to inefficient,
unnecessary or luxurious care of facilities (as defined by the Medicare
Provider Reimbursement Manual, HIM-15), and to activities not common
and accepted in the residential care field are not allowable.
17.1.4 Compensation, to be allowable, must be
reasonable and for services that are necessary, and pertinent to the operation
of the facility. The services must actually be performed and must be paid in
full. The compensation must be reported to all appropriate state and federal
tax authorities to the extent required by law for income tax, social security,
and unemployment insurance purposes.
Reimbursement may not be claimed for personal expenses of
the provider not related to member care. Bonuses that are part of a written
policy of the provider and that require some measurable and attainable employee
job performance expectations are allowable. Bonuses based solely on the
availability of any anticipated savings are not allowable.
17.1.5 Costs incurred for room and board that
are rendered in common to eligible members, as well as to ineligible members,
will be allowed on a pro rata basis, unless there is a specific allocation
defined elsewhere in these Principles.
17.1.6 Effective November 1, 2017, costs
incurred by a residential care facility to comply with changes in federal or
state laws, regulations, and rules or local ordinances and not otherwise
specified in rules adopted by the Department are considered reasonable and
necessary costs. Reimbursement for these additional regulatory costs will be
paid via a supplemental payment that is added to the per diem rate until the
Department adjusts for the routine limit, as applicable, to fairly and properly
reimburse facilities for these costs.
Requests for rate adjustments must be made in writing and
addressed to:
Director of Rate-Setting
11 State House Station
Augusta, ME 04333
The Department may deny or modify the adjustment request
based on documentation provided and will provide written notification of
adjustment request determination.
17.2
Room and Board Reimbursement
Rate
17.2.1 The reimbursement rate will
consist of a rate for routine services, and fixed/capital costs as defined in
Principles 20 through 33. It will be offset by the program allowance received
by the facility in accordance with the Principles of Reimbursement, Chapter
III, Section 97, Appendices C and F.
17.2.2 The facility must account for and
report all costs. To comply with the MaineCare requirements, the facility must
segregate room and board costs from costs related to providing direct services
in accordance with the Principles of Reimbursement, Chapter III, Section 97,
Appendix C and F.
17.2.3 The
Department will set interim per diem daily rates as follows:
Interim daily rates for Appendix C medical and remedial
service facilities, and funded by DHHS, are set by the Office of Rate-Setting,
DHHS.
Interim daily rates for Appendix F non-case mixed medical
and remedial service facilities, funded by DHHS- Office of Aging and Disability
Services, are set by the DHHS, Office of Rate-Setting.
