Reimbursement

Reimbursement A. Participating Mississippi facilities must prepare and submit a Medicaid cost report for reimbursement of long term care facilities. 1. All cost reports are due by the end of the fifth (5th) calendar month following the reporting period. 2. Failure to file a cost report by the due date or the extended due date will result in a penalty of fifty dollars ($50.00) per day and may result in the termination of the provider agreement. B. The Division of Medicaid uses a prospective method of reimbursement. 1. The rates are determined from cost report data. 2. Standard rates are determined annually with an effective date of January first (1st). 3. In no case may the reimbursement rate for services provided exceed an individual facility’s customary charges to the general public for such services in the aggregate, except for those public facilities rendering such services free of charge or at a nominal charge. 4. Prospective rates may be adjusted by the Division of Medicaid pursuant to changes in federal and/or state laws or regulations when authorized by the state legislature. 5. Prospective rates may be adjusted by the Division of Medicaid based on revisions to allowable costs or to correct errors when authorized by the state legislature. a) These revisions may result from amended cost reports, field visit reviews, or other corrections. b) Facilities are notified in writing of amounts due to or from the Division of Medicaid as a result of these adjustments. c) There is no time limit for requesting settlement of these amounts. This is applicable to claims for dates of service since July 1, 1993. C. The Division of Medicaid conducts periodic field level cost report financial reviews of selected long term care facilities, including nursing facilities, intermediate care facilities for the mentally retarded, and psychiatric residential treatment facilities, to verify the accuracy and reasonableness of the financial and statistical information contained in the Medicaid cost reports. Adjustments will be made as necessary to the reviewed cost reports based on the results of the reviews. D. Notwithstanding any other provision of this article, it shall be the duty of each nursing facility, intermediate care facility for the mentally retarded, psychiatric residential treatment facility, and nursing facility for the severely disabled that is participating in the Medicaid program to keep and maintain books, documents and other records as prescribed by the Division of Medicaid in substantiation of its cost reports for a period of three (3) years after the date of submission to the Division of Medicaid of an original cost report, or three (3) years after the date of submission to the Division of Medicaid of an amended cost report. 1. Providers must maintain adequate documentation including, but not limited to, financial records and statistical data, for proper determination of costs payable under the Medicaid program. a) The cost report must be based on the documentation maintained by the facility. b) All non-governmental facilities must file cost reports based on the accrual method of accounting. c) Governmental facilities have the option to use the cash basis of accounting for reporting. 2. Documentation of financial and statistical data should be maintained in a consistent manner from one period to another and must be current, accurate and in sufficient detail to support costs contained in the cost report. 3. Providers must make available to the Division of Medicaid all documentation that substantiates the information included in the facility cost report for the purpose of determining compliance. a) These records must be made available as requested by the Division of Medicaid. b) All documentation which substantiates the information included in the cost report, including any documentation relating to home office and/or management company costs must be made available to Division of Medicaid reviewers as requested by the Division. E. Services and charges include the following: 1. The facility may charge any amount greater than or equal to the Medicaid rate for non- Medicaid residents for the provision of services under the State Medicaid Plan. 2. While the facility may set their basic per diem charge for non-Medicaid residents at any level, the services covered by that charge must be identical to the services provided to Medicaid residents and covered by the Medicaid per diem rate. 3. Any items and services available in the facility that are not covered under Title XVIII or the facility’s basic per diem rate or charge must be available and priced identically for all residents in the facility. F. Medicaid allows payment for the date of admission to the PRTF. Medicaid does not cover the date of discharge from the facility. A Medicaid-eligible beneficiary cannot be charged for the date of discharge. If a beneficiary is discharged on the date of admission, the day is covered as the date of admission. G. Private room coverage by Medicaid is as follows: 1. The overall average cost per day determined from the cost report includes the cost of private rooms. 2. The average cost per day is used to compute PRTF reimbursement rates. Therefore, the cost of a private room is included in the reimbursement rate and no extra charge can be made to the beneficiary, his/her family or the Medicaid program. 3. Medicaid reimbursement is considered as payment in full for the beneficiary. H. The following rules apply to hospital leave: 1. A fifteen (15) day length of stay is allowed in a non-psychiatric unit of a hospital. The facility must reserve the hospitalized resident’s bed in anticipation of his/her return. The bed cannot be filled with another resident during the covered period of hospital leave. 2. A resident must be discharged from the facility if he/she remains in the hospital for over fifteen (15) days. A leave of absence for hospitalization is broken if the resident returns to the facility for twenty-four (24) hours. 3. Facilities cannot refuse to readmit a resident from hospital leave when the resident has not been hospitalized for more than fifteen (15) days and still requires PRTF services. I. If a resident elopes from the facility and remains absent for twenty-four (24) hours or longer, he/she must be discharged from the facility. If further treatment at the same facility is desired after the end of the twenty-four (24) hours, the child/adolescent must go through a readmission process. J. The following rules apply to therapeutic leave: 1. An absence from the facility for eight (8) hours or more within one calendar day constitutes a leave day. 2. Medicaid coverage of therapeutic leave days per fiscal year, July 1 – June 30, is eighteen (18) days for a PRTF. 3. Each therapeutic leave day taken each month must be reported on the billing mechanism. 4. The attending physician must approve all therapeutic leave days. Documentation must include goals to be achieved during the leave, the duration of leave, who participated in the leave, and the outcome of the leave. K. Payment during therapeutic leave from the facility is as follows: 1. A temporary absence of a resident from a PRTF does not interrupt the monthly payments to the facility under the provisions as outlined in Part 207, Chapter 4 Rule 4.6 J. 2. Each facility is required to maintain leave records and indicate periods of therapeutic leave days. 3. Before a resident departs on therapeutic leave, the facility must provide each resident and family member or legal representative written information explaining leave policies. The information must define the period of time the resident is permitted to return and resume residence in the facility. 4. A refund of payment will be demanded for all leave days taken in excess of the allowable or authorized number of days. L. The PRTF must provide non-emergency transportation. 1. Effective February 1, 2019, the PRTF cannot use the Non-Emergency Transportation (NET) Broker to arrange transportation for residents. PRTFs may use NET providers that also provide NET services for the NET Broker if: a) The facility arranges the transportation, and b) Pays the NET provider directly. 2. Prior to February 1, 2019, the PRTF must: a) Arrange and pay for non-emergency transportation and place the cost on the cost report, or b) Utilize the NET Broker to arrange non-emergency transportation for residents.