441—81.10 (249A) Payment procedures.
	 81.10(1) Method of payment. Except for Medicaid accountability measures payment established in paragraph 81.6(16)“g,” facilities shall be reimbursed under a modified price-based vendor payment program. A per diem rate shall be established based on information submitted according to rule 441—81.6(249A). Effective July 1, 2002, the per diem rate shall include an amount for Medicaid accountability measures.
	 81.10(2) Authorization of payment. The department shall authorize payment for care in a facility. The authorization shall be obtained prior to admission of the resident, whenever possible. For a nursing facility to be eligible for Medicaid payment for a resident, the facility must, when applicable, exhaust all Medicare benefits.
	 81.10(3) Rescinded IAB 8/9/89, effective 10/1/89.
	 81.10(4) Periods authorized for payment.
	  a.   	 Payment shall be made on a per diem basis for the portion of the month the resident is in the facility.
	  b.   	 Payment will be authorized as long as the resident is certified as needing care in a nursing facility.
	  c.   	 Payment will be approved for the day of admission but not the day of discharge or death.
	  d.   	 Payment will be approved for periods the resident is absent overnight for purpose of visitation or vacation. The facility will be paid to hold the bed for a period not to exceed 18 days in any calendar year. Additional days shall be based upon a recommendation by the resident’s physician in the plan of care that additional days would be rehabilitative.
	  e.   	 Payment will be approved for a period not to exceed 10 days in any calendar month when the resident is absent due to hospitalization. Medicaid payment to the facility may not be initiated while a resident is on reserve bed days unless the person was residing in the facility as a private pay resident prior to the hospitalization and returns to the facility as a resident.
	  f.   	 Payment for periods when residents are absent for a visit shall be made at 42 percent of the nursing facility’s rate. Payment for periods when residents are absent for hospitalization shall:
	 (1) 	 Be made at 25 percent of the nursing facility’s rate if the facility occupancy percentage is 95 percent or greater.
	 (2) 	 Not be made if a facility’s occupancy percentage is less than 95 percent.
	 (3) 	 Be made at 42 percent of the nursing facility’s rate for special population facilities.
	  g.   	 Payment for residents determined by utilization review to require the residential level of care shall be made at the maximum state supplementary assistance rate. This rate is effective as of the date of final notice by utilization review that the lower level of care is required.
	  h.   	 In-state nursing facilities serving Medicaid eligible patients who require a ventilator at least six hours every day, are inappropriate for home care, and have medical needs that require skilled care as determined by the peer review organization shall receive reimbursement for the care of these patients equal to the sum of the Medicare-certified hospital-based nursing facility direct care rate component limit plus the Medicare-certified hospital-based nursing facility non-direct care rate component limit factor pursuant to subparagraph 81.6(16)“f”(3). Facilities may continue to receive reimbursement at this rate for 30 days for any person weaned from a respirator who continues to reside in the facility and continues to meet skilled care criteria for those 30 days.
	 81.10(5) Supplementation. Only the amount of client participation may be billed to the resident for the cost of care and the facility must accept the combination of client participation and payment made through the Iowa Medicaid program as payment in full for the care of a resident. No additional charges shall be made to residents or family members for any supplies or services required in the facility-developed plan of care for the resident.
Residents may choose to spend their personal funds on items of personal care such as professional beauty or barber services but the facility shall not require this expenditure and shall not routinely obligate residents to any use of their personal funds.
	  a.   	 Supplies or services which the facility shall provide:
	 (1) 	 Nursing services, social work services, activity programs, individual and group therapy, rehabilitation or habilitation programs provided by facility staff in order to carry out the plan of care for the resident.
	 (2) 	 Services related to the nutrition, comfort, cleanliness and grooming of a resident as required under state licensure and Medicaid survey regulations.
	 (3) 	 Medical equipment and supplies including wheelchairs, medical supplies except for those listed in 441—paragraph 78.10(4)“b,” oxygen except under circumstances specified in 441—paragraph 78.10(2)“a,” and other items required in the facility-developed plan of care.
	 (4) 	 Nonprescription drugs ordered by the physician except for those specified in 441—78.1(2)“f.”
	 (5) 	 Fees charged by medical professionals for services requested by the facility which do not meet criteria for direct Medicaid payment.
	  b.   	 The facility shall arrange for transportation to receive necessary medical services outside the facility. If a family member, friend, or volunteer is not available to provide the transportation at no charge, the facility shall arrange and pay for the medically necessary transportation.
	  c.   	 The Medicaid program will provide direct payment to relieve the facility of payment responsibility for certain medical equipment and services which meet the Medicare definition of medical necessity and are provided by vendors enrolled in the Medicaid programs including:
	 (1) 	 Physician services.
	 (2) 	 Ambulance services.
	 (3) 	 Hospital services.
	 (4) 	 Hearing aids, braces and prosthetic devices.
	 (5) 	 Therapy services.
	  d.   	 Other supplies or services for which direct Medicaid payment may be available include:
	 (1) 	 Drugs covered pursuant to 441—78.1(2).
	 (2) 	 Dental services.
	 (3) 	 Optician and optometrist services.
	 (4) 	 Repair of medical equipment and appliances which belong to the resident.
	 (5) 	 Transportation to receive medical services outside the community subject to limitations specified in rule 441—78.13(249A).
	 (6) 	 Other medical services specified in 441—Chapter 78.
	  e.   	 The following supplementation is permitted:
	 (1) 	 The resident, the resident’s family, or friends may pay to hold the resident’s bed in cases where a resident who is not discharged from the facility spends over 18 days per year on visits (or longer under 81.10(4)“d”) or spends over 10 days per calendar month on a hospital stay. These supplementation payments shall not exceed the amount the department would pay to hold the bed under paragraph 81.10(4)“f.”
When the resident is discharged, the facility may handle the holding of the bed in the same manner as for a private paying resident.
	 (2) 	 Payments made by the resident’s family toward cost of care of the resident shall not be considered as supplementation so long as the payments are included in client participation and are not over and above the payment made by the state for care of the resident.
	 (3) 	 If a physician does not order a nonprescription drug by brand name, the facility may offer a generic. If a resident or family member requests a brand name, the resident or family member may pay for the brand-name nonprescription drug.
	 81.10(6) Payment for out-of-state care. Rescinded IAB 9/5/90, effective 11/1/90.
	 81.10(7) Comparative charges between private pay and Medicaid residents. Rescinded IAB 2/6/02, effective 4/1/02.
[ARC 8344B, IAB 12/2/09, effective 12/1/09]