Current through Register No. 40, October 3, 2024
(a) In
accordance with RSA
167:3-e, IV, the medical services proposed
for a recipient shall be cost effective if the estimated cost of care outside
an institution is no higher than the estimated medicaid cost of appropriate
institutional care.
(b) For each
recipient, cost effectiveness shall be monitored monthly and determined
annually by the department as follows:
(1)
The department shall obtain Title XIX payment data on the costs paid by Title
XIX for the recipient's home care from the department's cost reports generated
for each recipient from the Medicaid Management Information System (MMIS)
;
(2) For each recipient, the items
or services included in the home care cost data in (1) above shall include only
those items or services listed in (c) below;
(3) The items or services included in (d)
below shall not be included in home care cost data for (1) above, or in
institutional cost of care data in (c) below;
(4) The department shall utilize, as
institutional cost of care data, the most recently published inpatient per diem
Title XIX rates for hospitals, psychiatric hospitals, nursing facilities, or
ICF-MR;
(5) The department shall
determine the per diem rate to use as the recipient's institutional cost of
care by selecting the rate for the facility in (4) above that most closely
corresponds to the degree of care determined and utilized for the recipient's
eligibility determination pursuant to
He-W
508.04; and
(6) The department shall compare the costs of
the recipient's home care to the recipient's institutional cost of care, as
determined in He-W 508.06(b) (1) -(b)
(5) .
(c) The costs associated with the following
categories of service, which are included in an institution's per diem rate,
shall be the only costs utilized in determining the costs incurred for the
recipient's home care in accordance with
He-W
508.06(b) (1) and (2) above:
(1) Mental health services, including
psychotherapy and community mental health center services;
(2) Family planning services;
(3) Drugs which are included in the per diem
of the institution in (b) (4) above that is utilized in the calculation in (b)
(6) above;
(4) Durable medical
equipment;
(5) Medical
supplies;
(6) Dental
services;
(7) Private duty nursing
services;
(8) Physical
therapy;
(9) Occupational
therapy;
(10) Speech
therapy;
(11) Care provided through
the Home and Community Based Care for the Developmentally Disabled waiver in
accordance with He-M 517, with the exception of assistive technology support
services, environmental modifications, employment services, respite and
specialty services that would not otherwise be included in the institutional
per diem rate;
(12) Home and
community-based care provided through the In Home Supports Waiver for Children
with Developmental Disabilities in accordance with He-M 524, with the exception
of environmental modifications, respite, and consultative services not
otherwise included in the institutional per diem rate;
(13) Case management services;
(14) Home health; and
(15) Early supports and services.
(d) Costs associated with the
following categories of service, which are not included in an institution's per
diem rate, shall not be included in home care cost data in (b) (1) above or in
institutional cost of care data in (c) above:
(1) Inpatient services, including acute
psychiatric admissions;
(2)
Outpatient services;
(3) Laboratory
services;
(4) X-ray
services;
(5) Medical assistance
services provided by education agencies in accordance with He-M 1301;
(6) Ambulance services;
(7) Wheelchair van services;
(8) Audiology services;
(9) Ophthalmology services;
(10) Podiatry services;
(11) Chiropractic services;
(12) Physician services, including services
of a psychiatrist;
(13) Advanced
registered nurse practitioner services;
(14) DCYF/DJSS medicaid funded services to
include private non-medical institutional placement services (PNMI) and
residential placement;
(15) Youth
development center or other youth detention center placements;
(16) Rural health clinics and federally
qualified health centers;
(17)
Short term stays of 30 days or less in an intermediate care facility for the
mentally retarded or in a nursing facility;
(18) Services provided on an acute or
short-term basis, in response to an illness or injury, rather than care for the
chronic condition which is the basis for the home care;
(19) Mileage reimbursement; and
(20) Medicaid health insurance premium
payments.
#9291, eff
7-1-09
