Nursing Facility Invasive Ventilator Program

PURPOSE: This rule sets forth the requirements for participation in the MO HealthNet Invasive Ventilator Program and the per diem add-on amounts to be applied to nursing facility reimbursement rates, established in 13 CSR 70-10.015 and 13 CSR 70-10.016. The services provided under the Invasive Ventilator Program are in addition to the nursing facility services already provided by the facility and as such are subject to all policies, rules, regulations, and provider agreements applicable to providing nursing facility services to MO HealthNet participants. (1) The Invasive Ventilator Program is limited to— (A) Nursing facilities licensed by the Department of Health and Senior Services (DHSS) and certified for participation in the MO HealthNet program and enrolled in the MO HealthNet Invasive Ventilator Program; and (B) Services provided to adult MO HealthNet participants who are dependent on an invasive ventilator as a means of life support. An invasive ventilator generates breath delivered to the participant through an artificial airway positioned in the participant’s trachea. (2) Reimbursement for Invasive Ventilator Care. Providers approved for participation in the Invasive Ventilator Program will receive payment in the form of a per diem add-on to their reimbursement rate established in accordance with 13 CSR 7010.015. The per diem add-on amount will be one hundred fifty dollars ($150.00) will be paid for MO HealthNet participants who are dependent on a ventilator full time as a means of life support. (3) Provider Requirements for Participation in the Invasive Ventilator Program. (A) Nursing facilities seeking to participate in the Invasive Ventilator Program must submit the following information to Missouri Medicaid Audit and Compliance (MMAC), Provider Enrollment Unit: 1. A completed Invasive Ventilator Program Provider application; and 2. Any other information or documentation requested by MMAC to assist in determining enrollment status. (B) MMAC may enter into agreements with facilities for the participation in the MO HealthNet Invasive Ventilator Program through the provider enrollment process only if the provider agrees to the following terms: 1. The provider must maintain and provide documentation demonstrating— A. Medicaid (Title XIX) Certification; B. The provider has the capacity and capability to provide invasive ventilator medical care as documented by DHSS, MO HealthNet Division (MHD), and MMAC records; C. Adherence to regulatory requirements established by DHSS, MHD, and MMAC; D. The medical condition of the participant to verify they meet the criteria for participation in this program; and E. The provider has the following written agreements: (I) A written agreement with an enrolled MO HealthNet Durable Medical Equipment (DME) provider which must include a service contract for invasive ventilator equipment. DME providers will bill MO HealthNet for the necessary ventilator; (II) A written agreement with a local emergency transportation provider; (III) A written agreement with a local hospital capable of providing the necessary care for invasive ventilatordependent participants, when appropriate; (IV) Presence of written emergency procedures including but not limited to the following: (a) Procedures to care for and transport invasive ventilator-dependent participants in the event of an emergency evacuation; (b) Procedures to care for invasive ventilatordependent participants in the event of power failure; and (c) Procedures to care for invasive ventilatordependent participants in the event of equipment failure; 2. Individuals qualifying for participation in the Invasive Ventilator Program must be placed in contiguous rooms; and 3. In addition to the covered items and services included in the reimbursement rate set forth in 13 CSR 70-10.015— A. The nursing facility must purchase one (1) Ambu bag per invasive ventilator dependent participant and place it in a designated location readily accessible at the bedside to ensure access in the event of an emergency; B. The provider must ensure the necessary equipment to accommodate the needs of the invasive ventilator-dependent participants is provided by the DME provider. The equipment and supplies covered under the MO HealthNet DME program will be payable directly to the DME provider; C. Proper invasive ventilator and tracheostomy supplies and equipment are provided to the participant; D. Each invasive ventilator is equipped with an alarm on both the pressure valve and the volume valve; and E. Each invasive ventilator is equipped with internal batteries to provide a short term back-up system in case of a total loss of power, and the battery must be checked as recommended by the manufacturer. (C) Termination of Participation in Invasive Ventilator Program. 1. Providers desiring to discontinue providing invasive ventilator services shall notify MMAC Provider Enrollment Unit in writing, at least sixty (60) days prior to the date of termination. Payment for invasive ventilator participants already residing in facilities who wish to discontinue providing invasive ventilator services will remain at the previous invasive ventilator rate as long as the participant meets the invasive ventilator criteria and as long as all related criteria are met by the provider or the participant is discharged. (4) Participant Eligibility for Participation in Invasive Ventilator Program. (A) Pre-certification must be obtained through MO HealthNet in order to receive payment under the Invasive Ventilator Program. The pre-certification must be initiated by an authorized medical assistance provider who has evaluated the medical needs of the individual. Authorized providers include physicians, advanced practice nurses, respiratory therapists, hospitals, and nursing facilities. 1. The pre-certification application will be available by contacting the Clinical Services Unit/Invasive Ventilator Program. 2. The pre-certification period will be approved for the duration of the physician’s prescription for invasive ventilation. If the invasive ventilator is used for weaning purposes, a precertification must be completed every ninety (90) days to ensure individuals still meet the requirements for participation in this program. An approved pre-certification request does not guarantee payment. The provider must verify participant eligibility on the date of service using the Interactive Voice Response (IVR) System at (573) 635-8908 or by logging onto the MO HealthNet Internet Web portal at www.emomed.com. (B) Accessibility to Records. The provider must make accessible to MHD, MMAC, and/or DHSS all provider, participant, and other records necessary to determine that the needs of the participant are being met and to determine the appropriateness of invasive ventilator services. (C) In the event that it is determined through the precertification process that the participant is no longer in need of or receiving invasive ventilator services, MHD shall discontinue the add-on per diem authorized by this regulation for the participant and reduce the rate of payment to the provider to the provider’s standard MO HealthNet per diem rate established under 13 CSR 70-10.015. (5) Cost Reporting Requirements. (A) Providers will be required to separately identify the invasive ventilator-dependent patient days regardless of payer source that relate to dates of service within the cost reporting time period by completing a supplemental schedule as provided by MHD. (B) Due to the complex record-keeping requirements needed to identify the specific cost of this program, MHD will remove the cost as a revenue offset determined as follows. The days from each category identified above will be multiplied by the related Invasive Ventilator add-on amount and offset against the expenses. This will ensure the additional cost of caring for these participants will be removed from the allowable cost in determining the prospective reimbursement rate. The offset will be allocated among the cost components as follows: Patient Care—sixty percent (60%), Ancillary—thirty percent (30%), and Administrative—five percent (5%). The remaining five percent (5%) will not be offset because the capital costs are easily identified and will be removed as non-allowable. AUTHORITY: section 208.159, RSMo 2000, and sections 208.153 and 208.201, RSMo Supp. 2012.* Original rule filed April 1, 2013, effective Oct. 30, 2013. *Original authority: 208.153, RSMo 1967, amended 1967, 1973, 1989, 1990, 1991, 2007, 2012; 208.159, RSMo 1979; and 208.201, RSMo 1987, amended 2007.