Section 471-45-018 - PAYMENT FOR SERVICES FOR LONG TERM CARE CLIENTS WITH SPECIAL NEEDS Payment for services to all special needs clients must be prior authorized by Department staff in the Central Office.
018.01NEBRASKA FACILITIES. To establish a Nebraska facility's payment rate for care of special needs clients:(A) The facility must submit Form FA-66, Long Term Care Cost Report, to the Department for each fiscal year ending June 30. Medicare cost reporting forms may be substituted when Form FA-66 is not otherwise required to be submitted. Form FA-66 must be completed in accordance with this chapter, Completion of Form FA-66, Long Term Care Cost Report, Rates for Nursing Facility Services, as applicable. Medicare cost reports must be completed in accordance with Medicare's Provider Reimbursement Manual (HIM15). If the facility provides both nursing facility services and special needs services, direct accounting, or cost allocations necessary to distribute costs between the nursing facility and the special needs unit must be approved by the Department;(B) The Department shall compute the allowable cost per day from the most recent State fiscal year Form FA-66 or the most recent Medicare cost report, as applicable, which will be the basis from which a prospective rate is negotiated. Payment for fixed costs is limited to the lower of the individual facility's fixed cost per diem or a maximum per diem of $54.00 excluding personal property and real estate taxes. Negotiations may include, but are not limited to, discussion of appropriate inflation or deflation expectations for the rate period and significant increases or decreases in the cost of providing services that are not reflected in the applicable cost report;(C) If the facility has no prior cost experience in providing special needs services, the facility must submit a budget for the provision of the intended service. The Department must concur that the budgeted cost per day meets a reasonable expectation of the cost of providing said service, taking into account the cost per day of similar facilities providing similar services. Budgets will be used until the facility has at least six months of actual cost experience;(D) An incentive factor calculated at eight per cent of allowable costs is added to the allowable costs of proprietary facilities. An incentive factor calculated at four percent of allowable costs is added to the allowable costs of other than propriety facilities;(E) After a rate is agreed upon, the provider must sign a provider agreement addendum. The addendum originated by the Department, must include:(i) The rate and its applicable dates;(ii) A description of the criteria for care; and(iii) A full description of the services to be provided under the established per diem as well as any services that are not provided under the per diem and are billed separately; and(F) Reimbursement must reflect the facility's actual reasonable cost of providing services to special needs clients and must be updated annually using an appropriate inflation adjustment.018.02OUT-OF-STATE FACILITIES. The Department pays out-of-state facilities participating in Medicaid at the rates established by that state's Medicaid program for nursing facility days, bed hold days and therapeutic leave days at the time of establishment of the Medicaid provider agreement. The rates are periodically updated to align with the current and applicable rates assigned by the out-of-state facility's State Medicaid program.471 Neb. Admin. Code, ch. 45, § 018
Adopted effective 6/6/2022Amended effective 6/2/2024