HAR §17-1739-73. Wait listed reimbursements

(a) Payments for wait listed patients shall reflect the level of care required by the patient. The facility shall receive a routine per diem for each day that a wait listed patient remains in the acute care part of the facility. Room and board wait listed rates are to be determined based upon the statewide weighted average costs of providing either SNF or ICF services by distinct part facilities per the medicaid long-term care prospective payment rate calculations with the following exceptions: (1) The wait listed rates cannot exceed the facility's own distinct part SNF or ICF prospective payment rates; (2) A facility with a distinct part SNF, but no ICF, would have an ICF wait listed rate based on the statewide weighted average but not to exceed the facility's distinct SNF prospective payment rate; and (3) In no case will any relief granted under rate reconsideration be used to adjust the wait listed rates. (b) Wait listed rates shall be annually adjusted by the same inflation factors as the long-term care PPS rates. (c) The rate for wait listed long-term care patients in acute care beds does not include ancillary services except for medical supplies and maintenance therapy. These excluded ancillary services must therefore be billed separately. Reimbursements will be consistent with the ancillary rates paid to long term care facilities. [Eff 11/13/95 ] (Auth: HRS §346-59) (Imp: 42 C.F.R. §447.252) UNOFFICIAL 1739-27 §17-1739-74 Payment for services rendered to patients with other health insurance. Medicaid is a secondary payor. In no case shall medicaid pay a sum, when considered in conjunction with payments from all other sources (including the patient's cost share and Medicare), that exceeds the amount that would have been paid if no other source of reimbursement existed. [Eff 11/13/95 ] (Auth: HRS §346-59) (Imp: 42 C.F.R. §447.252) §17-1739-75 Limitations on acute care facility payment. (a) Calculation of the prospective payment rate shall not be affected by a public provider's imposition of nominal charges in accordance with federal regulations. However, for providers whose charges are less than costs on the most recently filed cost report and who do not qualify as a nominal charge provider, the prospective rate shall be reduced during the interim until the applicable cost report is filed and a settlement adjustment is made. The interim reduction shall be in proportion to the ratio of costs to charges on the most recent filed cost report. Updated data and charge structures may be provided to the department's fiscal intermediary if the provider believes that its rate structure has changed significantly since the most recent filed cost report, but the department will be responsible for approving the final interim rate reduction necessary to approximate final settlement as closely as possible. (b) Payment for out-of-state acute care facility services shall be the medicaid rate applicable in the facility's state. If an out of state medicaid rate is not available, the weighted average Hawaii medicaid rate applicable to services provided in comparable Hawaii facilities shall be used. (c) The department or its utilization review agent may deny full or partial payment if it is determined that the admission or transfer was not medically necessary or the diagnosis or procedure code was not correctly assigned, or the patient was retained in the facility longer than necessary. The department shall recover amounts due using the most expedient methods possible which shall include but not be limited to offsetting amounts against current payments due providers. [Eff 11/13/95 ] (Auth: HRS §346-59) (Imp: 42 C.F.R. §447.252) UNOFFICIAL 1739-28