A. The nursing
facility must provide and pay for all items and services required to meet the
needs of a resident.
B. Items and
services covered by Medicare or any other third party must be billed to
Medicare or the other third party and are considered non-allowable on the cost
report. Applicable crossover claims must also be filed with the Division of
Medicaid.
C. The following items
and services are included in the Medicaid per diem rates and cannot be billed
separately to the Division of Medicaid or charged to a resident:
1. Room/bed maintenance services,
2. Nursing services,
3. Respiratory therapy (RT)
services,
4. Dietary services,
including nutritional supplements,
5. Activity services,
6. Medically-related social
services,
7. Laundry services
including the residents' personal laundry,
8. Over-the-counter (OTC) drugs,
9. Legend drugs not covered by Medicaid drug
program, Medicare, private, Veterans Affairs (VA), or any other payor
source,
10. Medical supplies
including, but not limited to, those listed below. The Division of Medicaid
defines medical supplies as medically necessary disposable items, primarily
serving a medical purpose, having therapeutic or diagnostic characteristics
essential in enabling a resident to effectively carry out a practitioner's
prescribed treatment for illness, injury, or disease and appropriate for use in
the nursing facility. [Refer to Miss. Admin. Code Part 207, Rule 2.6.D. for
medical supplies which must be billed outside the per diem rate.]
a) Enteral supplies,
b) Diabetic supplies,
c) Incontinence garments, and
d) Oxygen administration supplies.
11. Durable medical equipment
(DME), and/or medical appliances, except for DME and/or medical appliances
listed in Miss. Admin. Code Part 207, Rule 2.6.D. The Division of Medicaid
defines DME and/or medical appliances as an item that (1) can withstand
repeated use, (2) primarily and customarily used to serve a medical purpose,
(3) is generally not useful to a resident in the absence of illness, injury or
congenital defect, and (4) is appropriate for use in the nursing
facility.
12. Routine personal
hygiene items and services as required to meet the needs of the residents
including, but not limited to:
a) Hair hygiene
supplies,
b) Comb and
brush,
c) Bath soap,
d) Disinfecting soaps or specialized
cleansing agents when indicated to treat special skin problems or to fight
infection,
e) Razor and shaving
cream,
f) Toothbrush and
toothpaste,
g) Denture adhesive and
denture cleaner,
h) Dental
floss,
i) Moisturizing
lotion,
j) Tissues, cotton balls,
and cotton swabs,
k)
Deodorant,
l) Incontinence
supplies,
m) Sanitary napkins and
related supplies,
n) Towels and
washcloths,
o) Hair and nail
hygiene services, including shampoos, trims and simple haircuts as part of
routine grooming care, and
p)
Bathing.
13. Private room
coverage as medically necessary:
a) The
Medicaid per diem reimbursement rate includes reimbursement for a resident's
placement in a private room if medically necessary and ordered by a physician.
The Medicaid reimbursement for a medically necessary private room is considered
payment in full for the private room. The resident, the resident's family or
the Division of Medicaid cannot be charged for the difference between a private
and semi-private room if medically necessary.
b) The resident may be charged the difference
between the private room rate and the semiprivate room rate when it is the
choice of the resident or family if the provider informs the resident in
writing of the amount of the charge at the time of admission or when the
resident becomes eligible for Medicaid.
14. Ventilators. [Refer to Miss. Admin. Code
Part 207, Rule
2.15.]
15. The nursing facility must provide
non-emergency transportation unless the resident chooses to be transported by a
family member or friend.
16. The
nursing facility cannot use the Non-Emergency Transportation (NET) Broker to
arrange transportation for residents. Nursing facilities may use NET providers
that also provide NET services for the NET Broker if:
a) The nursing facility arranges the
transportation, and
b) Pays the NET
provider directly.
D. The following items and services are not
included in the Medicaid per diem rates, are considered non-allowable costs on
the nursing facility's cost report, and must be billed directly to the Division
of Medicaid by a separate provider with a separate provider number from that of
the nursing facility:
1. Laboratory
services,
2. X-ray
services,
3. Drugs covered by the
Medicaid drug program, Medicare, Veteran's Affairs (VA), or any other payor
source,
4. Physical therapy (PT),
occupational therapy (OT), and speech-language pathology (SLP)
services,
5. Ostomy
supplies,
6. Continuous Positive
Airway Pressure (CPAP) Devices effective January 2, 2015,
7. Bi-level Positive Airway Pressure (BiPAP)
Devices effective January 2, 2015.
8. Individualized, resident specific custom
manual and/or custom motorized/power wheelchairs uniquely constructed or
substantially modified for a specific resident effective January 2, 2015.
[Refer to Miss. Admin. Code Part 207, Rule
2.18 for definition and coverage
criteria.]
9. Emergency
transportation described in Miss. Admin. Code Part 201.
E. Prior authorization from a Utilization
Management/Quality Improvement Organization (UM/QIO), the Division of Medicaid
or designated entity is required for the following:
1. Individualized, resident specific custom
manual and/or custom motorized/power wheelchairs uniquely constructed or
substantially modified for a specific resident, and
2. PT, OT and SLP services, and
3. All other DME and/or medical appliances
identified in Part 209 requiring prior authorization.
F. Prior authorization from the Division of
Medicaid or UM/QIO is required for ventilators except for those in a Nursing
Facility for the Severely Disabled (NFSD).
G. All nursing facilities must prominently
display the below information in the nursing facility, and provide to
applicants for admission and residents the below information in both oral and
written form:
1. How to apply for and use
Medicare and Medicaid benefits, and
2. How to receive refunds for previous
payments covered by such benefits.
H. The nursing facility must:
1. Inform each resident who is entitled to
Medicaid benefits, in writing, at the time of admission to the nursing facility
or when the resident becomes eligible for Medicaid of:
a) The items and services that are included
in the nursing facility services under the State Plan and for which the
resident may not be charged, and
b)
Those other items and services that the nursing facility offers and for which
the resident may be charged, and the amount of charges for those
services.
2. Inform each
resident when changes are made to the items and services specified in Miss.
Admin. Code Part 207, Rule 2.6.G.1.
3. Inform each resident before, or at the
time of admission, and periodically during the resident's stay, of services
available in the facility and of charges for those services, including any
charges for services not covered under Medicare or by the facility's per diem
rate.
I. The nursing
facility may charge any amount greater than or equal to the Medicaid rate for
non-Medicaid residents for items and services consistent with the notice stated
in Miss. Admin. Code Part 207, Rule 2.6.G.
1.
The nursing facility's non-Medicaid per diem rate may be set above the Medicaid
per diem rate but the items and services included in the non-Medicaid rate must
be identical to the items and services included in the Medicaid per diem
rate.
2. Items and services
available in the nursing facility not covered under Title XVIII or the nursing
facility's Medicaid per diem rate must be available and priced identically for
all residents in the facility.
J. A nursing facility cannot require a
deposit before admitting a Medicaid beneficiary.
42 C.F.R. §§
483.10,
483.65;
Miss. Code Ann. §§
43-13-117,
43-13-121.
