Current through Reg. 49, No. 38; September 20, 2024
(a) A facility provides, under the terms of
the contract, for the total medical, nursing, and psychosocial needs of each
recipient.
(b) The daily rate is
compatible with reasonable charges consistent with efficiency, economy, and
quality of total care. The facility must ensure that care meets the health
needs and promotes the maximum well-being of recipients. The following items
and services are included in the payment rate made to the facility by the
Department of Aging and Disability Services (DADS) and, therefore, the facility
must provide:
(1) nursing care;
(2) social services;
(3) regular, special, and supplemental diets,
including tube feedings;
(4)
nonlegend drugs, with the exception of insulin, and alcoholic beverages unless
prescribed for medicinal purposes. Alcoholic beverages:
(A) prescribed for medicinal purposes must
include the dosage and frequency of the alcohol; and
(B) not prescribed for medicinal purposes are
at the expense of the recipient or family;
(5) for a recipient who is not eligible for
Medicare Part D benefits, legend drugs that are not covered by the Medicaid
Vendor Drug Program;
(6) for a
recipient who is eligible for Medicare Part D benefits, legend drugs in a
category that is not covered by Medicare Part D and that are not covered by the
Medicaid Vendor Drug Program;
(7)
regular laundry services, except dry cleaning;
(8) medical accessories, such as canulas,
tubes, masks, catheters, ostomy bags and supplies, IV fluids, IV equipment, and
equipment that can be used by more than one person, such as wheelchairs,
adjustable chairs, crutches, canes, mattresses, hospital-type beds, enteral
pumps, trapeze bars, walkers, and oxygen equipment, such as tanks,
concentrators, tubing, masks, valves, and regulators.
(A) Facilities are required to maintain, in
good repair, equipment necessary to meet the needs of the recipient.
(B) If a recipient desires equipment for
exclusive use, its purchase is the responsibility of the recipient:
(i) Only the recipient can use the equipment,
and it must be identified as the personal property of the recipient.
(ii) Upon discharge from the facility, the
recipient retains the equipment he purchased. If the recipient dies, the
purchased equipment must be Transferred to the estate. If it is donated or sold
to the facility by the recipient or the estate, the transaction must be
documented. (See § 554.416 of Title 40 (relating to Personal
Property)).
(C) If a
recipient owns a piece of equipment that is medically necessary, the facility
must maintain and repair the equipment.
(D) When Part B Medicare benefits are
accessed to pay for equipment and accessories, the recipient or family may not
be charged by the facility or supply company for any portion of these
items;
(9) medical
supplies, including, but not limited to tongue depressors, swabs, bandaids,
cotton balls, and alcohol; and
(10)
basic personal hygiene items and services to meet the needs of the residents
(See § 554.405(h) of Title 40 (relating to Additional Requirements for
Trust Funds in Medicaid-Certified Facilities) for a list of such items and
services). The specific type or brand of personal hygiene items used by the
facility must be disclosed to the recipient; then, if a recipient prefers to
use a specific type or brand of a personal hygiene item(s) rather than the
item(s) furnished by the facility, he may use his personal funds to purchase
the item(s).
(A) Before purchasing or
charging for the preferred item(s), the facility must secure written
authorization from the recipient or family indicating his desired preference,
the date, and signature of the person requesting the preferred item(s). The
signature may not be that of an employee of the facility.
(B) If the recipient's personal funds are
used to purchase an item(s), the item(s) is for his sole use.
(C) When the facility purchases personal
hygiene item(s) with the recipient's personal funds, the facility must ensure
that the item(s) is in an individual container or package that is labeled with
the recipient's name. The facility is not held responsible for labeling
personal hygiene items brought into the facility and not reported to the
management.
(c) Facilities are not required to provide
any particular brand of non-legend drug, medical accessory, equipment, or
supply, but only those items necessary to ensure appropriate recipient care.
(1) Unless the physician orders a specific
type or brand, the facility may choose the type or brand.
(2) If the recipient or family prefers a
specific type or brand of item rather than the one furnished by the facility,
the recipient, responsible party, or family may be billed for the item, or the
recipient's personal funds may be used to purchase the item, or both.
(3) Before purchasing or charging for the
preferred item, the facility must secure written authorization from the
recipient or family indicating his desired preference, the date, and signature
of the person requesting the preferred item. The signature may not be that of
an employee of the facility.
(d) If a resident has requested and freely
chosen to participate in an activity, or to have an item or service provided
that is not included, or is different than that provided, in the daily vendor
rate, then the resident may be charged for the activity, item, or service.
(1) When documentation is present that
supports the above criteria, and that is required by § 554.405(d)(5) of
Title 40, the amount may be paid from the resident's trust fund.
(2) When the facility acts as a collection
agent for any item, service, or activity not included in the daily rate, the
facility must be able to provide documentation that clearly indicates that any
charges made to the recipient or his trust fund are pass-through costs only.
The facility may not charge any fees, including handling fees, for these types
of transactions.
(e)
Except as described in paragraphs (1) and (2) of this subsection, DADS makes
vendor payments to Nursing Facilities for the day a recipient enters a nursing
facility, but not for the day a recipient leaves a facility. The two exceptions
are as follows.
(1) If entrance and departure
are on the same day, and the recipient does not enter another Title XIX
facility on that day, DADS pays for the entire day.
(2) If departure is because of the
recipient's death and the deceased recipient is not sent to another Title XIX
facility for legal procedures necessary upon the death of the recipient, DADS
pays for the entire day.
(f) Vendor payments are made to Medicaid
Nursing Facilities that comply with the PASARR requirements.
