471 Neb. Admin. Code, ch. 45, § 004

Current through June 17, 2024

Section 471-45-004 - ALLOWABLE COSTS

The following items are allowable costs under Medicaid:

004.01COST OF MEETING LICENSURE AND CERTIFICATION STANDARDS. Allowable costs for meeting licensure and certification standards are those costs incurred in order to:

(A) Meet the definition and requirements for a nursing facility of Title XIX of the Social Security Act, Section 1919;

(B) Comply with the standards prescribed by the Secretary of the Federal Health and Human Services for nursing facilities in 42 Code of Federal Regulations (CFR) 442;

(C) Comply with requirements established by the Nebraska Department of Health and Human Services Division of Public Health standards, under 42 CFR 431.610; and

(D) Comply with any other state law licensing requirements necessary for providing nursing facility services, as applicable.

004.02ROUTINE SERVICES. Routine nursing facility services include regular room, dietary, and nursing services; social services where required by certification standards; minor medical supplies; oxygen and oxygen equipment; the use of equipment and facilities; and other routine services.

004.03ANCILLARY SERVICES. Ancillary services are those services which are either provided by or purchased by a facility and are not properly classified as routine services. The facility must contract for ancillary services not readily available in the facility. If ancillary services are provided by a licensed provider or another licensed facility, the ancillary service provider must submit a separate claim for each client served. Allowable costs paid to physical, occupational, and speech therapists are limited to reasonable amounts paid for general consulting services plus reasonable transportation costs not covered through direct billing. General consulting services are not client specific, but instead, are staff related. These services include staff education, in-services, and seminars. Respiratory therapy is an allowable cost. Department-required independent qualified mental retardation professional assessments are considered ancillary services.

004.04PAYMENTS TO OTHER PROVIDERS. Items for which payment may be authorized to non-nursing facility providers and are not considered part of the facility's Medicaid Per Diem are listed below. To be covered, the client's condition must meet the criteria for coverage for the item as outlined in the appropriate Medicaid provider chapter. The provider of the service may be required to request prior authorization of payment for the service. Items for which payment may be authorized are:

(A) Legend drugs, over the counter drugs, and compounded prescriptions, including intravenous solutions and dilutants. Bulk supply over the counter drugs may be provided by the facility in accordance with physician orders and then become an allowable cost on the facility's cost report;

(B) Personal appliances and devices, if recommended in writing by a physician;

(C) Orthoses, lower and upper limb, foot and spinal;

(D) Prostheses, breast, eye, lower and upper limb;

(E) Ambulance services required to transport a client to obtain and after receiving Medicaid-covered medical care;

(i) To be covered, ambulance services must be medically necessary and reasonable. Medical necessity is established when the client's condition is such that use of any other method of transportation is contraindicated. In any case in which some means of transportation other than an ambulance could be used without endangering the client's health, whether or not such other transportation is actually available, Medicaid will not make payment for ambulance service; or

(ii) Non-emergency ambulance transports to a physician or practitioner's office, clinic, or therapy enter are covered when the client is bed confined before, during and after transport and when the services cannot or cannot reasonably be expected to be provided at the client's residence, including the nursing facility.

004.05PAYMENTS TO NURSING FACILITY PROVIDER SEPARATE FROM PER DIEM RATES. Items for which payment may be made to nursing facility providers and are not considered part of the facility's Medicaid per diem are listed below. To be covered, the client's condition must meet the criteria for coverage for the item outlined in the appropriate Medicaid provider chapter. Reimbursement to nursing facility providers separate from per diem rates is based on a Medicaid fee schedule. Except as otherwise noted in the plan, state-developed fee schedule rates are the same for both governmental and private providers of nursing facility services. The agency's fee schedule rate was set as of October 1, 2017, and is effective for services provided on or after that date. Items for which payment may be made are:

(A) Non-standard wheelchairs, including power-operated vehicles, and wheelchair seating systems, including certain pressure reducing wheelchair cushions, needed for the client's permanent and full time use;

(B) Air fluidized bed units and low air loss bed units; and

(C) Negative pressure wound therapy.

471 Neb. Admin. Code, ch. 45, § 004

Adopted effective 6/6/2022

Amended effective 6/2/2024