Specialized rates for extraordinary medical care

1. A specialized rate for an individual with extraordinary medical needs may be established if the criteria in both subdivisions a and b are met. a. (1) The individual requires specialized therapies that are: (a) Restorative in nature (restorative means the individual has the ability to improve); (b) Medically necessary and provided in the facility; (c) Of at least two different types; and (d) Provided in excess of fifteen hours per week; (2) The individual requires extensive pulmonary care resulting from: (a) Suctioning and related tracheostomy care performed by a licensed nurse or therapist in excess of three and one-half hours in a twenty-four-hour period; or (b) A drug-resistant respiratory infection; (3) The individual requires total parenteral nutrition (TPN) and: (a) The individual is not eligible for or has been denied Medicare part A or B benefits; and (b) The individual requires total parenteral nutrition based on medical necessity for a minimum of three months; or (4) The individual requires the use of a ventilator and: (a) Is dependent on the ventilator a minimum of six hours per day; (b) Requires direct care by a licensed nurse, nurse aide, or therapist on a daily average of nine hours per day; (c) Is physiologically stable; and (d) Attempts to wean the individual from the ventilator have occurred during the acute hospital stay. b. Costs to provide direct care to the individual for the specialized services must exceed two and one-quarter times the actual direct care rate, adjusted for inflation, prior to limitations, for the individual's resident classification, except the department may use a cost limitation of one and three-quarters times the actual direct care rate, if specialized equipment is purchased for use by the resident. Costs that may be included in determining if the cost factor is exceeded include salaries and fringe benefits of all direct care staff, nursing supplies, drugs, dietary supplements, and specialized equipment costs. 2. A specialized rate must be calculated for an individual who meets the criteria by subtracting the actual cost per day for direct care, prior to limitations, for the individual's classification from the total cost per day for the individual. 3. A one-time startup cost of one thousand dollars must be included in the initial specialized rate for the first thirty days after the effective date of the specialized rate. 4. Except as provided for in subsection 7, all income received for a specialized rate must be offset proportionately to the affected cost categories. 5. The facility shall report costs on a monthly basis for the first three full months after admission and on a quarterly basis thereafter. The specialized rates must be adjusted to actual on a prospective basis based on the report submissions. 6. The specialized rate must be paid in addition to the rate established for the individual's resident classification and may only be paid for in-house resident days. 7. If a specialized rate has been established and costs to provide direct care to the individual decrease to less than the cost limits provided for in subdivision b of subsection 1, the specialized rate must continue until the end of the rate year. Income from the specialized rate may not be offset to reported costs for the report year in which the costs to provide direct care to the individual decreased to less than the established cost limits.