Current through Vol. 42, No. 1, September 16, 2024
The Oklahoma Health Care Authority (OHCA) shall reimburse
long-term care facilities in accordance with its federally-approved Oklahoma
Medicaid Plan. According to the Oklahoma Medicaid Plan, per-diem rates for
long-term care facilities are established on, among other things, analyses of
annual uniform cost reports. These reports may only include allowable costs, as
follows:
(1) To be allowable, the
costs shall be reasonable and necessary for services related to resident care,
and pertinent to the operation of the long-term care facility. More
specifically:
(A) To be reasonable, costs
shall be such as would ordinarily be incurred for comparable services provided
by comparable facilities, for example, facilities of similar size and level of
care; and
(B) To be necessary,
costs related to patient care must be common and accepted occurrences; and,
(C) Allowable costs for services
and items directly related to resident care include routine services, as
established by Oklahoma Administrative Code (OAC)
317:30-5-133.1,
and quality of care assessment fees, as established by OAC
317:30-5-131.2.
Ancillary services, as established by OAC
317:30-5-133.2,
are not allowable costs, but may be reimbursed outside the long-term care
facility rate, unless reimbursement is available from Medicare or other
insurance or benefit programs.
(2) The following costs shall not be
allowable:
(A) Costs resulting from
inefficient operations;
(B) Costs
resulting from unnecessary or luxurious care;
(C) Costs related to activities not common
and accepted in a long-term care facility, as determined by OHCA or its
designee;
(D) Costs that are not
actually paid by the provider, including, but not limited to, costs that are
discharged in bankruptcy; forgiven; or converted to a promissory note;
(E) Costs that are paid to a
related party that has not been identified on the reports;
(F) Cost of services, facilities, and
supplies furnished by organizations related to the provider, by common
ownership or control, that exceed the price of comparable services, facilities,
or supplies purchased by independent providers in Oklahoma, in accordance with
42 Code of Federal Regulations § 413.17; and,
(G) Costs or financial transactions used to
circumvent OHCA's applicable reimbursement rules.
(3) Allowable costs shall include only those
costs that are considered allowable for Medicare purposes and that are
consistent with federal Medicaid requirements. The guidelines for allowable
costs in the Medicare program are set forth in the Medicare Provider
Reimbursement Manual, HCFA- Pub. 15.
