Ch. 7, § 19. Extraordinary Care Clients

(a) The Department and a nursing facility may negotiate to provide skilled nursing facility services and special equipment and staffing that is medically necessary and preauthorized by the Department, but not included in the services provided by nursing facility's per diem rate. Payment will be the nursing facility's per diem rate, plus the negotiated extraordinary care rate. (i) The only items that may qualify for an extraordinary care rate are: (A) Tracheostomy; (B) Ventilator; (C) Morbid obesity; (D) Psychiatric care for clients with significant behaviors that cannot otherwise be safely cared for in a standard nursing facility setting without increased staffing or special accommodations, including clients with significant physical aggression, delirium and/or psychosis; or (E) Case by case situations where the Department determines a condition requires special care or clinically complex care. (ii) The Department will negotiate with nursing facilities on a case-by-case basis to determine the extraordinary care rate and billing procedures for an extraordinary care client. (iii) Prior to negotiations, the nursing facility must submit to the Department: (A) A treatment plan; (B) A proposed extraordinary care rate, including relevant financial records and medical records that document the medical necessity for services provided to an extraordinary care client; and (C) All other specific documentation requested by the Department to process the extraordinary care rate request. (iv) The Department must reevaluate the condition of an extraordinary care client fifteen days after admission, again thirty days after admission, again ninety days after admission, and every six months thereafter. (v) The Department must review the extraordinary care client's records annually to determine if renegotiating the extraordinary care rate is necessary to reflect changes in the extraordinary care client's condition. (b) The extraordinary care rate must not exceed the actual cost of the services provided to the extraordinary care client. (c) The nursing facility must maintain records of the costs it incurs in furnishing services to each extraordinary care client. Costs related to services furnished to extraordinary care clients, other than nursing facility services, are not allowable costs for purposes of determining the nursing facility's per diem rate.