Current through Register Vol. 54, No. 12, March 23, 2024
(a)
Scope and effect of an
exceptional DME grant.
(1) A grant
authorizes exceptional payments to a nursing facility in addition to the
nursing facility's case-mix per diem payment rate for nursing facility services
provided to the resident. The amount of the exceptional payments authorized by
the grant is deemed to be the necessary, reasonable and prudent cost of the
exceptional DME and the related services and items identified in the nursing
facility's grant.
(2) A grant does
not authorize exceptional payments for nursing facility services that are
provided to MA residents other than the resident, nor does it limit costs that
are, or must be, incurred by a nursing facility to provide services to any of
the nursing facility's residents (including the resident) in accordance with
applicable law and regulations.
(b)
Applicability of laws.
Nursing facility services provided by a nursing facility receiving a grant,
including services paid by the grant, remain subject to applicable Federal and
State laws and regulations, including the laws and regulations governing the MA
Program.
(c)
Reporting of
exceptional DME costs and grant payments.
(1) The nursing facility shall report on the
MA-11, the costs related to the acquisition of exceptional DME and related
services and items paid by a grant. In identifying the nursing facility's
allowable costs, the nursing facility shall adjust those reported costs to the
necessary, reasonable and prudent cost amounts identified in the nursing
facility's grant.
(2) The nursing
facility shall offset all payments made by the Department under a grant against
the allowable cost of the exceptional DME and related services and items paid
by the grant.
(3) The nursing
facility shall identify and report in the MA-11, the costs related to the
acquisition of exceptional DME and related services and items, the adjustment
to the amount identified in the grant, and the offset of the payment made by
the Department under the grant using the accrual basis of accounting.
(d)
Payment in
full. A grant does not waive the preclusion on supplementation
established by law. Payment made by the Department under a grant is payment in
full for nursing facility services involving the exceptional DME and any
related services and items. The entire payment for all MA nursing facility
services provided to the resident, including the exceptional DME and any
related services and items shall include both of the following:
(1) The nursing facility's case-mix per diem
rate.
(2) The exceptional payments
authorized by the grant.
(e)
Utilization review.
Nursing facility services paid by a grant are subject to utilization review by
the Department, including assessments of the resident's continuing need for the
exceptional DME.
(f)
Dispute resolution. A dispute relating to a grant, including a
dispute relating to payments which the nursing facility believes are authorized
by the grant and a dispute arising from the termination, suspension or recovery
actions taken under §
1187.157 (relating to termination
or suspension of exceptional DME grants and recovery of exceptional payments),
shall be brought initially and exclusively for adjudication to the Department's
Bureau of Hearings and Appeals.
(g)
Records. In addition to the nursing facility's existing
obligations to maintain and provide documents and records, a nursing facility
receiving a grant shall maintain and, upon request, provide to the Department
additional documents and records as may be necessary for the Department to
determine the nursing facility's compliance with this subchapter and the terms
of the nursing facility's grant, including documents and records as may be
necessary for the Department to determine the maximum allowable cost of the
exceptional DME as specified in §
1187.155(b)
(relating to exceptional DME grants-payment conditions and
limitations).
(h)
Term of
the grant. A grant is effective on the date specified in the nursing
facility's grant and ends on the date the grant is terminated under §
1187.157.
(i)
Acquisition,
maintenance, use and disposal of exceptional DME.
(1) A nursing facility shall obtain
exceptional DME and related services and items paid by a grant at the lowest
practicable cost and shall purchase by means of competitive bidding whenever
required by law.
(2) Unless
otherwise approved in writing by the Department, a nursing facility may use
exceptional DME paid by a grant only as specified by the nursing facility's
grant.
(3) Except as specified
otherwise in paragraph (5), a nursing facility has title to any exceptional DME
and related items purchased by the nursing facility under the grant.
(4) If an item of exceptional DME purchased
under a grant is no longer necessary to provide care and services to the
resident, and subject to paragraph (2), the nursing facility shall make the
item available for the use, as necessary, in the care and treatment of other MA
residents of the nursing facility unless directed by the Department to transfer
the exceptional DME in accordance with paragraph (5).
(5) Upon termination of a grant, the
Department may direct that the nursing facility transfer the exceptional DME
and related items to another provider designated by the Department or to the
resident. Title to the transferred exceptional DME and related items shall then
vest in the designated provider or the resident. If a transfer is required
under this paragraph, §
1187.61(c)(1)
(relating to movable property cost policies) does not apply.
(6) A nursing facility shall, in accordance
with sound business practice, maintain and administer a program for the
maintenance, repair, protection, preservation and insurance of exceptional DME
paid by a grant.
(7) If a nursing
facility is indemnified, reimbursed or otherwise compensated for any loss,
destruction or damage to exceptional DME paid by a grant, the nursing facility
shall, at the Department's direction, use the proceeds to replace, repair or
renovate the property involved.
