Current through 2024-38, September 18, 2024
34.1
Per Diem
Costs
34.1.1
For DHHS Licensed
Facilities-Appendix C (Other than Adult Intellectual Disability
Facilities):
Principle. Payment of routine services costs will be made
prospectively by the Department using audited 1998 costs (as filed or pro forma
costs used in rate setting for new facilities) as a base year, inflated by the
DRI index to July 1, 2001. The Department will set the routine services per
diem for each facility at the lesser of the facility-specific inflated base
year rate or the upper limit, whichever is less, and as of July 1, 2004, will
reduce this amount by twenty-fivecent (25¢) per diem. This becomes the
facility-specific cap. Providers will be reimbursed for the average annual per
diem cost for routine services up to the facility-specific cap. The average
annual per diem cost for routine multiplied by bed days of care provided to
members will determine reimbursement. Routine costs will be off set by the
program allowance paid by the MaineCare program in accordance with Section
33.
Effective July 1, 2001, the Commissioner of DHHS has set the
gross upper limit on routine costs per day at twenty-four dollars and
ninety-five cents ($24.95) for facilities with twenty-four (24) or fewer beds,
twenty-eight dollars and fifteen cents ($28.15) for facilities with twenty-five
(25) or more beds, and thirty-two dollars and seventy cents ($32.70) for
specialty Alzheimer's facilities. This will be offset by the program allowance.
For facilities that receive MaineCare payments for medical and remedial
services under Section 97, Chapters II and III, Appendix C of the MBM, the
Department may approve routine costs in excess of these amounts upon
justification by the provider. In that event, the approved costs become the
facility-specific caps, and the facility will not be subject to the upper limit
contained in Section 34.1.1. In either event, as of July 1, 2004, the
Department will reduce that amount by twenty-five cent (25¢) per
diem.
34.1.2
For DHHS
Licensed Facilities-Appendix F-Office of Aging and Disability Services
Effective July 1, 2001, DHHS Aging and Disability Services
has set the upper limit on routine per diem costs at fourteen dollars and six
cents ($14.06). This is the net after the program allowance has been offset.
Subsequent to that date, the upper limit will be adjusted annually to reflect
the DRI index. For facilities funded by DHHS Aging and Disability Services,
costs will be set prospectively using audited FY 1996 costs, removing medical
supplies, inflated by the DRI index for FY 2001. Routine costs will be offset
by the program allowance paid by the MaineCare Program in accordance with
Section
33.
34.2
Bed-Hold Days
Providers may be reimbursed for up to thirty bedhold days
per calendar year when the resident is absent from the facility. Billing codes
are BL and MRBL.
34.3
Occupancy Adjustments
34.3.1
Principle. To the extent that per diem costs are allowable, such
costs will be adjusted for providers with one (1) level of care whose annual
level of occupancy is less than ninety percent (90%). The adjustment to the per
diem costs shall be based on a theoretical level of occupancy of ninety percent
(90%).
The above percentage level is eighty percent (80%) in those
facilities licensed as Level III facilities.
34.3.1(a) For new providers whose first
fiscal year of operation for audit reporting purposes will include nine months
or less, the actual member census will be used, and the cap on routine services
will bewaived. For new providers coming into the system whose first fiscal year
of operation for audit reporting purposes will include a period of time greater
than nine (9) months, the ninety percent (90%) (and 80% in those facilities
licensed as Level III facilities), occupancy adjustment will not apply for the
first ninety (90) days of operation.
34.3.1(b) For all subsequent cost reporting
periods after the reporting periods addressed in Section 34.3.1(a), the ninety
percent (90%) and eighty percent (80%) occupancy requirements as stated in
Section 34.3.1 will apply.
34.3.2
Persons Living in Facilities Who
Are Not Members.In the event owners, employees, or others reside in the
facility, all costs will be pro-rated over the total number of people residing
there. Only those pro-rated costs related to serving members will be considered
as allowable costs. Only the pro-rated share of utilities and food will be
deducted in determining allowable costs in non-profit facilities, because the
live-in staff has no ownership in the non-profit home. The following factors
will be considered in determining if persons are residing in the facility: they
generally treat the facility as if it were their home, they have no other
permanent residence, they receive personal mail at the facility, they maintain
their personal belongings at the facility, or they sleep in the facility, or
they sleep in the facility for extended periods of time.
34.4
Rates for New Facilities
34.4.1
Principle. For facilities
opened after July 1, 2001, the Department must approve a facility's initial
routine and capital/fixed costs in order to receive payment under these
Principles. A pro forma cost report and supporting documentation detailing the
provider's total operating costs, including proposed direct care costs that
will be covered by MaineCare, routine operating costs and capital/fixed costs,
must be submitted in order to establish the initial interim rate. Required data
includes ownership interests, related partyinterests, projected financial
statements, sources and uses of funds, terms of any new or existing borrowing,
detail of the total estimated/actual project costs such as for land,
building/renovations/construction, equipment and soft costs, depreciation
schedule, startup cost budget, and staffing schedule. This information will be
provided on forms approved by the Department and must be of sufficient detail
to substantiate costs projected on the pro forma cost report. The capital cost
data will be reviewed by the Department and a calculation will be made of the
maximum amount that the Department may reimburse for depreciation expense,
interest expense, and start-up costs, there by, establishing the provider's
depreciable basis or historical cost. The interim rate for routine costs will
be approved at the lesser of the pro forma cost report or the estimate average
routine costs for the industry. Future routine cost caps will be established
based on the audited costs for the first complete year of operation, subject to
the upper limit.
34.4.2 The interim
payment rate will be used to calculate over or underpayment to the provider
after the provider submits a report of actual operating expenses and financial
statements and the DHHS, Division of Audit, completes an audit of the
provider's records.
34.4.3
Subsequent rates for the routine component will be calculated by taking the
audited allowable routine costs (subject to the upper limit) for the first
complete operating period and inflating them forward to the rate setting
period. Capital/fixed costs will be based on actual allowable costs for the
prior year and will not be inflated.
34.5
Final Settlements
34.5.1 After completion of the final audit,
all overpayments or underpayments will be adjusted on a lump sum basis or as
stated in Section
15. The final audit may consist of a
full scope examination by the DHHS, Division of Audit personnel, and will be
conducted on an annual basis.
Reimbursement will be limited to the total actual allowable
fixed and routine service costs, not to exceed the facility-specific cap set
for routine service costs per Section 34.1.1. These total allowable costs shall
be divided by the actual number of bed days, or ninety percent (90%) of
licensed capacity, whichever is greater (five (5) and six (6) bed facilities
may use eighty percent ( 80%) of licensed capacity), in order to determine a
cost per bed day.
The cost per bed day shall be multiplied by the number of
MaineCare eligible days to determine the total reimbursable costs.
Final settlement consists of allowable costs determined
through the audit, compared to the interim payments received by the
provider.
34.6
Recovery of Overpayments
34.6.1
The Department will recover overpayments made to a provider either by set-off,
recoupment, or any other method allowed by law.
34.6.2 The Department may withhold payment on
pending or future claims in an amount equal to the overpayment. The amount may
be withheld all at once or over a period of time established by the Department.
Amounts are to be repaid within ninety (90) days of the date the audit is
finalized unless otherwise negotiated with the Department.
34.6.3 Should there be insufficient claims
sent to the Department against which the Department can set-off the amount of
an overpayment, the provider shall be directed to remit payment in full. If
repayment is not made, the Department may exercise any or all appropriate
action against the provider and exercise all other civil remedies in order to
recover the overpayments.
34.7
Appeal Procedure
34.7.1 A facility may administratively appeal
any of the following types of determinations through the DHHS, Division of
Audit:
34.7.1(a) Audit adjustments and
calculation of an audited per diem rate;
34.7.1(b) Adjustments to per diem
rate;
34.7.1(c) Historical
costs.
34.7.2
Administrative appeals will proceed in the following manner:
34.7.2(a) Within sixty (60) days of receipt
of an audit or other appealable determination, the facility must request, in
writing, an informal review before the Director, DHHS, Division of Audit or
his/her designee. The facility must forward with the request, any and all
specific information that is relative to the issues in dispute, note the
monetary amount each issue represents, and identify the appropriate principle
supporting the request. Only issues presented in this manner and time frame
will be considered at an informal review or at subsequent administrative
hearing.
34.7.2(b) The Director or
his/her designee shall notify the provider in writing of the decision made as a
result of such informal review. If the provider disagrees with the result of
the informal review, the provider may request an administrative hearing before
the Commissioner or a presiding officer designated by the Commissioner. 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. The hearing shall proceed in accordance with the
Department's Administrative Hearings Manual.
34.7.2(c) To the extent the Department rules
in favor of the facility, the audit report will be corrected.
34.7.2(d) To the extent the Department
upholds the original determination of the DHHS, Division of Audit, that
decision may be appealed pursuant to the Administrative Procedure
Act,
5 M.R.S.A.
§11001
et
seq.
34.7.3 A
facility may administratively appeal any of the following types of
determinations through the DHHS, Office of Rate-Setting:
34.7.3(a) Regulatory Compliance
Costs
34.7.3(b) Extraordinary
Circumstances Allowance
34.7.4
Administrative appeals will proceed in the following manner:
34.7.4(a) Within sixty (60) days of receipt
of a Rate-Setting determination outlined in 34.7.3, the facility must make the
request, in writing and addressed to the Director of MaineCare Services. This
review will be conducted by the Director of MaineCare Services, or other
designated Department representative who was not involved in the decision under
review. The informal review will consist solely of a review of documents in the
Department's possession including submitted materials/documentation and, if
deemed necessary by the Department, it may include a personal meeting with the
provider to obtain clarification of the materials. Issues that are not raised
by the provider through the written request for an informal review or the
submission of additional materials for consideration prior to the informal
review are waived in subsequent appeal proceedings. The request for informal
review may not be amended to add further issues.
A written report of the decision resulting from the informal
review will be issued to the provider.
34.7.4(b) A provider must properly request an
informal review and obtain a decision before requesting an administrative
hearing. If the provider is dissatisfied with the informal decision, he or she
may write the Commissioner of the Department of Health and Human Services to
request a hearing, provided he/she does so within sixty (60) calendar days of
the date of receipt of the informal review report on the Department's action.
Subsequent appeal proceedings will be limited only to those issues raised
during the informal review process.
The Office of Administrative Hearings shall notify the
provider in writing of the date, time, and place of the hearing, and shall
designate a presiding officer. Providers and provider applicants will be given
advance notice of the hearing at least twenty (20) calendar days from the
mailing date. The hearing shall be held in conformity with the Maine
Administrative Procedure Act,
5 M.R.S. §8001
et seq. and the Administrative Hearings Regulations.
The presiding officer shall issue a written decision and
findings of fact to the provider or, pursuant to provisions of the
Administrative Hearings Regulations, issue a written recommendation to the
Commissioner of Health and Human Services. The Commissioner will then make the
final decision. Legal counsel may represent providers and provider applicants
at a hearing, and may request or subpoena persons to appear at the hearing
where they can be expected to present testimony or documents relating to issues
at the hearing.
If the provider is dissatisfied with the final decision, an
appeal may be taken to the Superior Court pursuant to the
Administrative Procedure Act.
34.7.5
Informal Review Prior
ApprovalsA.
For Appendix C
Medical and Remedial Service Facilities:
If DHHS denies a request in whole or in part for approval of
any item requiring prior approval, the provider may request an informal review
of the decision from the Division of Licensing and Certification. A request for
informal review must be made to the Director, Office of MaineCare Services, 11
State House Station, Augusta, Maine 04333-0011, within sixty (60) days of the
denial. Any further appeal will proceed according to Section 34.7.2(b) of these
Principles.
B.
For
Appendix F Non-Case Mixed Medical and Remedial Services Facilities
If DHHS Office of Aging and Disability Services denies a
request in whole or in part for approval of any item requiring prior approval,
the provider may request an informal review of the decision. A request for
informal review must be made to DHHS Office of Aging and Disability Services,
Program Director, Intellectual Disability Services, 11 State House Station,
Augusta, Maine 04333-0011 within sixty (60) days of the denial. The request for
review shall state the reasons for the request and shall be accompanied by any
supporting documentation. The program director shall forward a written response
to the provider within sixty (60) days of receipt of a complete request for
review. If the decision of the program director is denied, any further appeal
shall follow 14-191 CMR Chapter 40, of the service agreement.
34.8
Deficiency Per
Diem Rate
34.8.1 When certain
conditions relating to these Principles are found in a facility receiving
payment under these Principles, the Department may reduce reimbursement to
ninety percent (90%) of the provider's per diem rate. This "deficiency rate"
will be applied thirty (30) days following the provider's receipt of written
notice of the specific condition that exists. If the provider can present
documentation prior to the effective date of the "deficiency rate" that the
condition no longer exists, the "deficiency rate" will not be applied. If the
condition is not corrected, a reduction in rate will remain in effect until the
records are corrected and verified by the DHHS, Division of Audit. Written
notification of whether the Department believes the deficiencies have been
corrected will be sent to the provider. No retroactive adjustments to the full
rate shall be made for the period that the "deficiency rate" is in effect if it
is properly invoked.
Conditions under which a ninety percent (90%) "deficiency
rate" will be invoked include:
34.8.1(a) Failure to submit a cost report and
financial statement within five (5) months of the end of the provider's fiscal
period.
34.8.1(b) Failure to
produce accurate and auditable financial and statistical records in sufficient
detail to substantiate at least ninety-eight percent (98%) of total costs
reported by the provider. Required records are described in Section
18.
34.8.2 If the provider can produce verifiable
records to document at least ninety-eight percent (98%) of its reported
expenses, then the undocumented expenses will be disallowed but no "deficiency
rate" will be applied.
34.8.3 When
a "deficiency rate" has been in effect for three (3) months and the deficient
condition has not been corrected, the provider may be notified of the
suspension of the Provider Agreement and/or Service Agreement. This will be
effective one month from receipt of notice.The Department will not reimburse
the provider for any services provided after the effective date of the
suspension of the Provider Agreement/Service Agreement. The provider shall
submit a final cost report in the case of termination of the Provider
Agreement/Service Agreement in accordance with the cost reporting
requirements.
34.9
Inflation Adjustment
The Commissioner of the Department will determine if an
inflation adjustment will be made and the amount of that adjustment.
For the state fiscal year ending June 30, 2020 and each year
thereafter, the MaineCare payment rates attributable to wages and salaries in
routine services costs for Appendix C PNMIs must be increased by an inflation
factor in accordance with the United States Department of Labor, Bureau of
Labor Statistics Consumer Price Index - medical care services
index.
