A. The intermediate
care facility for individuals with intellectual disabilities (ICF/IID) must
provide for all items and services required to meet the needs of a resident
according to the comprehensive functional assessment and the individual program
plan (IPP).
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. Physical Therapy (PT), Occupational
Therapy (OT), and Speech-Language Pathology (SLP) 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 the Medicaid
program, Medicare, private, Veteran's Administration (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 ICF/IID. [Refer to Miss. Admin. Code Part 207, Rule
3.4.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), except for DME listed in Miss. Admin. Code Part 207,
Rule
3.4.D. The Division of Medicaid
defines DME as an item that (1) can withstand repeated use, (2) is 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 ICF/IID. [Refer to Miss. Admin. Code Part 207, Rule
3.4.D. for DME which must be billed
outside the per diem rate.]
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. The ICF/IID must provide non-emergency
transportation unless the resident chooses to be transported by a family member
or friend.
15. The ICF/IID cannot
use the Non-Emergency Transportation (NET) Broker to arrange transportation for
residents. ICF/IIDs may use NET providers that also provide NET services for
the NET Broker if:
a) The ICF/IID 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 ICF/IID'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 ICF/IID:
1. Laboratory services,
2. X-ray services,
3. Drugs covered by the Medicaid drug
program,
4. Ostomy
supplies,
5. Continuous Positive
Airway Pressure (CPAP) Devices effective January 2, 2015,
6. Bi-level Positive Airway Pressure (BiPAP)
Devices effective January 2, 2015, and/or
7. Individualized, resident specific custom
manual and/or custom motorized/power wheelchairs uniquely constructed or
substantially modified for a specific resident when prior authorized by a
Utilization Management/Quality Improvement Organization (UM/QIO), the Division
of Medicaid, or a designated entity effective January 2, 2015.
8. Emergency transportation described in
Miss. Admin. Code Part 201.
E. All ICF/IID's must prominently display the
below information in the ICF/IID, 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.
F. The ICF/IID must:
1. Inform each resident who is entitled to
Medicaid benefits, in writing, at the time of admission to the ICF/IID or when
the resident becomes eligible for Medicaid of:
a) The items and services that are included
in the ICF/IID services under the State Plan and for which the resident may not
be charged, and
b) Those other
items and services that the ICF/IID 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
3.4.F.1.
3. Inform each resident before, or at the
time of admission, and periodically during the resident's stay, of services
available in the ICF/IID and of charges for those services, including any
charges for services not covered under Medicare or by the ICF/IID's per diem
rate.
G. The ICF/IID 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
3.4.F.
1. The ICF/IID'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
ICF/IID not covered under Title XVIII or the ICF/IID's Medicaid per diem rate
must be available and priced identically for all residents in the
ICF/IID.
H. An ICF/IID
cannot require a deposit before admitting a Medicaid beneficiary.
I. Refer to Miss. Admin. Code Part 224, Rule
1.4 for coverage of
immunizations.
42 C.F.R.
§§
483.12,
483.440;
Miss. Code Ann. §§
43-13-117,
43-13-121.
