Section 480-4-002 - GENERAL PROVIDER REQUIREMENTS002.01COMPLIANCE WITH MEDICAID PROVIDER REQUIREMENTS. To participate in Nebraska Medicaid, providers of Home and Community-Based Waiver services must comply with all applicable provider participation requirements identified in 471 Nebraska Administrative Code (NAC) Chapters 1-000, 2-000 and 3-000. In the event that provider participation requirements in 471 NAC Chapters 1-000, 2-000 or 3-000 conflict with requirements outlined in this Chapter, the individual provider participation requirements in this chapter will govern.002.02SERVICE AUTHORIZATION. Waiver services will be authorized for each participant up to a 12 month period. All authorized services are based on needs identified in the personcentered plan (PCP) and the results of ongoing monitoring activities. A copy of the authorization is supplied to both the participant and the provider identifying which tasks the provider is authorized to perform. Providers are responsible for knowing and understanding the tasks they are authorized to perform for each participant they serve. The service authorization must be complete before services are performed.002.03PROVIDER CAPABILITIES. Providers must have the knowledge and skills to respond to emergency situations. Additionally, providers must have the physical and mental abilities to safely perform all requirements of the service that has been authorized. Failure to meet these standards will be grounds for termination or denial.002.04REASONABLE CAUTION. Providers must exercise reasonable caution and care in the use and storage of participants' property, resources, equipment, appliances, tools, and supplies.002.05PROVIDER OWNED AND OPERATED SETTINGS. If services are provided in a provider owned and operated setting, the provider must comply with the following requirements. Failure to meet these standards will be grounds for termination or denial of a Medicaid provider agreement.(A) Ensure that the facility or home is architecturally designed to accommodate the needs of the participants being served;(B) Have available an operable telephone;(C) Post emergency phone numbers by the telephone;(D) Ensure that the home or facility is accessible to the participant, clean, in good repair, free from hazards, and free of rodents and insects;(E) Ensure that the facility or home is equipped to provide comfortable temperature and ventilation conditions;(F) Ensure that toilet facilities are clean and in working order;(G) Ensure that the eating areas and equipment are clean and in good repair;(H) Ensure that the home or facility is free from fire hazards;(I) Ensure that the furnace, water heater, any firearms, medications, and poisons are inaccessible to the participant;(J) Ensure that any household pets have all necessary vaccinations;(K) The unit or dwelling in which the participant resides must be a specific place owned, rented, or occupied under a legally enforceable residency agreement; and(L) The provider must cooperate with the Department in completing any assessments regarding the community-based nature of the property.002.06PARTICIPATION STANDARDS. All Home and Community-Based Services (HCBS) Waiver providers must meet the standards outlined in 471 NAC 2-000. Additional standards including but not limited to the following apply for providers of Home and Community-Based Waiver services:(A) Follow all applicable Department policies and procedures found in NAC Titles 465, 471, 473, 474, and 480; (i) Bill only for services which are authorized and actually provided;(B) Accept payment as payment in full for the agreed upon service(s) unless the participant has been assigned a portion of the cost by the Department. Provider will not charge participants any difference between the agreed upon rate and private pay rate;(C) No one may provide services for a spouse, minor child, or any participant that the provider has an obligation to support;(D) Not engage in any activity that influences service approval or utilization if they are an employee of the Department, the relative of a Department staff person;(E) Retain all records related to provider enrollment and service provision, including financial records. Records must be maintained for retention periods in compliance with federal and state law, but no record may be destroyed prior to expiration of a six year retention period;(F) Allow federal, state, or local offices responsible for program administration or audit to review service records, in accordance with 42 CFR 431.107. Inspections, reviews, and audits may be conducted on site;(G) Provide services as an independent contractor, if the provider is an individual, recognizing that they are not an employee of the Department or of the State;(H) Understand that any false claims, including claims submitted electronically, statements, documents, or concealment of material fact may be prosecuted under applicable state or federal laws per 42 CFR 455.18;(I) Respect every participant's right to confidentiality and safeguard confidential information;(J) Understand and accept responsibility for the participant's safety and property;(K) Not transfer this agreement to any other entity or person;(L) Not use any federal funds received to influence agency or congressional staff;(M) Not engage in or have an ongoing history of criminal activity that may be harmful or may endanger individuals for whom they provide services. This may include a listing on the child or adult central registries of abuse and neglect, a listing on sex offender registries, or a history of criminal convictions;(N) Agency providers agree to allow Department staff to review agency policies regarding hiring and reporting to ensure that appropriate procedures regarding abuse, neglect, and law violations are in place. The agency provider must allow the Department access to records in order to establish compliance with this requirement;(O) Have the knowledge, experience, and skills necessary to perform the tasks;(P) Be capable of recognizing signs of distress in a participant and know how to access available emergency resources if a crisis situation occurs;(Q) Report changes to appropriate Department staff including but not limited to no longer being able or willing to provide the service, or changes in participant function;(R) Report all incidents in which there is reasonable cause to believe the participant has been subjected to abuse, neglect, or exploitation. All such incidents will be reported to law enforcement and to the Department;(S) Be age 19 or older if an individual provider; or assure that agency staff who assume the following roles are age 19 or older: director, administrator, agency representative for signing legal documents, or provider of in-home participant services;(T) Persons may not be eligible to provide services if they are also a recipient of Chore, Personal Assistance Services (PAS), or similar assistance services; and(U) Providers entering the participant's home to provide services may not be accompanied in the participant's home by any individuals, including the provider's minor children, whose presence is unnecessary to the provision of services to the participant, or who are not authorized to provide services to the participant.002.07DENIAL, TERMINATION AND SANCTION OF HOME AND COMMUNITY-BASED SERVICES (HCBS) WAIVER PROVIDERS. In addition to the reasons for denial, termination, and sanction listed in 471 NAC Chapter 2-000, Waiver Providers are subject to sanction, termination or denial of service approvals and service provider agreements when charges are pending, or a conviction has occurred. No service provider agreement will be issued or remain in effect if there is a conviction for, admission of, or substantial evidence of crimes against a child or vulnerable adult, crimes involving intentional bodily harm, or crimes involving the illegal use of a controlled substance on the part of the provider or any other household members when services are provided in the same location the provider lists as their home address. The provider and household members must not engage in or have a history of behavior injurious to, or which may endanger the health or safety of the participant. Agency providers are responsible for screening their employees for the listed provider standards. Agency providers approved to provide Home and Community-Based Waiver services may not employ persons that have such charges in their history if that person will be providing direct care services.002.08REPORTS OF ABUSE OR NEGLECT. Agency providers must ensure they have policies that strictly comply with this chapter to ensure that appropriate procedures regarding abuse or neglect are in place. 002.08(A)REGISTRY CHECKS. Medicaid providers must be cross-referenced with the Adult Protective Services and Child Protective Services Central Registries. For services being provided in the same location the provider lists as their home, members of the household must also be checked in the Central Registries.002.08(B)REPORTED ABUSE OR NEGLECT. If a report of abuse or neglect concerning a provider, or a household member when service is provided in the same location the provider lists as their home address Department staff will immediately terminate the service provider agreement. If a report of abuse or neglect is indicated, the Department will not enroll the provider.002.09ONGOING PARTICIPATION REQUIREMENTS. Annually, the Department will conduct an in-person review with each provider to ensure the provider continues to meet general and service specific provider standards. This review will also include a screening of the sex offender, Adult Protective Services, and Child Protective Services Central Registries, and may include an additional criminal background check.002.10CLAIMS SUBMISSION. Refer to 471 NAC 3-000. Services must be delivered before they can be billed. Providers are responsible for verifying that the information is accurate and complete prior to submission.002.11SOCIAL SECURITY TAX WITHHOLDING. When required by law, the Department withholds Social Security taxes, also known as Federal Insurance Contribution Act, (FICA) from provider payments. The employee's share of Social Security tax is withheld from provider payments only when in-home service is provided by an individual not affiliated with an agency. The Department, upon receiving a signed "Employer Appointment of Agent," acts on behalf of participants who receive in-home services to withhold mandatory Federal Insurance Contribution Act (FICA) taxes from individual providers and pays the participant's matching tax share to the Internal Revenue Service (IRS). 002.11(A)EARNINGS TAXED FOR SOCIAL SECURITY. Affected providers are subject to Social Security tax payment for each calendar year in which they are paid a federally determined amount or more for services provided to one participant. The Department will withhold this tax from all payments to affected providers. If a provider's earnings do not reach this annual amount for Federal Insurance Contribution Act (FICA) services per participant, the amount withheld for that year is refunded.002.11(B)SOCIAL SECURITY TAX RATES. The Department remits to the IRS an amount equal to the current Social Security tax rate for specified "in-home" services. Half of this amount is withheld from the provider as the employee's share; the other half is provided by the Department on behalf of the participant employer.002.12RECORD REQUIREMENTS. Providers of Waiver services must retain for six years the following material: (A) Documentation which supports provision of services to each participant served under the Waiver;(B) Any other documentation determined necessary by the Department to support selection and provision of services under a person-centered plan (PCP);(C) Financial information necessary to allow for an independent audit under the Waiver;(D) Documentation which supports requests for payment under the Waiver; and(E) Provider agreements with the Department.480 Neb. Admin. Code, ch. 4, § 002
Adopted effective 10/3/2021