La. Admin. Code tit. 50 § II-10307

Current through Register Vol. 50, No. 11, November 20, 2024

Section II-10307 - Payments

NOTE: Regulations for this Section are found in the state's Medicaid Eligibility Manual, Chapter XIX (19).

A. Income Consideration in Determining Payment

1. Clients receiving care under Title XIX. The client's applicable income (liability) will be determined when computing the ICF/MR's vendor payments. Vendor payments are subject to the following conditions.

a. Vendor payments will begin with the first day the client is determined to be categorically and medically eligible or the date of admission, whichever is later.

b. Vendor payment will be made for the number of eligible days as determined by the ICF/MR per diem rate less the client's per diem applicable income.

c. If a client transfers from one facility to another, the vendors' payment to each facility will be calculated by multiplying the number of eligible days times the ICF/MR per diem rate less the client's liability.

2. Client Personal Care Allowance. The ICF/MR will not require that any part of a client's personal care allowance be paid as part of the ICF/MR's fee. Personal care allowance is an amount set apart from a client's available income to be used by the client for his/her personal use. The amount is determined by DHH.

B. Payment Limitations

1. Temporary Absence of the Client. A client's temporary absence from an ICF/MR will not interrupt the monthly vendor payment to the ICF/MR, provided the following conditions are met:

a. the ICF/MR keeps a bed available for the client's return; and

b. the absence is for one of the following reasons:

i. hospitalization, which does not exceed seven days per hospitalization; or

ii. leave of absence. A temporary stay outside the ICF/MR provided for in the client's written Individual Habilitation Plan. A leave of absence will not exceed 45 days per fiscal year (July 1 through June 30), and will not exceed 30 consecutive days in any single occurrence. Certain leaves of absence will be excluded from the annual 45-day limit as long as the leave does not exceed the 30 consecutive day limit and is included in the written Individual Habilitation Plan. These exceptions are as follows:

(a). Special Olympics;

(b). roadrunner-sponsored events;

(c). Louisiana planned conferences;

(d). trial discharge leave;

(e). official state holidays.

NOTE: Elopements and unauthorized absences under the individual habilitation plan count against allowable leave days. However, Title XIX eligibility is not affected if the absence does not exceed 30 consecutive days and if the ICF-MR has not discharged the client.

c. the period of absence shall be determined by counting the first day of absence as the day on which the first 24-hour period of absence expires;

d. a period of 24 continuous hours or more shall be considered an absence. Likewise, a temporary leave of absence for hospitalization or a home visit is broken only if the client returns to the ICF/MR for 24 hours or longer;

e. upon admission, a client must remain in the ICF/MR at least 24 continuous hours in order for the ICF/MR to submit a payment claim for a day of service or reserve a bed;

EXAMPLE : A client admitted to an ICF/MR in the morning and transferred to the hospital that afternoon would not be eligible for any vendor payment for ICF/MR services.

f. if a client transfers from one facility to another, the unused leave days for the fiscal year also transfer. No additional leave days are allocated as a result of a transfer;

g. the ICF/MR shall promptly notify DHH of absences beyond the applicable 30- or seven-day limitations. Payment to the ICF/MR shall be terminated from the thirty-first or eight day, depending upon the leave of absence. Payment will commence after the individual has been determined eligible for Title XIX benefits and has remained in the ICF/MR for 30 consecutive days;

h. the limit on Title XIX payment for leave days does not mean that further leave days are prohibited when provided for in the Individual Habilitation Plan. After the Title XIX payment limit is met, further leave days may be arranged between the ICF/MR and the client, family or responsible party. Such arrangements may include the following options:

i. the ICF/MR may charge the client, family or responsible party an amount not to exceed the Title XIX daily rate;

ii. the ICF/MR may charge the client, family or responsible party a portion of the Title XIX daily rate;

iii. the ICF/MR may absorb the cost into its operation costs.

2. Temporary Absence of the Client Due to Evacuations. When local conditions require evacuation of ICF/MR residents, the following payment procedures apply:

a. when clients are evacuated for less than 24 hours, the monthly vendor payment is not interrupted;

b. when staff is sent with clients to the evacuation site, the monthly vendor payment is not interrupted;

c. when clients are evacuated to a family's or friend's home at the ICF/MR's request, the ICF/MR shall not submit a claim for a day of service or leave day, and the client's liability shall not be collected;

d. when clients go home at the family's request or on their own initiative, a leave day shall be charged;

e. when clients are admitted to the hospital for the purpose of evacuation of the ICF/MR, Medicaid payment shall not be made for hospital charges.

3. Payment Policy in regard to Date of Admission, Discharge, or Death

a. Medicaid (Title XIX) payments shall be made effective as of the admission date to the ICF/MR. If the client is medically certified as of that date and if either of the following conditions is met:

i. the client is eligible for Medicaid benefits in the ICF/MR (excluding the medically needy); or

ii. the client was in a continuous institutional living arrangement (nursing home, hospital, ICF/MR, or a combination of these institutional living arrangements) for 30consecutive days; the client must also be determined financially eligible for Medical Assistance.

b. The continuous stay requirement is:

i. considered met if the client dies during the first 30 consecutive days.

ii. not interrupted by the client's absence from the ICF/MR when the absence is for hospitalization or leave of absence which is part of the written Individual Habilitation Plan.

c. The client's applicable income is applied toward the ICF/MR fee effective with the date Medicaid payment is to begin.

d. Medicaid payment is not made for the date of discharge; however, neither the client, family, nor responsible party is to be billed for the date of discharge.

e. Medicaid payment is made for the day of client's death.

NOTE : The ICF/MR shall promptly notify DHH/BHSF of admissions, death, and/or all discharges.

4. Advance Deposits

a. An ICF/MR shall neither require nor accept an advance deposit from an individual whose Medicaid (Title XIX) eligibility has been established.

EXCEPTION : An ICF/MR may require an advance deposit for the current month only on that part of the total payment which is the client's liability.

b. If advance deposits or payments are required from the client, family, or responsible party upon admission when Medicaid (Title XIX) eligibility has not been established, such a deposit shall be refunded or credited to the person upon receipt of vendor payment.

5. Retroactive Payment. When individuals enter an ICF/MR before their Medicaid (Title XIX) eligibility has been established payment for ICF/MR services is made retroactive to the first day of eligibility after admission.

6. Timely Filing for Reimbursements. Vendor payments cannot be made if more than 12 months have elapsed between the month of initial services and submittal of a claim for these services. Exceptions for payments of claims over 12 months old can be made with authorization from DHH/BHSF only.

7. Refunds to Clients

a. When the ICF/MR receives vendor payments, it shall refund any fees for services collected from clients, family or responsible party by the end of the month in which vendor payment is received.

b. Advance payments for a client's liability (applicable income) shall be refunded promptly if he/she leaves the ICF/MR.

c. The ICF/MR shall adhere to the following procedures for refunds:

i. The proportionate amount for the remaining days of the month shall be refunded to the client, family, or the responsible party no later than 30 days following the date of discharge. If the client has not yet been certified, the procedures spelled out in (a) above shall apply.

ii. No penalty shall be charged to the client, family, or responsible party even if the circumstances surrounding the discharge occurred as follows:

(a). without prior notice; or

(b). within the initial month; or

(c). within some other "minimum stay" period established by the ICF/MR.

iii. Proof of refund of the unused portion of the applicable income shall be furnished to BHSF upon request.

8. ICF/MR Refunds to the Department

a. Nonparticipating ICF/MR. Vendor payments made for services performed while an ICF/MR is in a nonparticipating status with the Medicaid Program shall be refunded to the Office of Management and Financing, Post Office Box 629, Baton Rouge, LA 70821-0629. The refund shall be made payable to the "Department of Health and Hospitals-Medicaid Program."

b. Participating ICF/MR. A currently participating Title XIX, ICF/MR shall correct billing or payment errors by use of appropriate adjustment void or Patient Liability (PLI) adjustment forms.

9. Sitters. An ICF/MR will neither expect nor require a client to have a sitter. However, the ICF/MR shall permit clients, families, or responsible parties directly to employ and pay sitters when indicated, subject to the following limitations:

a. The use of sitters will be entirely at the client's, family's, or responsible party's discretion. However, the ICF/MR shall have the right to approve the selection of a sitter. If the ICF/MR disapproves the selection of the sitter, the ICF/MR will provide written notification to the client, family, and/or responsible party, and to the Department of Health and Hospitals stating the reasons for disapproval.

b. Payment to sitters is the direct responsibility of the client, family or responsible party, unless:

i. the hospital's policy requires a sitter;

ii. the attending physician requires a sitter; or

iii. the Individual Habilitation Plan (IHP) requires a sitter.

NOTE: Psychiatric Hospitals are excluded from this requirement.

c. Payment to sitters is the direct responsibility of the ICF/MR facility when:

i. the hospital's policy requires a sitter and the client is on hospital leave days;

ii. the attending physician requires a sitter;

iii. the IHP requires a sitter.

d. A sitter will be expected to abide by the ICF/MR's rules and regulations, including health standards and professional ethics.

e. The presence of a sitter does not absolve the ICF/MR of its full responsibility for the client's care.

f. The ICF/MR is not responsible for providing a sitter if one is required while the resident is on home leave.

10. Tips. The ICF/MR shall not permit tips for services rendered by its employees.

La. Admin. Code tit. 50, § II-10307

Promulgated by the Department of Health and Human Resources, Office of Family Security, LR 13:578 (October 1987), amended by the Department of Health and Hospitals, Office of the Undersecretary, Bureau of Health Services Financing, LR 25:682 (April 1999), LR 31:1081 (May 2005), LR 31:1591 (July 2005).

AUTHORITY NOTE: Promulgated in accordance with R.S. 46:153.