Neb. Admin. Code tit. 471 — Nebraska Medical Assistance Program Services

Chapter 1 Administration

Neb. Admin. Code tit. 471, ch. 1 Administration {#sec-471-nac-1 omnilex-key=us-ne-regs-official--title-471--471 NAC 1}

TITLE 471 NEBRASKA MEDICAL ASSISTANCE PROGRAM SERVICES

CHAPTER 1 ADMINISTRATION

001. SCOPE AND AUTHORITY. The regulations govern the services provided under Nebraska’s Medicaid program as defined by Nebraska Revised Statute (Neb. Rev. Stat.) §§ 68‑901 to 68‑991.

002. NEBRASKA MEDICAID-COVERABLE SERVICES. Medicaid covers the services included and outlined in each service specific chapter in Nebraska Administrative Code (NAC) Titles 471, 473, 480, and 482. Each service must be medically necessary and appropriate, in accordance with this chapter, and any additional medical necessity requirements imposed by each service specific chapter in Title 471 NAC.

002.01 NEBRASKA MEDICAID MANAGED CARE PROGRAM. Each Managed Care Organization (MCO) provides behavioral health, physical health, dental services, and pharmacy services to eligible enrolled Medicaid clients. Medicaid operates Managed Care in accordance with Title 482 NAC.

002.01(A) BENEFITS. The Heritage Health plan is required to provide the services in the core benefits package as defined in 482 NAC 4, in the amount, duration, and scope as described in this chapter. The Managed Care Organizations (MCOs) can place appropriate limits on covered services consistent with medical necessity or based on utilization control.

002.01(B) PRIOR AUTHORIZATION, BILLING, AND PAYMENT. Services provided to clients enrolled in Managed Care are not billed to Medicaid. The provider will provide services only under an arrangement with the Managed Care Organization (MCO) , and the Managed Care Organization (MCO) will make timely payment in accordance with 482 NAC 4. The prior authorization requirements, payment limitations, and billing instructions outlined in Title 471 NAC do not apply to services provided to clients enrolled in Managed Care unless otherwise stated in this chapter.

002.02 GENERAL REQUIREMENTS FOR ALL SERVICES. Providers must be enrolled in Medicaid for the service provided, ordered, referred, or rendered to be coverable.

002.02(A) MEDICAL NECESSITY. Services and supplies which do not meet the definition of medical necessity are not covered. For purposes of Medicaid fee-for-service and Managed Care, medical necessity is health care services and supplies which are medically appropriate and:

(i) Necessary to meet the basic health needs of the client;

(ii) Rendered in the most cost‑efficient manner;

(iii) Rendered in a type of setting appropriate for the delivery of the covered service;

(iv) Consistent in type, frequency, and duration of treatment with scientifically based guidelines of national medical, research, or health care coverage organizations or governmental agencies;

(v) Consistent with the diagnosis of the condition;

(vi) Required for means other than convenience of the client or the physician;

(vii) No more intrusive or restrictive than necessary to provide a proper balance of safety, effectiveness, and efficiency; and

(viii) Relative to the goal of improved patient health outcomes.

002.02(B) PLACE OF SERVICE. Covered services in fee-for-service and Managed Care must be provided at the least expensive appropriate place of service. As deemed appropriate by Medicaid, payment for services provided at alternate places of service may either be denied, or reduced to what would have been payable at the least expensive appropriate place of service.

002.02(C) EXPERIMENTAL OR INVESTIGATIONAL. Medicaid in fee-for-service and Managed Care does not cover medical services which are considered investigational or experimental or which are not generally employed by the medical profession. While the circumstances leading to participation in an experimental or investigational program may meet the definition of medical necessity, payment for these services are prohibited.

002.02(C)(i) RELATED SERVICES. Medicaid does not pay for associated or adjunctive services that are directly related to non‑covered experimental or investigational services.

002.02(C)(ii) INVESTIGATIONAL OR EXPERIMENTAL CRITERIA. Services are deemed investigational or experimental by the Department. The Department may convene ad hoc advisory groups of experts to review requests for coverage. A service is deemed investigational or experimental if it meets any one of the following criteria:

(1) The Food and Drug Administration (FDA), or other regulatory authority, has not approved the service or treatment for general marketing to the public for the proposed use;

(2) Reliable evidence does not lead to the conclusion that there is a consensus within the medical community that the service is a generally accepted standard of care employed by the medical profession as a safe and effective service for treating or diagnosing the condition or illness for which its use is proposed. Reliable evidence includes peer reviewed literature with statistically significant data regarding the service for the specific disease and age group. Also, facility specific data, including short and long term outcomes, must be submitted to the Department;

(3) The service is available only through an Institutional Review Board (IRB) research protocol for the proposed use or subject to such an Institutional Review Board (IRB) process; or

(4) The service is the subject of an ongoing clinical trial that meets the definition of a Phase I, Phase II, or Phase III Clinical Trial, regardless of whether the trial is actually subject to Food and Drug Administration (FDA) oversight and regardless of whether an Institutional Review Board (IRB) process is required at any one particular institution.

002.02(C)(iii) DEFINITION OF CLINICAL TRIALS. For services not subject to Food and Drug Administration (FDA) approval, the following definitions apply:

(1) Phase I: Initial introduction of an investigational service into humans;

(2) Phase II: Controlled clinical studies conducted to evaluate the effectiveness and safety of the service being investigated; and

(3) Phase III: Clinical studies to further evaluate the effectiveness and safety of a service that is needed to determine the overall risk and benefit and to provide an adequate basis for determining patient selection criteria for the service as the recommended standard of care. These studies usually compare the new service to the current recommended standard of care.

002.02(D) FAMILY PLANNING SERVICES. Medicaid in fee-for-service and Managed Care covers family planning services, including consultation and procedures, when requested by the client. Family planning services and information must be provided to clients without regard to age, sex, or marital status, and must include medical, social, and educational services. The client must be allowed to exercise freedom of choice in choosing a method of family planning. Family planning services performed in family planning clinics must be prescribed by a physician, and furnished, directed, or supervised by a physician or registered nurse.

002.02(D)(i) COVERED SERVICES. Covered services for family planning include initial physical examination and health history, annual and follow-up visits, laboratory services, prescribing and supplying contraceptive supplies and devices, counseling services, and prescribing medication for specific treatment.

002.02(E) SERVICES PROVIDED OUTSIDE NEBRASKA. Payment in fee-for-service and Managed Care may be approved for services provided outside Nebraska in the following situations:

(1) When an emergency arises from accident or sudden illness while a client is visiting in another state and the client's health would be endangered if medical care is postponed until the client returns to Nebraska;

(2) When a client customarily obtains a medically necessary service in another state because the service is more accessible; or

(3) When the client requires a medically necessary service that is not available in Nebraska.

002.02(E)(i) PRIOR AUTHORIZATION REQUIREMENTS. Prior authorization in fee-for-service is required for services provided outside Nebraska when:

(1) The service is not available in Nebraska; or

(2) The service requires prior authorization under the applicable service specific chapter of Title 471 NAC.

002.02(E)(ii) PRIOR AUTHORIZATION PROCEDURES FOR OUT-OF-STATE SERVICES. In fee-for-service, the referring physician must submit request to the Department in written or electronic form. The request must include the following information or explanation as appropriate to the case:

(1) A summary evaluation by a licensed provider for the type of service rendered, and a statement indicating that the service is not available in Nebraska or is inadequate to meet the client's needs;

(2) The name, address, and telephone number of the out-of-state provider;

(3) An indication of whether the out-of-state provider is enrolled or is willing to enroll as a Nebraska Medicaid provider and accept the Medicaid allowable payment as payment in full for the services;

(4) A description of the client's condition. The physician must certify, based on a thorough evaluation, that the services being requested are medically necessary and not experimental or investigational;

(5) Identification of the physician who will be assuming follow-up care when the client returns to Nebraska;

(6) Any plan for follow-up and return visits, including a timeline for the visits and an explanation of the medical necessity for the return visits;

(7) If the client is requesting assistance with transportation, the type of transportation appropriate for the client's condition, and when ambulance, air ambulance, or commercial air transportation is being requested, the request must provide an explanation of medical necessity; and

(8) The client’s name, address, and Medicaid recipient identification number, or date of birth.

002.02(E)(iii) MANAGED CARE PROVIDERS. In Managed Care, the provider must provide services only under an arrangement with the Managed Care Organization (MCO).

002.02(F) SERVICES NOT DIRECTLY PROVIDED FOR TREATMENT OR DIAGNOSIS. Unless otherwise expressly allowed in Title 471, Medicaid in fee for service and Managed Care does not cover services provided to a client that are not directly related to diagnosis or treatment of the client’s condition.

002.02(G) SERVICES REQUIRED TO TREAT COMPLICATIONS OR CONDITIONS RESULTING FROM NON-COVERED SERVICES. Medicaid in fee-for-service and Managed Care may consider payment for medically necessary services that are required to treat complications or conditions resulting from non-covered services. Coverage of complication or conditions resulting from non-covered services will be determined at the discretion of the Department. If the services in question are determined to be part of a previous non-covered service, that is, an extension or a periodic segment of a non-covered service or follow-up care associated with it, the subsequent services will be denied.

002.02(H) DRUG REBATES. Medicaid covers prescribed drugs only if the labeler has signed a Rebate Participation Agreement with the Centers for Medicare and Medicaid Services (CMS).

002.02(H)(i) REBATE DISPUTE RESOLUTION. In any quarter, if a manufacturer discovers a discrepancy in Medicaid utilization information that the manufacturer and the Department are unable to resolve in good faith, the manufacturer must provide written notice of the discrepancy by National Drug Code (NDC) number to the Department within 30 days of receipt of the quarterly drug rebate invoice which contains the Medicaid utilization information.

002.02(H)(i)(1) MANUFACTURER DISPUTE. If the manufacturer, in good faith, believes that the Medicaid utilization information is erroneous, the manufacturer must pay the Department that portion of the rebate amount claimed that is not disputed within 30 days after receiving the Medicaid utilization information. Following resolution of the dispute, the balance due, if any, plus a reasonable rate of interest as set forth in Section 1903(d)(5) of the Social Security Act must be paid or credited by the manufacturer or by the Department by the due date of the next quarterly payment.

002.02(H)(i)(2) WRITTEN REQUEST. The Department and the manufacturer must use their best efforts to resolve the discrepancy within 60 days of receipt of notification. If the Department and the manufacturer are not able to resolve a discrepancy within 60 days, the manufacturer may file a written request for an administrative hearing under 465 NAC 6.

002.02(H)(i)(2)(a) HEARING DECISION. The hearing decision is not binding on the Secretary of Health and Human Services, Centers for Medicare and Medicaid Services (CMS), for purposes of their authority to implement a civil money penalty provision in accordance with the statute or rebate agreement.

002.02(H)(i)(3) PAYMENT ADJUSTMENTS. Adjustments to rebate payments must be made if information indicates that either Medicaid utilization information, average manufacturer price (AMP), or best price is greater or less than the amount previously specified.

002.02(H)(ii) MANUFACTURER RIGHT TO APPEAL. Every manufacturer of a rebatable drug that has a signed rebate agreement has the limited right to appeal to the Medicaid Director for a hearing. This appeal right is limited to any discrepancies in the quarterly Medicaid utilization information only. No other matter relating to that manufacturer's drugs may be appealed to the Director.

002.02(H)(ii)(1) HEARING REQUEST. A manufacturer must request a hearing within 90 days of the date the Department gives notice to the manufacturer of the availability of the hearing process for the disputed drugs.

002.02(H)(ii)(2) HEARING PROCEDURES. Hearings are scheduled and conducted according to 465 NAC 6.

002.02(H)(iii) SUPPLEMENTAL DRUG REBATES. In addition to the requirements for drug rebates as described in this chapter. Medicaid may negotiate and contract for supplemental rebates with labelers of prescribed drugs. The negotiations and contracts may be between the labeler and the Department or an entity under contract with the Department to negotiate these supplemental rebates, including a single or multi-state drug purchasing pool. Any entity under contract with the Department will be fee based, and there will be no financial incentives or bonuses based on inclusion or exclusion of medications from the Preferred Drug List.

002.02(I) REQUIREMENTS FOR WRITTEN PRESCRIPTIONS. Medicaid in fee-for-service and Managed Care will not pay for written prescriptions for prescribed drugs unless executed on a tamper-resistant pad as required by federal law.

002.02(I)(i) EXCLUSIONS. The following prescriptions and other items are not required to be written on tamper-resistant prescription pads:

(1) Orders for drugs provided in Nursing Facilities, Intermediate Care Facility for clients with Developmental Disabilities (ICF/DD) facilities, and other specified institutional and clinical settings for which the drug is not separately reimbursed, but is reimbursed as part of a total service including:

(a) Inpatient and outpatient hospital;

(b) Hospice;

(c) Dental;

(d) Laboratory;

(e) X-ray; and

(f) Renal dialysis;

(2) Faxed prescriptions;

(3) Telephoned, or otherwise orally transmitted prescriptions; and

(4) E-prescribed when the prescription is transmitted electronically.

002.02(I)(ii) REQUIREMENTS. A written Medicaid prescription must contain at least one of the three following characteristics:

(1) An industry-recognized feature designed to prevent unauthorized copying of a completed or blank prescription form, such as a high security watermark on the reverse side of the blank or thermochromic ink;

(2) An industry-recognized feature designed to prevent erasure or modification of information written on the prescription by the prescriber, such as tamper-resistant background ink that shows erasures or attempts to change written information; or

(3) An industry-recognized feature designed to prevent the use of counterfeit prescription forms, such as sequentially numbered blanks or duplicate or triplicate blanks.

002.02(I)(iii) EMERGENCY FILLS. Medicaid will pay for emergency fills for prescriptions written on non-tamper resistant pads only when the prescriber provides a verbal, faxed, electronic, or compliant written prescription within 72 hours after the date on which the prescription was filled. In an emergency situation, this allows a pharmacy to telephone a prescriber to obtain a verbal order for a prescription written on a non-compliant paper. The pharmacy must document the call on the face of the written prescription.

002.02 (J) MANAGED CARE CLIENTS. Clients participating in the Managed Care plans are required to access services through their primary care provider.

003. FEDERAL AND STATE REQUIREMENTS. The Department is required by federal and state law to meet certain provisions in the administration of Medicaid.

003.01 MEDICAL ASSISTANCE ADVISORY COMMITTEE. The Medicaid Director will appoint an advisory committee to advise the Director in the development of health and medical care services policies. Members of the committee include: physicians and other representatives of the health professions who are familiar with the medical needs of low-income population groups and with the resources available and required for their care; members of consumers' groups, including Medicaid clients; and consumer organizations, such as labor unions, cooperatives, consumer-sponsored prepaid group practice plans, and others; the Director of Public Health and the Chief Executive Officer of Health and Human Services. Members are appointed on a rotating basis to provide continuity of membership.

003.02 UTILIZATION REVIEW. Any individual or entity must provide the Department with any documentation or information requested as part of the Department’s utilization review.

004 . CLIENT RESTRICTED SERVICES PROGRAM. This section applies to medical services in Medicaid fee-for-service and Managed Care.

004.01 RESTRICTED SERVICES CRITERIA. The Department may restrict a client to obtain Medicaid services only from a designated provider, or renew a period of restricted services, when the client has used Medicaid services at a frequency or amount that is not medically necessary. When evaluating whether a client has used services at a frequency or amount that is not medically necessary, the Department may consider any of the following criteria:

(A) Number, type, or dosage of prescriptions obtained by the client;

(B) Number of prescribers prescribing medication to the client;

(C) Number of pharmacies dispensing to a client;

(D) Number of clinic or emergency room encounters; or

(E) Whether the client displays at-risk behavior, as exhibited by any of the following:

(i) A client with a medical history of seeking and obtaining health care services at a frequency or amount that is not medically necessary; or

(ii) Behaviors or practices that could jeopardize a client's medical treatment or health including, but not limited to:

(1) Forging or altering prescriptions;

(2) Noncompliance with medical or drug and alcohol treatment;

(3) Paying cash for medical services that result in a controlled substance prescription or paying cash for controlled substances;

(4) Arrests for diversion of controlled substance prescriptions;

(5) Positive urine drug screen for illicit drugs or non-prescribed controlled substances;

(6) Negative urine drug screen for prescribed controlled substances; or

(7) Use of a client's Medicaid card for an unauthorized purpose.

004.02 DESIGNATION OF RESTRICTED SERVICES PROVIDER(S). The Department will designate a provider to provide services to a client placed into restrictive services. A designated provider must be located within a reasonable distance of, and must be reasonably accessible to, the client.

004.02(A) DURATION OF RESTRICTED SERVICES. A client placed into restricted services must obtain Medicaid services from the designated provider for a period of no more than 12 months. Upon the expiration of a period of restricted services, the Department may renew such period based upon the Department’s review of the client’s pattern of utilization.

004.02(B) DURATION OF PROVIDER DESIGNATION. A client placed in restricted services must remain with the designated provider, unless any of the following occur:

(i) The designated provider is no longer located within a reasonable distance of, or is no longer reasonably accessible to, the client;

(ii) The designated provider refuses to continue to serve the client;

(iii) The designated provider is no longer enrolled in Medicaid; or

(iv) A change is requested by the client and approved by the Department. A client may request a change of the designated provider no later than 90 days after a designation is made. Such request must be made to the Department in writing.

004.03 SERVICES BY PROVIDERS NOT LISTED AS RESTRICTED SERVICES PROVIDERS. Claims for services provided to a restricted services client by other than the

designated provider will not be approved, with the following exceptions:

(A) Emergency care is defined as medically necessary services provided to a client who requires immediate medical attention to sustain life or to prevent any condition which could cause permanent disability to body functions;

(B) A primary care provider may refer a restricted services client to a non-designated provider for a specified length of time. Any referral made by a primary care provider to a non-designated provider must be approved by the Department prior to the non-designated provider providing services to the client. Referrals are not required for the following:

(i) Non-emergent medical transportation;

(ii) Home and community based services;

(iii) Mental health and substance abuse services;

(iv) Routine eye exams;

(v) Radiology services;

(vi) Laboratory services;

(vii) Family planning;

(viii) Obstetrics provider services only;

(ix) Dialysis; and

(x) Nursing home services; and

(C) Prescriptions will be covered if prescribed or authorized by a primary care provider, or within the setting of a hospital for non-emergency care if approved by a primary care provider.

004.04 RESTRICTED SERVICES NOTIFICATION. The client will be provided notice of the client’s placement into restrictive services no fewer than 10 days before restricted services are imposed.

004.04(A) CLIENT APPEAL RIGHTS. A client may appeal the Department’s decision to place the client into restricted services. Any appeal must be submitted in writing no later than 90 days after the client is placed into restricted services. If an appeal is submitted within 10 days after notice of the client’s placement into restrictive services is mailed, the effective date of the restricted services will be stayed until the appeal has been decided.

004.04(B) CHANGE IN DESIGNATED PROVIDER. A client may appeal the Department’s decision to deny the client’s request to change a designated provider. Any appeal must be submitted in writing no later than 90 days after the Department’s decision.

004.05 PHARMACY CLAIMS. Pharmacy claims submitted for prescriptions dispensed to a client in the restricted services program by providers other than a designated provider will not be paid except in a medical emergency. A pharmacy submitting a claim must provide documents indicating a medical emergency existed at the time the prescription was dispensed.

00 5 . ADVANCE DIRECTIVES. An advance directive is a written instruction, such as a living will or durable power of attorney for health care, recognized under applicable law that relates to the provision of medical care if the client becomes incapacitated. Medicaid‑participating hospitals, nursing facilities, providers of home health care or personal care services, hospice programs, and Managed Care Organizations (MCOs) must:

(A) Maintain written policies, procedures, and materials concerning advance directives;

(B) Provide written information to all adult clients receiving medical care by or through the provider or organization concerning their rights under applicable law to:

(i) Make decisions concerning their medical care;

(ii) Accept or refuse medical or surgical treatment; and

(iii) Formulate advance directives, such as living wills or durable power of attorney for health care;

(C) Provide written information to all adult clients on the provider's policies concerning implementation of these rights;

(D) Document in the client's medical record whether the client has executed an advance directive;

(E) Not condition the provision of care or otherwise discriminate against a client based on whether that client has executed an advance directive;

(F) Ensure compliance with requirements of applicable law concerning advance directives; and

(G) Provide for educating staff and the community on advance directives.

005.01 WHEN PROVIDERS GIVE INFORMATION CONCERING ADVANCE DIRECTIVES. Providers must give information concerning advance directives to each adult client as follows:

(A) A hospital must give information at the time of the client's admission as an inpatient;

(B) A nursing facility must give information at the time of the client's admission as a resident;

(C) A provider of home health care or personal care services must give information to the client in advance of the client's coming under the care of the provider;

(D) A hospice program must give information at the time of initial receipt of hospice care by the client; and

(E) A Managed Care Organization (MCO) must give information at the time of enrollment. If a managed care plan has more than one medical record for its members, it must document in all medical records.

005.02 INFORMATION CONCERING ADVANCE DIRECTIVES AT THE TIME AN INCAPACITATED CLIENT IS ADMITTED. A client could be admitted to a facility in a comatose or otherwise incapacitated state and be unable to receive information or articulate whether the client has executed an advance directive. In this case, to the extent that a facility issues materials about policies and procedures to the families or to the surrogates or other concerned persons of the incapacitated client in accordance with applicable law, it must also include the information concerning advance directives. This does not relieve the facility from its obligation to provide this information to the patient once the client is no longer incapacitated.

005.03 PREVIOUSLY EXECUTED ADVANCE DIRECTIVES. When the client or a relative, surrogate, or other concerned or related client presents the facility with a copy of the client's advance directive, the facility must comply with the advance directive to the extent allowed under applicable law. This does not preclude a facility from objecting as a matter of conscience if it is permitted to do so under applicable law.

005.04 INFORMATION CONCERNING ADVANCE DIRECTIVES ABSENT CONTRARY LAW. Absent contrary applicable law, if no one comes forward with a previously executed advance directive and the client is incapacitated or otherwise unable to receive information or articulate whether the client has executed an advance directive, the facility will note that the client was not able to receive information and was unable to communicate whether an advance direct.

History

• Effective 2025-01-20

Chapter 2 Provider Participation

Neb. Admin. Code tit. 471, ch. 2 Provider Participation {#sec-471-nac-2 omnilex-key=us-ne-regs-official--title-471--471 NAC 2}

001. SCOPE AND AUTHORITY . These regulations govern services provided under the Medical Assistance Act, Nebraska Revised Statute (Neb. Rev. Stat.) §§ 68-901 to 68-991.

002. DEFINITIONS . The following definitions apply:

002.01 ABUSE. Practices or actions that are inconsistent with sound fiscal, business, or medical practices and result in an unnecessary cost to Medicaid or in reimbursement for services that are not medically necessary or that fail to meet professionally recognized standards for health care. Abuse may include underutilization or overutilization.

002.02 AFFILIATES. Persons having an overt or covert relationship such that any one of them directly or indirectly controls or has the power to control another.

002.03 BILLING. Presenting, or causing to be presented, a claim for payment to the Department, its agents, or assignees.

002.04 BILLING AGENT. An entity that submits or facilitates the submission of claims for payment to the Department.

002.05 CLAIM. A request for payment for services rendered or supplied by a provider to a client.

002.06 CLEARINGHOUSE. An entity that processes or facilitates the processing of information received from another entity in the following formats:

(A) In a nonstandard format or containing nonstandard data content into a standard transaction; or

(B) In a standard transaction into nonstandard format or data content.

002.07 CLOSED-END PROVIDER ENROLLMENT. An enrollment that is for a specific period of time.

002.08 EXCLUDED PERSON OR ENTITY. Any individual or entity that is no longer eligible to participate as a provider, owner, managing employee, affiliate, or other individual or entity associated with an enrolled provider in Medicaid due to a sanction.

002.09 EXCLUSION. Prohibition from participating in Medicaid or affiliating with an enrolled provider.

002.10 FRAUD. An intentional deception or misrepresentation made by a person with the knowledge that the deception could result in some unauthorized benefit to himself, herself, or some other person. It includes any act that constitutes fraud under applicable federal or state law. Fraud includes, but is not limited to, the willful false statement or representation, or impersonation or other device, made by a client, applicant, provider, Department employee, or any other person, for the purpose of obtaining or attempting to obtain, or aiding or abetting any person to obtain:

(A) An assistance certificate of award to which the individual is not entitled;

(B) Any commodity, food stuff, food coupon, or payment to which the individual is not entitled or a larger amount of payment than that to which the individual is entitled;

(C) Any payment made on behalf of a client of medical assistance or social services;

(D) Any other benefit administered by the State of Nebraska, its agents or assignees; or

(E) Assistance in violation of any statutory provision relating to programs administered by the Department.

002.11 INITIAL ENROLLMENT. A provider’s first time enrolling with Medicaid.

002.12 MANAGING EMPLOYEE. With respect to an entity, an individual, including a general manager, business manager, administrator, or director, who exercises operational or managerial control over the entity, or who directly or indirectly conducts the day-to-day operations of the entity.

002.13 MEDICAID EXCLUDED PROVIDERS LIST. List of providers, persons, and entities that have been terminated or excluded from participation with Medicaid.

002.14 OPEN-ENDED PROVIDER ENROLLMENT. An enrollment that has no termination date and continues in force as long as the provider satisfies the applicable eligibility criteria.

002.15 OTHER INDIVIDUALS OR ENTITIES ASSOCIATED WITH THE ENROLLED PROVIDER. Ancillary healthcare professionals or staff who do not see Medicaid patients but are associated with a provider.

002.16 OVERUTILIZATION. Overutilization includes:

(A) A documented pattern of ordering, performing, or billing tests, examinations, medical visits, surgeries, drugs, or merchandise for which there is no demonstrable need; or

(B) Inducing, furnishing, or otherwise causing a client to receive services or merchandise not otherwise required by the client, ordered by the attending physician, or deemed appropriate by a utilization review committee.

002.17 OVERPAYMENT. Any erroneous payment to a provider, whether made due to the result of fraud, waste, abuse, inadvertence, or Department error.

002.18 PARTICIPATION. Participation in Medicaid includes providing, referring, furnishing, ordering, or prescribing services to a Medicaid client or causing services to be provided, referred, furnished, ordered, or prescribed for a Medicaid client.

002.19 PAYMENT. Reimbursement or compensation by the Department, its agents, assignees, or managed care plans.

002.20 PERSON. Any individual, company, firm, association, corporation, or other legal entity.

002.21 PERSON WITH AN OWNERSHIP OR CONTROL INTEREST. A person who:

(A) Has directly or indirectly an ownership interest of five percent or more in the entity;

(B) Is the owner of a whole or part interest in any mortgage, deed of trust, note, or other obligation secured, in whole or in part, by the entity or any of the property or assets thereof, which whole or part interest is equal to or exceeds five percent of the total property and assets of the entity;

(C) Is an officer or director of the entity, if the entity is organized as a corporation; or

(D) Is a partner in the entity, if the entity is organized as a partnership.

002.22 PATIENT WAIVER. An agreement by which the client agrees to release his or her medical records to state or federal authorities accomplished by the client signing the "Application for Assistance."

002.23 REACTIVATION. Enrollment of a provider whose previous service provider enrollment was terminated or excluded by the Department, and removal from the Medicaid excluded providers list.

002.24 RE-ENROLLMENT. Enrollment of a provider whose previous service provider enrollment expired or was voluntarily closed by the provider.

002.25 REVALIDATION. Process by which the Department confirms a provider’s enrollment-related information is valid, updated, and accurate.

002.26 TERMINATION FROM PARTICIPATION. An exclusion from participation in Medicaid.

002.27 TRADING PARTNER AGREEMENT. An agreement related to the electronic exchange of information between the Department and a trading partner.

002.28 TRADING PARTNER. A health care plan, provider, or clearinghouse that transmits any health information in electronic form.

002.29 UNDERUTILIZATION. Not furnishing required services, or a lack of treatment or referrals when there is a demonstrable need.

002.30 USUAL AND CUSTOMARY CHARGE. The provider's charges to the general public for equivalent goods or services.

002.31 WITHHOLDING OF PAYMENTS. An adjustment of the amounts paid to the provider on pending and subsequently submitted claims to offset overpayments previously made to the provider.

003. PROVIDER REQUIREMENTS .

003.01 PROVIDER ELIGIBILITY. To be eligible to participate in Title XIX (Medicaid) and Title XXI Children’s Health Insurance Program (CHIP), the provider must meet the general standards for all providers in 471 Nebraska Administrative Code (NAC) Chapters 1, 2, and 3, if appropriate, and the standards for participation for each provider type included within:

(A) Each provider specific chapter of Title 471 NAC;

(B) Title 480 NAC for Home and Community-Based Waiver Services;

(C) Title 403 and 404 NAC for Community-Based Services for Individuals with Developmental Disabilities; and

(D) Title 482 NAC for Managed Care Services.

003.02 PROVIDER ENROLLMENT. The Department will not cover services rendered, ordered, or referred by a provider, or pay a provider for services, when that provider is not enrolled with Medicaid in accordance with 471 NAC 2. Each provider business location where services are rendered must be enrolled.

003.02(A) PROVIDER SCREENING. The Department will, at a minimum, screen all providers as provided in 42 Code of Federal Regulations (CFR) Part 455, Subpart E. In accordance with 42 CFR 455.452, the Department may enact additional or more stringent screening methods which will be included within either the NAC or Nebraska state law. The Department will deny or terminate the enrollment of any provider that fails to comply with or meet all applicable screening requirements.

003.02(A)(i) SITE VISITS. A provider must permit the Centers for Medicare and Medicaid Services (CMS) and the Department to conduct unannounced onsite inspections of any and all provider locations. The Department may deny or terminate the enrollment of a provider who fails to permit a site visit. The Department may also deny or terminate a provider if, based on the site visit, the Department determines the provider location does not match the service provider agreement or does not meet the standards for participation.

003.02(A)(ii) CATEGORICAL RISK LEVELS. All provider types are categorized into one of three risk levels based on a determination by the Centers for Medicare and Medicaid Services (CMS) and the state Medicaid agency of the risk of fraud, waste, and abuse. The risk level of a provider will be raised to high risk, regardless of their provider type risk level, when payments are suspended based on a credible allegation of fraud, the provider has an existing Medicaid overpayment, or the provider has been excluded by the Office of the Inspector General or any state’s Medicaid program within the last 10 years. Provider types are subject to screening requirements based on their applicable risk level.

003.02(A)(ii)(1) LOW RISK. Low risk screening includes:

003.02(A)(ii)(1)(a) LICENSE. Verification that the provider’s applicable license(s) is not expired and has no current limitations.

003.02(A)(ii)(1)(b) DATABASES. Pre- and post-enrollment database checks to confirm the identity and participation eligibility of the provider, owners, and managing employees.

003.02(A)(ii)(2) MODERATE RISK. Moderate risk screening includes all components of low risk screening as well as pre- and post-enrollment site visits.

003.02(A)(ii)(3) HIGH RISK. High risk screening includes all components of low and moderate risk screening as well as fingerprint based criminal background checks of the provider or any person who owns five percent or more direct or indirect ownership interest in the provider.

003.02(A)(iii) CRIMINAL BACKGROUND CHECKS. As a condition of enrollment, providers must consent to criminal background checks including fingerprinting when required to do so under State law or by risk level determined for that category of provider. Failure to consent to criminal background checks will result in the denial or termination of the service provider agreement.

003.02(A)(iv) FINGERPRINT SUBMISSION. Any high risk provider, or any person with a five percent or more ownership interest in a high risk provider, must submit a set of fingerprints, in a form and manner determined by the State Medicaid agency, within 30 days upon request from the Centers for Medicare and Medicaid Services (CMS) or the State Medicaid agency. Failure of the provider or owner, as applicable, to meet this requirement will result in the denial or termination of the service provider agreement.

003.02(B) SERVICE PROVIDER AGREEMENTS. Each provider must have an approved service provider agreement with the Department. By signing the service provider agreement, a provider agrees to comply with all provisions stated therein. A service provider agreement is not an employment agreement or contract, and enrollment as a Medicaid provider does not constitute employment by or with the Department and does not guarantee referrals. Service provider agreements cannot be transferred to any other person or entity.

003.02(B)(i) REQUIRED FORMS. Providers must complete, sign, and submit to the Department the following forms as appropriate:

(1) MC-19, "Service Provider Agreement";

(2) MLTC-62, “Nebraska Ownership/Controlling Interest and Convictions Disclosure”;

(3) All applicable addendum forms;

(4) “United States Citizenship Attestation form”; and

(5) MS-84 “State of Nebraska ACH/EFT Enrollment form”.

Certain providers of home and community-based services must also complete provider agreement forms as indicated in Title 480 NAC. Certain providers of medical transportation services must also complete the service provider agreement form as indicated in Titles 473 and 474 NAC.

The Department may require a provider to periodically complete a new service provider agreement to update information or eligibility, and may terminate the enrollment of a provider that fails to comply with this requirement.

003.02(C) APPROVAL AND ENROLLMENT. The Department will review and screen each submitted service provider agreement and upon approval and enrollment will assign an effective date to the provider and a Medicaid provider number to use when billing Medicaid.

003.02(D) ORDERING AND REFERRING PROVIDERS. Ordering and referring physicians or other professionals providing Medicaid services must be enrolled providers and must include their National Provider Identifier (NPI) on any claims for items or services ordered or referred.

003.02(E) REACTIVATION. At the discretion of the Department, providers who have previously been terminated or excluded may or may not be reactivated as providers of Title XIX (Medicaid) and Title XXI Children’s Health Insurance Program (CHIP) services. At the end of a technical or time-limited termination period, the provider may request in writing that the Department reactivate the service provider agreement. The Medicaid Division may approve or deny reactivation of the service provider agreement. The provider may be reactivated conditionally with a closed-end service provider agreement or other restrictions or requirements as deemed to be necessary by the Department.

003.02(F) REVALIDATION. The Department must revalidate the enrollment of all providers at least every five years. Providers who do not complete revalidation will not be eligible past their revalidation due date.

003.02(G) APPLICATION FEE. At initial enrollment, re-enrollment, reactivation, and revalidation providers must submit to the Department an application fee before the Department can execute a service provider agreement. Exempt from this application fee requirement are the following:

(i) Individual physicians and non-physician practitioners;

(ii) Providers enrolled in or that have paid an application fee to Medicare or another State’s Medicaid or Children’s Health Insurance Program (CHIP); and

(iii) Providers or categories of providers that have received an application fee waiver from the Centers for Medicare and Medicaid Services (CMS).

003.02(H) TEMPORARY MORATORIA. A moratorium imposed under this section lasts for an initial period of six months and if necessary may be extended in six-month increments by the Department. Notice of any moratoria issued by the Department will be provided through a provider bulletin. The Department, in its discretion and under mandate from the Secretary of the United States Department of Health and Human Services enforces temporary moratoria under either of the following conditions:

(i) The Department must impose temporary moratoria on the enrollment of new providers or provider types that pose an increased risk to the Medicaid program as identified by the Secretary of the United States Department of Health and Human Services unless the Department determines that a temporary moratorium would adversely affect access to medical assistance; and

(ii) The Department may impose temporary moratoria or place numerical caps or other limits on the enrollment of new providers that it and the Secretary of the United States Department of Health and Human Services have identified as having significant potential for fraud, waste, or abuse unless the Department determines that such action would adversely affect access to medical assistance.

003.03 STANDARDS FOR PARTICIPATION. Providers must meet the following minimum requirements:

(1) Accept the philosophy of service provision which includes acceptance of, respect for, and a positive attitude toward Medicaid clients and the philosophy of client empowerment;

(2) Meet any applicable licensure or certification requirements and maintain current licensure or certification;

(3) Obtain adequate information on the medical and personal needs of each client, if applicable;

(4) Not discriminate against any client, employee, or applicant for employment because of race, age, color, religion, sex, handicap, or national origin, in accordance with 45 CFR Parts 80, 84, 90, and 41 CFR Part 60;

(5) Agree to a law enforcement criminal background check and Adult Protective Services and Child Protective Services Central Registry checks;

(6) Operate a drug-free workplace;

(7) Attend training on Medicaid as deemed necessary by the Department;

(8) Provide services within the scope of practice identified in state and federal law, and under all applicable state and federal licensure or certification requirements; and

(9) Agree to maintain up-to-date and accurate service provider agreement information by submitting any changes, within 35 days of the change, to the Department.

003.03(A) PROVIDER EMPLOYEES. Employees of providers are subject to the same standards.

003.04 DEPARTMENT EMPLOYEES AS PROVIDERS. No employee of the Department and its subdivisions, and Department contractors, except clinical consultants, may serve as providers under Medicaid or as paid consultants to enrolled providers without the express written approval of the Medicaid Director.

003.05 PRINCIPLES OF PROVIDING MEDICAL ASSISTANCE. The amount and type of service required is defined for each case through utilization review. The provider will limit services to essential health care. The plan for providing services within program guidelines through Medicaid is based on the following principles:

(A) All plans for medical care must provide for essential health services and for integration of treatment with social planning to reduce economic dependency;

(B) Medical care and services must be coordinated with health services available through existing public and private sources;

(C) Medical care and services must be provided as economically as is consistent with accepted standards of medical care and fair compensation to providers;

(D) Medical care and services must be within the licensure of the provider giving the care or service; and

(E) The client must be allowed, within these limitations, to exercise free choice in the selection of a qualified provider.

003.06 PROVIDER MATERIALS. The provider is responsible for understanding and complying with all applicable regulations and ensuring that employees, consultants, and contractors are informed about all applicable regulations, including:

(A) 471 NAC 1, 2, and 3;

(B) Each service specific chapter in Title 403, 404, 471 and 480 NAC that is applicable to services rendered by the provider, and instructions for forms and electronic transactions.

003.07 PROVIDER BULLETINS. The Medicaid Division may issue provider bulletins to inform providers of regulation interpretations.

003.08 ELECTRONIC INFORMATION EXCHANGE. Any entity that exchanges standard electronic transactions with the Department must have an approved trading partner agreement with the Department.

003.09 VERIFICATION OF LAWFUL PRESENCE. Individual providers enrolling as a solo practitioner must attest to:

(A) United States citizenship; or

(B) Status as a qualified alien under the Federal Immigration and Nationality Act, including disclosure of the alien number and official immigration documents as needed to verify status and work authorization.

004. SERVICE PROVIDER REQUIREMENTS . The following provider types have additional participation requirements that must be met in order to enroll and remain enrolled.

004.01 SCHOOL-BASED SERVICES. To participate in Medicaid, the Pay-to Provider must be a recognized public school, Educational Services Unit (ESU), or approved cooperative providing special education and related services. The following provider types are eligible to enroll as service rendering providers for school-based services:

(A) Occupational therapist, physical therapist, speech pathology, and audiologist;

(B) Mental health services:

(i) Physician;

(ii) Licensed psychologist;

(iii) Provisionally licensed psychologist;

(iv) Licensed independent mental health practitioner (LIMHP);

(v) Licensed mental health practitioner (LMHP);

(vi) Provisionally licensed mental health practitioner (PLMHP);

(vii) Licensed alcohol and drug counselor (LADC);

(viii) Provisionally licensed alcohol and drug counselor (PLADC);

(ix) Board certified behavioral analyst (BCBA);

(x) Board certified assistant behavioral analyst; and

(xi) Registered behavioral technician;

(C) Nursing services:

(i) Registered nurse (RN);

(ii) Licensed practical nurse (LPN);

(iii) Health technician; and

(iv) Health paraprofessional;

(D) Personal assistance service providers: Personal assistance service providers must be age 19 or older. Provider personnel must be employed by or under contract with the school district, Educational Services Unit (ESU), or approved cooperatives providing special education and related services. Nebraska school districts, Educational Services Units (ESUs), and approved cooperatives providing special education and related services must be enrolled in Medicaid as the qualified providers of services;

(E) Specialized transportation services: Provider personnel, driver, or transportation aide must be employed by or under contract with the school district, Educational Service Unit (ESU), or approved cooperatives providing special education and related services; and

(F) Optometrist services: Must be provided by a currently licensed optometrist in the school attended by the client. Provider personnel must be employed by or under contract with the school district, Educational Service Unit (ESU), or approved cooperatives providing special education and related services.

005. ADMINISTRATIVE SANCTIONS .

005.01 REASONS FOR SANCTIONS. The Department may, in its discretion, deny enrollment or sanction a provider for any of the following reasons:

(1) Improper billing and claims payment practices including, but not limited to:

(i) Presenting, or causing to be presented, any false or fraudulent claim for goods or services or merchandise for payment;

(ii) Submitting, or causing to be submitted, false information for the purpose of obtaining greater payment than that to which the provider is legally entitled;

(iii) Billing in excess of the usual and customary charges;

(iv) Presenting a claim, billing, or causing a claim to be presented for payment for services not rendered, including "no-shows";

(v) Submitting duplicate bills, including billing Medicaid twice for the same service, or billing both Medicaid and another insurer or government program;

(vi) Billing before the goods or services are provided or dispensed;

(vii) Billing for services provided by non-enrolled providers, certain sanctioned providers, or excluded persons;

(viii) Billing for services rendered by someone else as though the provider performed the services himself or herself;

(ix) Billing for services provided by an individual who is required to be licensed or certified and who did not meet that requirement when the service was provided;

(x) Billing for services provided outside the provider's scope of practice;

(xi) Upgrading services billed and rendered from those actually ordered; and

(xii) Upcoding services billed or billing a higher level of service than those actually provided;

(2) Altering medical records to obtain a higher classification of the client than is truly warranted;

(3) Submitting, or causing to be submitted, false information for the purpose of meeting prior authorization approval requirements, or obtaining payments for services rendered prior to the effective date of the service provider agreement or the date that the client has been determined to be Medicaid eligible;

(4) Failing to disclose or make available to the Department, or its authorized representatives, the following information:

(i) Records of services provided to Medicaid clients;

(ii) Records of payments by the Department, its agents, and others made for those services; and

(iii) Records that have been lost, misplaced, or destroyed prior to expiration of any applicable records retention period;

(5) Failing to provide and maintain quality, necessary, and appropriate services within accepted medical standards as determined by a body of peers, as documented by repeat deficiencies noted by the survey and certification agency, a peer review committee, medical review teams, or independent professional review teams, or by the determination of the Medicaid Director and consultants, or the Department or its designee, the Department's Quality Assurance Committee, any Department Inspection of Care, or a managed care plan's quality assurance committee;

(6) Breaching the terms of the Medicaid service provider agreement or submitting false or fraudulent application, including the service provider agreement and any necessary accompanying information, for participation as a Medicaid enrolled provider;

(7) Violating any provision of the Nebraska laws regarding Medicaid or any rule or regulation of Medicaid;

(8) Failing to comply with the terms of the provider certification on the Medicaid claim form as to the truth and accuracy of the information contained therein;

(9) Overutilization. A determination of overutilization may be based on a comparison of treatment practices of a specific provider compared to peers for similar types of clients;

(10) Underutilization;

(11) Rebating or accepting a fee or portion of a fee or charge for a Medicaid patient referral. Soliciting, offering, or receiving a kickback, bribe, or rebate;

(12) Violating any laws, regulations, or code of ethics governing the conduct of occupations or professions or regulated industries;

(13) Failing to meet any applicable licensure or certification standard required by state or federal law;

(14) Not accepting Medicaid as the payor of last resort, and billing Medicaid when the provider has, or reasonably should have had, knowledge of a liable third party;

(15) Not accepting Medicaid payment as payment in full for covered services, and collecting or attempting to collect additional payment from others, the client or responsible person, or collecting a portion of the service fee from the client or the client's family, except for required co-payments;

(16) Refusing to execute a new service provider agreement at the Department's request, failing to update a service provider agreement if required to do so by State or Federal law or failing to update service provider agreement information when changes have occurred;

(17) Failing to correct deficiencies in operations or improper billing practices after receiving written notice of these deficiencies or practices from the Department;

(18) Being formally reprimanded or censured by an association of the provider's peers for unethical practices;

(19) Being suspended, excluded, or terminated from participation in another governmental program, being convicted for civil or criminal violations of Medicaid, or any other state's Medicaid program; or having sanctions applied by the Department's agents or assignees or any other state's Medicaid program;

(20) Failing to repay or make arrangements for the repayment of overpayments or otherwise erroneous payments;

(21) Solicitation, borrowing, procuring, obtaining, accepting, stealing or otherwise appropriating any client’s funds and personal property by any means;

(22) Any action resulting in a reduction or depletion of a nursing facility or intermediate care facility for individuals with developmental disabilities (ICF/DD) Medicaid client's personal allowance funds or reserve account unless specifically authorized in writing by the client, or legal representative;

(23) Reporting of unallowable cost items on a provider's cost report;

(24) Violating conditions of an exclusion;

(25) Violating conditions of probationary or restricted licensure;

(26) Not having the appropriate Drug Enforcement Administration (DEA) license or state drug license;

(27) Loss, restriction, or lack of hospital privileges;

(28) Failure or inability to provide and maintain quality, necessary and appropriate services due to physical or mental health conditions of the service provider;

(29) Endangering health and safety of clients;

(30) Failure to obtain or maintain required surety bond(s);

(31) Failure to provide the Department with documentation of authorization for third parties to submit claims for the provider for payment to the Department or failing to update this information when changes have occurred;

(32) Breaching the terms of a trading partner agreement to exchange information electronically;

(33) Disclosure of information that must be protected in accordance with 42 CFR Part 431, Subpart F;

(34) Misusing or failing to use electronic records and claims submission systems when required to do so by the Department.

(35) The provider does not meet the applicable provider standards for participation in Medicaid as listed in Titles 403, 404, 471, 480, and 482 NAC;

(36) The provider, owner of the provider, or an employee of the provider has been excluded, sanctioned, or terminated from participation by Medicare or Medicaid or Children’s Health Insurance Program (CHIP) in any state;

(37) The provider is the respondent of a protection order;

(38) The provider, or household member(s) (if services are provided in the provider’s home), is on the Adult Protective Services Central Registry, the Child Protective Services Central Registry, or the Sex Offender Registry; or

(39) The provider, or household member(s) (if services are provided in the provider’s home), committed a crime:

(i) Against a child or vulnerable adult;

(ii) Of a nature, duration, or pattern that calls into question his or her regard for the law;

(iii) Involving the illegal use, possession, or distribution of a controlled substance; or

(iv) That, if repeated, could injure or harm the Medicaid program or a Medicaid client.

005.01(A) CRIMES. The Department deems a crime to have been committed when a conviction, admission, or substantial evidence of commission exists. In exercising its discretion, the Department considers the severity of the crime(s), the applicability of the crime(s) to the service(s) of the provider, the person’s role within the provider entity, and the amount of time that has passed since the commission of the crime(s).

005.01(B) CONVICTION OF INDIVIDUAL WITH AN OWNERSHIP INTEREST IN A PROVIDER. The Department must deny or terminate the enrollment of a provider where any person with a five percent or greater direct or indirect ownership interest in the provider has been convicted of a criminal offense related to that person’s involvement with a Medicare, Medicaid or Title XXI program within the last 10 years, unless the Department determines that denial or termination of enrollment is not in the best interest of the Medicaid program.

005.01(C) EXCLUSION OR TERMINATION FROM PARTICIPATION IN MEDICARE OR OTHER STATE MEDICAID OR CHILDREN’S HEALTH INSURANCE PROGRAM (CHIP). The Department must deny or terminate the enrollment of a provider that has been excluded or terminated from participating in Medicare or Medicaid or Children’s Health Insurance Program (CHIP) in any State.

005.02 SANCTIONS. The Department may impose one or more of the following sanctions against a provider or any person employed by or contracted with the provider entity responsible for a violation:

(1) Termination from participation in the Medicaid program;

(2) Termination from participation in Managed Care;

(3) Suspension or withholding of payments;

(4) Recoupment from future payments;

(5) Transfer to a closed-end service provider agreement not to exceed 12 months, or the shortening of an already existing closed-end service provider agreement;

(6) Provider education; or

(7) Exclusion from participation.

005.02(A) TERMINATION FROM PARTICIPATION IN MEDICAID. When terminated, the provider may be subject to the following types of exclusions:

(1) Permanent;

(2) Time-limited, which is an exclusion for a specified period of time;

(3) Technical, which is based on a provider’s failure to meet a standard or requirement and remains in effect until the Department determines the provider meets the standard or requirement; and

(4) Emergency, which is an immediate exclusion based on the Department’s determination that client health and safety may be at risk.

005.02(A)(i) CONDITIONS OF TERMINATION AND EXCLUSION. When a provider is terminated or excluded from Medicaid, Medicaid may not make reimbursement for services, items, or drugs that are rendered, referred, ordered, or prescribed by the terminated provider or caused to be rendered, referred, ordered, or prescribed for a Medicaid client. A terminated or excluded person or entity shall not have an ownership interest in a Medicaid enrolled provider entity.

005.02(A)(i)(1) EXCEPTION. Medicaid may pay claims from a submitting provider until the submitting provider and the client are notified of the termination of the rendering, referring, ordering, or prescribing provider. Medicaid may pay claims for emergency medical services when Medicaid staff or consultants determine that the services were medically necessary.

005.02(A)(i)(2) SUBMISSION OF CLAIMS. Termination or exclusion from participation will preclude a provider from submitting claims for payment, either personally or through any clinic, group, corporation, or other association, to the Department for any services or supplies provided under Medicaid, except for those services or supplies provided before the termination or exclusion.

005.02(A)(ii) EXCLUSION. The Department may impose the sanction of exclusion upon:

(1) Providers who allow service provider agreements to lapse or expire; and

(2) Other individuals or entities associated with an enrolled provider or provider whose service provider agreement has lapsed or has been terminated.

005.02(A)(iii) EXCLUDED PERSON OR ENTITY. No clinic, group, corporation, or other association which is a provider of services shall submit claims for payment to the Department for any services or supplies provided by a person within the organization who has been excluded from participation in Medicaid except for those services or supplies provided before the termination. A provider will not submit any claims to Medicaid that contain the costs of services provided by excluded persons or entities. If these provisions are violated by a clinic, group, corporation, or other association, the Department may sanction the organization and any individual person within the organization responsible for the violation.

005.02(B) SUSPENSION OR WITHHOLDING PAYMENTS. To prevent inappropriate Medicaid payments or to avoid further overpayments, the Department may sanction a provider by suspending the provider's payments with an immediate effective date. The Department will notify the provider by letter that its payments have been suspended. The provider may file an appeal regarding this action; however, the suspension of payments will remain in effect until the hearing decision is made. If a provider participates under one or more provider number, or changes numbers, the Department may, within its sole discretion suspend, withhold, or recoup payments from one or all of the provider numbers.

005.02(C) PROVIDER EDUCATION. A provider who has been sanctioned may be required to participate in a provider education program as a condition of participation.

005.03 IMPOSITION OF A SANCTION. The decision on the sanction to be imposed is at the discretion of the Medicaid Director. The following factors are considered in determining the sanctions to be imposed:

(1) Seriousness of the offenses;

(2) Extent of violations;

(3) History of prior violations;

(4) Prior imposition of sanctions;

(5) Prior provision of provider education;

(6) Provider willingness to comply with program rules;

(7) Whether a lesser sanction will be sufficient to remedy the problem; and

(8) Actions taken or recommended by peer review groups and licensing boards.

005.03(A) NOTICE TO THE PROVIDER. The Department will notify the provider at least 30 days before the effective date of the sanction, unless extenuating circumstances exist. The Department may impose a sanction on an emergency basis with immediate effect if, in the Department’s discretion, the provider’s continued enrollment and participation places a client’s health or safety at risk. The provider may file an appeal of the sanction; however, the sanction will remain in effect until the hearing decision is made.

005.03(B) NOTICE TO THE PUBLIC. When a sanction is imposed, the Department will give general notice to the public of the restriction, its basis, and its duration.

005.03(C) NOTIFICATION OF OTHER AGENCIES. When a provider has been sanctioned, the Department will notify, as appropriate, the applicable professional society, board of registration or licensure, and federal or state agencies. The notification will include a summary of the findings made and the sanctions imposed.

005.03(D) NOTIFICATION OF LOCAL DEPARTMENT OFFICES. When a provider's participation in Medicaid has been terminated, the Department will notify the local Department offices of the termination.

005.03(E) MEDICAID EXCLUDED PROVIDERS LIST. Terminated and excluded persons and entities will be placed on the Medicaid Excluded Providers list for the duration of the prohibition from participation.

005.04 SANCTION OF AFFILIATES AND ASSOCIATES. The Department may sanction all known affiliates of a provider or other persons associated with an enrolled provider. Each decision to sanction an affiliate or other person associated with an enrolled provider is made on a case by case basis after considering all relevant facts and circumstances. The Department may determine the violation, failure, or inadequacy of performance, which resulted in a provider sanction, took place in the course of the affiliate or otherwise associated person's official duty or with the knowledge or approval of the affiliate or associated person.

005.05 REACTIVATION. Persons and entities that have been terminated or excluded may request reactivation in writing once the exclusionary period has passed. Reactivation is at the discretion of the Department.

006. AUDITS . All services for which claims for payment are submitted to the Department are subject to audit. During a review audit, the provider must furnish to the Department, or its authorized representative, pertinent information regarding claims for payment. If an audit reveals that incorrect payments were made or that the provider's records do not support payments that have been made, the provider shall make restitution.

006.01 SAMPLING AND EXTRAPOLATION. The Department's procedure for auditing providers may involve the use of sampling and extrapolation. The provider shall pay to the Department the entire extrapolated amount of incorrect payments calculated under this procedure after notice and opportunity for hearing.

006.02 HEARINGS. The Department must allow the provider an opportunity to rebut the Department's audit findings. If the findings are based on sampling and extrapolation, in lieu of accepting the Department's sampling and extrapolation, the provider may present an audit of 100 percent of the claims filed and services rendered during the audit period. This audit must be completed by an independent auditor with no affiliation to the provider. Any audit of this type must demonstrate that the provider's records for the unaudited services provided during the audit period were in compliance with the Department's regulations. The provider must be prepared to submit supporting documentation to demonstrate this compliance.

007. APPEAL RIGHTS . Any adverse action under Title 471 NAC may be appealed to the Medicaid Director by the person or entity against whom the action was taken.

007.01 HEARING REQUEST PROCEDURE. The person or entity appealing an adverse action must submit a written hearing request to the Medicaid Director.

007.01(A) DEADLINES. The following deadlines apply when submitting an appeal request:

(i) Administrative sanctions must be appealed within 30 days of the date of the action;

(ii) Refund requests must be appealed within 30 days of the date of the action; and

(iii) All other actions must be appealed within 90 days of the date of the action.

007.01(B) APPEALING BEFORE EFFECTIVE DATE. A person or entity may appeal a termination or exclusion before the effective date of the proposed termination or exclusion. A termination or exclusion appealed before its effective date will not take effect until the appeal has been decided, unless the termination or exclusion is being imposed pursuant to 42 C.F.R. 455.416(c) or has an immediate effective date because of a threat to client health and safety.

007.02 HEARINGS. Appeal and hearing procedures are governed by 465 NAC 6.

008. DISCLOSURE OF INFORMATION BY PROVIDERS . Under 42 CFR 455, Subpart B, the Department requires providers to disclose the following information:

(1) Ownership and control;

(2) Business transactions; and

(3) The providers' owners and other persons convicted of crimes against Medicare, Medicaid, or Title XX (Social Services Block Grant) programs.

008.01 OWNERSHIP AND CONTROL. For each managing employee, person or entity with an ownership or control interest in the provider, and subcontractor of which the provider owns at least five percent, a provider must disclose the following:

(1) The name, address including, as applicable, the primary business address, every business location, and P.O. Box address, date of birth or incorporation, and Tax Identification Number or social security number as applicable;

(2) Whether anyone is related to another as spouse, parent, child, or sibling; and

(3) The name of any other disclosing entity in which a person named in this chapter has an ownership or controlling interest.

008.01(A) PERIODIC SURVEY AND CERTIFICATION. Any provider that is subject to periodic survey and certification of its compliance with Medicaid standards must supply this information to the Department at the time it is surveyed. Any provider that is not subject to periodic survey and certification must supply the information before entering into a service provider agreement with the Department as a part of the initial enrollment, re-enrollment, reactivation, or revalidation.

008.01(B) DISCLOSURE OF OWNERSHIP. The Department must not approve a service provider agreement, and must terminate an existing service provider agreement, if the provider fails to disclose ownership or control information. The Department shall not pay a provider who fails to disclose ownership or control information.

008.01(C) CHANGE OF INFORMATION. A provider must notify the Department of any changes or updates to the information supplied under 471 NAC 2 not later than 35 days after such changes or updates take effect.

008.02 BUSINESS TRANSACTIONS. Under 42 CFR 455.105(b) when requested, a provider must disclose, within 35 days of the date on the request, the following information:

(1) The ownership of any subcontractor with whom the provider has had business transactions totaling more than $25,000 during the 12-month period ending with the date of the request; and

(2) Any significant business transaction between the provider and any wholly-owned supplier, or between the provider and any sub-contractor, during the five-year period ending on the date of the request.

008.02(A) PAYMENT FOR SERVICES. The Department shall not pay providers who fail to comply with a request for this information, or pay for services provided during the period beginning on the day following the date the information was due to the Department and ending on the day before the date the Department received the information.

008.03 PERSONS CONVICTED OF CRIMES. Before the Department enters into or renews a service provider agreement, or upon request by the Department, the provider must disclose to the Department the identity of any person who:

(1) Has ownership or control interest in the provider, or is an agent or managing employee of the provider; and

(2) Has been convicted of a criminal offense related to that person's involvement in any program under Medicare, Medicaid, Title XXI Children’s Health Insurance Program (CHIP), or the Social Services Block Grant (Title XX) programs.

008.03(A) ENROLLMENT TERMINATION. The Department may refuse to enter into or renew a service provider agreement if any person who has an ownership or control interest in the provider, or who is an agent or managing employee of the provider, has been convicted of a criminal offense related to that person's involvement in any program under Medicare, Medicaid, Title XXI Children’s Health Insurance Program (CHIP), or the Social Services Block Grant (Title XX). The Department may deny or terminate enrollment if it determines that the provider did not fully and accurately disclose this information.

History

• Effective 2020-09-21

Chapter 3 Payment for Medicaid Services

Neb. Admin. Code tit. 471, ch. 3 Payment for Medicaid Services {#sec-471-nac-3 omnilex-key=us-ne-regs-official--title-471--471 NAC 3}

001. SCOPE AND AUTHORITY . The regulations govern the services provided under Nebraska’s Medicaid program as defined by the Medical Assistance Act (Nebraska Revised Statute § 68-901 et seq).

002. DEFINITIONS .

002.01 ADJUDICATE. To determine whether a claim or adjustment is to be paid or denied.

002.02 BALANCE BILLING. Billing the Department or client any amount after a provider has agreed to accept a payment as payment in full.

002.03 CASUALTY INSURER. An insurance policy which pays for medical care as a result of an accident, incident, injury, disability, or disease; for example, automobile insurance, homeowners insurance, commercial liability insurance, product liability insurance, workers compensation, etc.

002.04 CLAIM. A request for payment for services rendered or supplied by a provider to a client.

002.05 CLEARINGHOUSE. An entity which processes or facilitates the processing of information received from another entity in a nonstandard format or containing nonstandard data content into standard data elements or a standard transaction and receives a standard transaction from another entity and processes or facilitates the processing of health information into nonstandard or nonstandard data content for the receiving entity.

002.06 CLIENT ASSIGNMENT OF RIGHTS. The client's action to assign to the Department his or her rights, and the rights of any other eligible individuals on whose behalf he or she has legal authority under state law to assign such rights, to medical support and to payment for medical care from any liable third party, except Part A and B of Medicare. Assignment of rights is accomplished by signing the Medicaid application.

002.07 DENIAL. Non-payment of services or benefits by Nebraska Medicaid.

002.08 HEALTH INSURER. Any group health plan, as defined in section 607(1) of the Employee Retirement Income Security Act of 1974, as amended in 1993, an entity offering a service benefit plan, or a health maintenance organization (HMO).

002.09 HEALTHCARE COMMON PROCEDURE CODING SYSTEM (HCPCS). The system which contains the national codes adopted by the federal Secretary of Health and Human Services and includes American Medical Association’s Current Procedural Terminology (CPT) Level I procedure codes and Level 2 procedure codes.

002.10 INDIAN. An individual, defined at 25 United States Code (U.S.C.) sections 1603(c), 1603(f), and 1679(b), or who has been determined eligible, as an Indian, pursuant to 42 Code of Federal Regulations (C.F.R.) 136.12 or Title V of the Indian Health Care Improvement Act, to receive health care services from Indian Health Service, an Indian Tribe, Tribal Organization, Urban Indian Organization, or through referral under Contract Health Services.

002.11 INDIAN HEALTH CARE PROVIDER. A health care program, including contract health services, operated by the Indian Health Service or by an Indian Tribe, Tribal Organization, or Urban Indian Organization as those terms are defined 25 U.S.C. 1603.

002.12 MEDICARE ADVANTAGE PLAN. Coordinated care plans meeting Medicare C standards, including health maintenance organizations (HMO), Provider Sponsored Organizations (PSO), Preferred Providers Organizations (PPO), religious fraternal benefits plans, and other coordinated care plans. Individuals eligible for Medicare Part A and Part B may choose to enroll in a Medicare Advantage Plan instead of the traditional Medicare fee-for-service program. Part B only enrollees are ineligible.

002.13 MEDICAL SUPPORT. The obligation of a non-custodial parent to provide health insurance or pay for medical care ordered by a court or administrative body established under state law.

002.14 MEDICARE AND MEDICAID DUALLY ELIGIBLE INDIVIDUAL. Individuals dually eligible for Medicare and Medicaid during the same period of time.

002.15 MEDICARE PART A. A federal program, created by the Social Security Act of 1965, to provide coverage of hospital, skilled nursing, and certain other services for Medicare beneficiaries.

002.16 MEDICARE PART B. A federal program, created by the Social Security Act of 1965, to provide coverage of practitioner, durable medical equipment, supplies, and certain other services for Medicare beneficiaries.

002.17 MEDICARE PART D. A federal program, also known as the Medicare prescription drug benefit. This voluntary program provides coverage of certain drugs, classes of drugs, or therapeutic categories of drugs and certain medical supplies or equipment for all Medicare beneficiaries, including those beneficiaries also eligible for Medicaid. Clients who are dually eligible for Medicare and Medicaid are automatically enrolled in Part D.

002.18 MEDICARE PART D PLAN. An entity, approved by the Centers for Medicare and Medicaid Services, to provide coverage of Medicare Part D drugs and certain medical supplies for Medicare beneficiaries.

002.19 MEDICARE PART D DRUG. Any drug, class of drugs, or therapeutic category of drugs which is not a Medicare Part D Excluded drug, regardless of formulary, prior approval, or tier status by the Part D Plan.

002.20 MEDICARE PART D EXCLUDED DRUG. Any drug, class of drugs, or therapeutic category of drugs which is specifically excluded from coverage under the Medicare Modernization Act of 2003 and amendments to the act, or as defined by federal regulations implementing the Medicare Modernization Act.

002.21 MEDICARE PART D SUPPLIES OR EQUIPMENT. Insulin syringes, needles, alcohol swabs, gauze, and other products covered by Medicare Part D Plans.

002.22 NON-CUSTODIAL PARENT. Parent who does not reside with a child but has a legal responsibility to provide court or administrative ordered medical support for the child.

002.23 PAY AND CHASE. A recovery method in which Medicaid pays the total amount allowed under Nebraska Medicaid and then seeks to recover from liable third party resources.

002.24 PREFERRED PROVIDER ORGANIZATION (PPO). Fee for service plan with an incentive to use network providers to provide care for the plan's subscribers. Patients may see physicians outside the network but at reduced payment rate. A copayment may be required on certain services.

002.25 PRIVATE INSURER. This includes:

(A) Any commercial insurance company offering health or casualty insurance to individuals or groups, including both experience-related and indemnity contracts; (B) Any profit or nonprofit prepaid plan offering either medical services or full or partial payment for the diagnosis and treatment of an injury, disease, or disability; and (C) Any organization administering health or casualty insurance plans for professional associations, unions, fraternal groups, employer-employee benefit plans, and any similar organization offering these payments for services, including self-insured and self-funded plans, under section 607(1) of the Employee Retirement Income Security Act.

002.26 REMITTANCE ADVICE. The third party plan’s statement of payment for services. When billing Medicaid, this statement may be provided as a paper or electronic remittance advice, and must include the insurance company name, patient name, dates of service, charges, and amount paid. If charges were denied by insurance, the portion of the remittance advice showing the denial reason must be included.

002.27 SHARE OF COST. The amount of the client's income which must be obligated or paid for medical care before Medicaid payment can be made.

002.28 STANDARD TRANSACTION. An electronic transaction which complies with the applicable standard adopted under federal law.

002.29 SUBROGATION. Right of the state to stand in place of the client in collection of third party resources.

002.30 THIRD PARTY RESOURCE. Any individual, entity, or program which is, or may be, contractually or legally liable to pay all or part of the cost of any medical service furnished to an individual.

002.31 TRANSACTION. The exchange of information between two parties to carry out financial or administrative activities related to health care.

002.32 TRADING PARTNER AGREEMENT. An agreement related to the electronic exchange of information.

002.33 WAIVER CLAIM. A claim for which the Department has applied and received a cost avoidance waiver from the Centers for Medicare and Medicaid Services, or claims which are mandated to have cost avoidance waived under 42 C.F.R. 433.139.

002.34 WARRANT. A paper check or electronic funds transfer.

003. APPROVAL AND PAYMENT .

003.01 APPROVAL. Payment for medical care and services through Medicaid funds must be approved by the Department.

003.01(A) CONDITIONS FOR APPROVAL. Claims will be approved for payment when all of the following conditions are met:

(i) The provider was enrolled and eligible for payment under the Nebraska Medicaid State Plan on the date the service was provided; (ii) The client was eligible for Medicaid when the service was provided, or the service was provided during the period of retroactive eligibility; (iii) No more than 6 months have elapsed from the date of service when the claim is received by the Department (see 471 NAC 3-002.01A for exceptions); (iv) The medical care and services are within the guidelines of Medicaid; (v) The client's clinical record must contain information to meet state requirements; and (vi) A trading partner agreement has been approved, if required, for clearinghouses, billing agents, and providers submitting claims using electronic transactions.

003.01(B) EXCEPTIONS TO TIMELY FILING OF CLAIMS. Payment may be made by the Department for claims received more than six months after the date of service if the circumstances which delayed the submittal were beyond the provider's control. The Department will determine whether the circumstances were beyond the provider's control based on documentation submitted by the provider.

003.01(C) TIMELY PAYMENT OF CLAIMS. The Department must pay claims within 12 months of the date of receipt of the claim. This time limitation does not apply to:

(i) Retroactive adjustments paid to providers who are reimbursed under a retrospective payment system; (ii) Claims which have been filed in a timely manner for payment by Medicare, for which the Department may pay a Medicaid claim relating to the same services. Claims for the Medicaid portion must be submitted to the Department within six months from the date of the Medicare remittance advice; (iii) Claims from providers under investigation for alleged fraud or abuse; (iv) Payments made:

(1) In accordance with a court order; (2) To carry out hearing decisions or agency corrective actions taken to resolve a dispute; (3) To extend the benefits of a hearing decision, corrective action, or court order to others in the same situation as those directly affected by it; or (4) Third party casualty situations as specified in 471 NAC 3-004.06C.

003.01(D) DENIAL. The Department will not pay claims received more than two years after the date of service, except under the circumstances specified in this chapter.

003.01(E) PROVIDER’S FAILURE TO COOPERATE IN SECURING THIRD PARTY PAYMENT. The Department may deny payment of a provider's claims if the provider fails to apply third party payments to medical bills, to file necessary claims, or to cooperate in matters necessary to secure payment by insurance or other liable third parties.

003.02 PAYMENT.

003.02(A) UPPER LIMITS. The Department has established upper limits for payment as described in each provider chapter.

003.02(B) COVERAGE EXCEPTION. Certain medical services, while being medically necessary, may exceed the Nebraska Medicaid coverage guidelines which have been established by the Department. Under these circumstances, the determination of medical necessity for payment purposes is based upon the professional judgment of the Department's consultants and other appropriate staff.

003.02(C) PAYMENT IN FULL. Providers participating in Nebraska Medicaid agree to accept as payment in full the amount paid according to the Department's payment methodologies after all other sources have been exhausted.

003.02(C)(i) EXCEPTION. If a client resides in a nursing facility, a payment to the facility for the client to occupy a single room is not considered income in the client’s budget if Medicaid is or will be paying any part of the nursing facility care.

003.02(D) CHARGES TO THE GENERAL PUBLIC. Providers will not exceed their charges to the general public when billing the Department. A provider who offers a discount to certain individuals will apply the same discount to Medicaid clients who would otherwise qualify for the discount.

003.02(E) METHOD OF PAYMENT. Payment for all approved medical services within the scope of Nebraska Medicaid will be made by electronic funds transfer to the provider who supplied the services.

003.02(F) BILLED CHARGES. If the provider's billed charges are less than the Department's allowable payment, the Department pays the provider's billed charges.

003.02(F)(i) EXCEPTION. Inpatient hospital services are paid on a diagnosis-related group or per diem basis, regardless of billed charges.

003.03 POST-PAYMENT REVIEW. Payment for a service does not indicate compliance with Department policy. Monitoring is accomplished by post-payment review to verify Department policy has been followed. A refund will be requested if post-payment review finds payment has been made for claims or services not in compliance with Department policy. During a post-payment review, claims submitted for payment may be subjected to further review or not processed pending the outcome of the review.

003.04 PAYMENT FOR MEDICAL EXPENSES. Payment may not be made from Department funds for medical expenses which have been paid from public or private sources. Individuals who are otherwise eligible but who have excess income must obligate the excess amount for medical care before payment for medical services can be approved through Nebraska Medicaid.

003.05 ADJUSTMENTS TO PAYMENT REDUCTIONS OR DISALLOWANCES. Providers are restricted to a maximum time limitation of 90 days to request an adjustment to a claim, regardless of the reason for the adjustment or whether the claim was disallowed in part or in whole, unless documentation of extenuating circumstances is submitted to and approved by the Department. The 90-day limitation begins with the payment date of the paper remittance advice or with the payment date of the electronic remittance advice.

003.06 REFUNDS.

003.06(A) REFUNDS REQUESTED BY THE DEPARTMENT. When the Department requests a refund of all or part of a paid claim, the provider is allowed 30 days to refund the amount requested, to show the refund has already been made, to document why the refund request is in error, or appeal. The provider's failure to respond within 30 days is cause for the Department to recoup from future provider payments until the refund is paid in full or to sanction the provider. The refund request constitutes notice of the sanction to recoup from future payments. Refunds resulting from third party resource payment must also be made as required in this chapter.

003.06(B) THIRD PARTY LIABILITY REFUNDS. When third party liability payments are received after a claim has been submitted to the Department, the provider must refund the Department within 30 days. The refund must be accompanied by a copy of the documentation, such as the explanation of benefits or electronic coordination of benefits.

003.06(C) PROVIDER REFUNDS TO THE DEPARTMENT. Providers have the responsibility to review all payments to ensure no overpayments have been received. The provider must refund all overpayments to the Department within 30 days of identifying the overpayment.

003.07 ADMINISTRATIVE FINALITY. Administrative decision or inaction in the allowable cost determination process for any provider, which is otherwise final, may be reopened by the Department within three years of the date of notice of the decision or inaction in order to examine the accuracy of a determination which is otherwise final. The Director is the sole authority in deciding whether to reopen.

003.07(A) SITUATIONS ALLOWING FOR REOPEN. Action to reopen may be taken:

(i) On the initiative of the Department within the three-year period; (ii) In response to a written request from a provider or other entity within the three-year period. Whether the Director will reopen a determination, which is otherwise final, depends on whether new and material evidence has been submitted, a clear and obvious error has been made, or the determination is found to be inconsistent with the law, regulations and rulings, or general instructions; or (iii) At any time fraud or abuse is suspected.

003.07(B) FAIR HEARING. The right to a fair hearing does not apply to a finding by the Director which indicates a reopening or correction of a determination or decision is not warranted.

003.08 BILLING THE CLIENT. Providers participating in Nebraska Medicaid agree to accept payment from the Department as payment in full. The provider will not bill the client for Nebraska Medicaid covered services if the claim is denied by the Department for lack of medical necessity or for failure to follow a procedural requirement. The provider will not bill the client for services covered by Nebraska Medicaid. It is not a violation of Department regulations for the provider to bill the client for services not covered by Nebraska Medicaid. It is not a violation for a provider to bill the client for services when it is determined the client has received money from a third party resource and the money was designated to pay medical bills. If the client agrees in advance in writing to pay for the non-covered service, the provider may bill the client.

003.08(A) VERIFICATION OF ELIGIBILITY. The provider has the responsibility to verify the client's eligibility for Medicaid and any limitations which apply to a specific client.

003.09 SECTION 1122 SANCTIONS. When the United States Department of Health and Human Services imposes a sanction under section 1122 of the Social Security Act and instructs the Department to withhold or recoup the federal share of the capital expenditure, the Department will withhold the federal and the state share of the capital expenditure.

004. BILLING REQUIREMENTS .

004.01 CLAIMS SUBMISSION. Providers will submit claims for payment for medical services on the appropriate Medicaid billing forms as identified by the Department or the appropriate health care claim format for electronic transactions. Billing requirements for specified services are found in the applicable 471 NAC chapter.

004.02 CLAIM CERTIFICATION. The submission of the claim form by the provider, the provider’s authorized representative, or the provider’s billing agent on behalf of an approved provider certifies:

(A) The services were medically indicated and necessary to the health of the patient, and were personally rendered by the provider or under the provider's direction; (B) The services were provided in compliance with the provisions of Title VI of the Civil Rights Act of 1964 and Section 504 of the Rehabilitation Act of 1973; (C) The amounts claimed are in compliance with the Department's policies, and no additional charge has been or will be made; (D) The information on the claim is true, accurate, and complete; (E) Each service is documented in the provider's files, and documentation is available to the Department, the United States Department of Health and Human Services, and state and federal fraud and abuse units; and (F) The provider understands payment and resolution of this claim will be made from federal and state funds, and any false claims, statements, or documents, or concealment of a material fact may be prosecuted under applicable federal or state laws.

004.03 PAPER SUBMISSION. The provider, the provider's authorized representative, or the provider's billing agent on behalf of an approved provider must sign the paper Medicaid billing forms which contain signature fields. Computer generated signatures are accepted and must be the signature of the service rendering provider, not the clinic or corporation. When a computer-encoded document is used as the Medicaid billing mechanism, the Department may request the provider's source input document from the provider for input verification and signature requirements. The signature constitutes certification as required by this chapter.

004.04 ELECTRONIC SUBMISSION. The submission of any electronic claim by the provider, the provider’s authorization representative, or the provider’s billing agent on behalf of an approved provider constitutes certification as required by this chapter.

004.05 ELECTRONIC CLAIMS AND COMPUTER ENCODED CLAIM DOCUMENTATION. The provider will allow the authorized representatives of the United States Department of Health and Human Services, the Department, and state and federal fraud and abuse units to review and audit the provider's or the provider's billing agent's or clearinghouse’s data processing procedures and supportive software documentation involved in the production of the computer-encoded claims or electronic claims submitted to the Department. The provider has agreed to allow the Department and its authorized representative’s access to its records under the service provider agreement.

005. THIRD PARTY RESOURCES .

005.01 THIRD PARTY RESOURCE PAYMENT. All third party resources available to a Medicaid client must be utilized for all or part of their medical costs before Medicaid. Medicaid payment is made only after all third party resources have been exhausted or met their legal contractual or legal obligations to pay. Medicaid is the payor of last resort.

005.01(A) EXCEPTIONS. The Nebraska Chronic Renal Disease Program and the Medically Handicapped Children's Program are not included as a third party resource.

005.02 AVAILABILITY OF THIRD PARTY RESOURCE INFORMATION. The Coordination of Benefits and Third Party Liability Unit of the Department maintains all known current health insurance, casualty insurance, and Medicare coverage on the Nebraska Medicaid Eligibility System (NMES). Providers may also obtain this information using the standard electronic Health Care Eligibility Benefit Inquiry and Response transaction. If the provider becomes aware of any additional third party resources, the provider must contact the Department and report the new sources.

005.02(A) REQUEST FOR RELEASE OF PATIENT ACCOUNT INFORMATION. To alert the Department to a potential third party resource, the provider must notify the Department when a provider receives a request for an itemized bill or a request for the balance of a bill from the client, an attorney, an insurance company, or employer. This does not include routine billing information requests to process insurance or Medicare. The provider may release the information in accordance with the provider's standard office practice.

005.03 PAYOR OF LAST RESORT. Medicaid clients who have third party resources must exhaust these resources before Medicaid considers payment for services. Medicaid will not pay for medical services as a primary payor if a third party resource is contractually or legally obligated to pay for the service.

005.03(A) BILLING THIRD PARTY RESOURCES. Providers must bill all third party resources and the client, when there is a share of cost obligation, for services provided to the client, except for waiver claims. Providers must submit all charges and Medicare covered services provided to Medicare and Medicaid dually eligible individuals to Medicare plus any Medicare supplement plans for resolution prior to billing Medicaid.

005.03(B) WAIVER CLAIMS. Certain services, defined as waiver claims, are an exception to the requirements of this chapter. Providers may submit these claims to Medicaid before submitting to a third party resource. Nebraska Medicaid pays these claims and Department staff initiate recovery activities for any third party resource. This does not prohibit the provider from billing the third party resource before billing Medicaid. In these situations, the provider does not bill Medicaid until the claim is resolved.

005.03(C) SERVICES NOT COVERED BY MEDICARE. Nebraska Medicaid may cover services within the scope of Nebraska Medicaid which are not covered by Medicare. Nebraska Medicaid does not cover any Medicare Part D Drug or Medicare Part D covered supply or equipment, even if coverage is denied by the Medicare Part D Plan. For services not covered by Medicare, documentation of the Medicare denial is not required.

005.04 MEDICARE PART A AND B DEDUCTIBLE AND COINSURANCE. In some cases, Medicaid pays the deductible and coinsurance for Medicare-covered services. The Department accepts Medicare's utilization review and payment decisions for Medicare allowable fees, except after crediting any amount received from Medicare for Medicare-covered services and crediting any amount received from any third party resource, Medicaid will pay the lesser of the Medicare or Medicaid allowable amount of any remaining amount due.

005.04(A) MEDICARE PART D MONTHLY PREMIUM, DEDUCTIBLE, CO-INSURANCE, AND COVERAGE GAPS. Medicaid does not pay the premium, deductible, co-insurance, copays, or coverage gaps for Medicare Part D.

005.04(B) MEDICARE PART A COINSURANCE FOR NURSING FACILITY SERVICES. For nursing facility services covered under Medicare Part A, Medicaid payments are limited to rates and payments according to the following method:

(i) If the Medicare payment amount for a claim exceeds or equals the Medicaid rate or payment for the claim, Medicaid reimbursement will be zero. (ii) If the Medicaid rate and payment for a claim exceeds the Medicare payment amount for the claim, Medicaid reimbursement is the lesser of:

(1) The difference between the Medicaid rate and payment minus the Medicare payment amount; or (2) The Medicare coinsurance and deductible, if any, for the claim.

005.05 PROVIDER PAYMENT IN FULL. Medicaid payment is the lower of the provider's usual and customary charge or the Medicaid allowable less all third party payment. When a claim is submitted to Medicaid with a payment from a third party resource, the provider is considered paid in full when payment from the third parties and Medicaid equals or exceeds the Medicaid allowable amount. The provider may only bill the client for services not covered by Nebraska Medicaid, for Nebraska Medicaid copayment fees, where applicable, or if the client has received payment from the third party resource.

005.05(A) MEDICARE PART A AND PART B. Department payment of Medicare coinsurance and deductible constitutes payment in full. The provider will not balance bill.

005.05(B) MEDICARE ADVANTAGE. Department payment of Medicare Advantage coinsurance and deductible constitutes payment in full to the provider. The provider will not balance bill.

005.05(C) MEDICARE PART D. Nebraska Medicaid does not pay premiums, deductibles, co-insurance, copays, or coverage gaps for Medicare Part D.

005.05(D) MEDICARE WAIVER OF LIABILITY. When a Medicare and Medicaid dually eligible individual signs a Medicare Waiver of Liability and Medicare denies the claim as not reasonable and necessary, Nebraska Medicaid will not pay the claim.

005.05(E) USE OF CONTRACTS BY MEDICARE AND MEDICAID DUALLY ELIGIBLE INDIVIDUALS. If providers negotiate private contracts with Medicare and Medicaid dually eligible individuals for which no claim is to be submitted to Medicare and for which the provider receives no reimbursement from Medicare directly, neither Medicare nor Medicaid would cover the services provided under the private contract.

005.05(F) CASUALTY SETTLEMENTS WITH A THIRD PARTY RESOURCE. When a provider enters into an agreement with a Medicaid client or a representative of the client to accept less than billed charges, the provider is considered paid in full. No further payment is due from either the client or Nebraska Medicaid.

005.05(G) PROVIDER’S FAILURE TO COOPERATE IN SECURING THIRD PARTY PAYMENT. The provider's failure to file necessary claims for third party resources, except waiver claims, or to cooperate in securing payments by other third party resources is grounds for denial of the claims. If Nebraska Medicaid denies claims for these services, the client cannot be billed unless the payment went to the client.

005.06 FILING CLAIMS WITH THIRD PARTY RESOURCES.

005.06(A) WAIVER OF COOPERATION FOR GOOD CAUSE. With respect to obtaining medical care support and payments or identifying and providing information to assist the State in pursuing liable third parties for a child for whom the individual can legally assign rights, the Department must find cooperation is not in the best interests of the individual or the person to whom Medicaid is being furnished because it is anticipated cooperation will result in reprisal against, and cause physical or emotional harm to, the individual or other person as described in chapter one of this title.

005.06(B) TIMELY FILING OF CLAIMS WITH HEALTH INSURANCE. Providers must first submit all claims to third party resources. To secure a provider's right to Medicaid consideration for payment, a claim must be filed within 12 months from service date even if the third party resource has not been resolved. If the provider fails to submit a claim or fails to contact the Department within 12 months from the date of service, Nebraska Medicaid will not pay the claim.

005.06(B)(i) DENIAL DUE TO THIRD PARTY RESOURCE. If the provider files a claim with Nebraska Medicaid within 12 months of the date of service and receives a Medicaid denial due to the existence of a third party resource, the provider is allowed up to 12 months from the original receipt date of the Medicaid claim to resolve the third party resource. The provider must submit the claim adjustment to Nebraska Medicaid within six months of the date on the insurance or Medicare remittance advice no later than 12 months from the original receipt date of the Medicaid claim.

005.06(C) TIMELY FILING OF CLAIMS WITH CASUALTY INSURANCE. Providers must submit claims within 24 months of the date of service.

005.06(C)(i) EXCEPTION. The Department can make payment beyond 24 months if the provider can document action was taken to obtain payment from the third party. If a provider has received a denial from the Department due to the existence of casualty insurance coverage, the provider has sought payment from the third party, and the provider has waited 24 months without receiving payment from the third party, the provider can request the Department reconsider payment. If the provider has filed a lien, the provider must release the lien upon receipt of payment from the Department. These situations are reviewed on a case by case basis.

005.06(D) FILING MEDICAID CLAIMS AFTER RESOLVING THIRD PARTY RESOURCES. Providers will bill Nebraska Medicaid only when all third party resources have failed to cover the service or when a portion of the cost of the service has been paid. The provider must submit the third party documentation with each claim submitted to the Department. The dates of service on the third party documentation must match the dates of service on each claim.

005.06(D)(i) BILLING THE USUAL AND CUSTOMARY CHARGE. When billing Nebraska Medicaid, the provider must bill the usual and customary charge for each service. The provider cannot submit a claim showing only the Medicaid allowable amount or the difference between the Medicaid allowable amount and the amount of the third party payment.

005.06(D)(ii) ADJUSTMENT REQUEST. After the provider has submitted a claim with third party resource documentation and the Department has adjudicated the claim for payment, if the provider wishes to request an adjustment, the provider must submit the adjustment request within 90 days from the payment date on the Remittance Advice.

005.07 THIRD PARTY RESOURCE DENIALS.

005.07(A) HEALTH INSURANCE DENIALS. Nebraska Medicaid will recognize and consider payment on claims the health insurance has denied with a valid health insurance denial.

005.07(B) MEDICARE DENIALS. Nebraska Medicaid will recognize and consider payment on claims Medicare has denied when the claim is submitted with a valid Medicare denial.

005.07(B)(i) EXCEPTION. The Department will not consider payment for services which have been denied by Medicare for lack of medical necessity.

005.07(C) CASUALTY INSURANCE DENIALS. Nebraska Medicaid will recognize and consider payment on claims involving casualty coverage denial when the claim is submitted with a valid casualty denial.

005.07(C)(i) PAYMENT PENDING LIABILITY DETERMINATION. The insurer's statement indicating payment cannot be made at this time due to a pending liability determination or litigation is not a valid denial.

005.08 FILING ELECTRONIC CLAIMS WITH THIRD PARTY RESOURCES. Medicaid will accept electronic claims when third party resources are available. The health insurance and Medicare documentation is required.

005.08(A) AUTOMATIC TRANSFER OF CLAIMS FROM MEDICARE. Nebraska Medicaid accepts Medicare crossover claims directly from Medicare's fiscal intermediaries and will pay the deductible and coinsurance when no additional third party resource is identified. Claims received from Medicare must include Medicare supplemental insurance coordination of benefits and remittance advice documentation, if applicable.

005.09 THIRD PARTY RESOURCE REVERSAL OF PAYMENT TO PROVIDER. If a provider filed a claim with a third party resource and received payment in full, and thus did not bill Medicaid, and the third party resource reverses its determination after 12 months from the date of service, the provider may bill Nebraska Medicaid for the services. The provider must bill Nebraska Medicaid within 60 days from the date on the third party reversal document and refund. The provider must submit documentation of the reversal with the claim. The claim may be considered for payment by Nebraska Medicaid only if the date of service is no more than 24 months from the date of receipt of claim.

005.10 PRIOR AUTHORIZATION AND THIRD PARTY RESOURCES. The provider must resolve all third party resources before Nebraska Medicaid can consider paying a claim regardless of whether Medicaid prior authorization has been given.

005.11 MEDICAID ELIGIBILITY AND THIRD PARTY RESOURCES. The provider must resolve all third party resources before Nebraska Medicaid can consider paying a claim, regardless of whether the client is eligible for Medicaid, with the exception of waiver claims. A client's eligibility for Nebraska Medicaid does not guarantee payment of a claim.

005.12 LONG-TERM CARE INSURANCE POLICIES. A long-term care indemnity policy is considered a health insurance policy when the policy allows assignment of benefits and covers medical care based on specified criteria. Long-Term Care insurance which meets this criteria is not considered income for eligibility determination.

005.12(A) NURSING FACILITY CLAIMS. Because nursing facility claims are included in the category of "waiver claims," Nebraska Medicaid will pay these claims at the specific per diem for the client, less any excess income or share of cost the client is obligated to pay the provider for the monthly services. The Coordination of Benefits Unit will seek recovery on all of these policies. Because the claims have been paid, the provider will not bill the insurer. The provider must assist the Coordination of Benefits Unit in obtaining reimbursement from these policies by furnishing any medical documentation the insurer requests.

005.12(B) BILLING LONG-TERM CARE INSURANCE. A provider may choose to bill the long term care insurance; in these situations, the provider does not bill Medicaid. If the provider or the client receives a payment directly from the insurer, the payment must be sent to the Coordination of Benefits and Third Party Liability Unit.

005.12(C) PAYMENT RECEIVED BY THE DEPARTMENT. Whenever the Department receives any payments from long-term care insurance which exceed what Medicaid has paid toward the care of the client, the Department will apply the excess to any Medicaid expenditure for the Medicaid client regardless of whether the expenditure was covered by the third party. The application of the excess third party liability payment is not limited to a particular Medicaid service and can be applied to any claims paid by Medicaid. After the excess payment has been applied to all claims, any remaining amount will be paid to the client or the client’s authorized representative.

005.13 MEDICAL SUPPORT FROM NON-CUSTODIAL PARENTS. When children with a non-custodial parent become Medicaid eligible, medical support is court ordered in compliance with Omnibus Budget Reconciliation Act 1993. The County Attorney's staff or Child Support Enforcement staff will notify the Coordination of Benefits and Third Party Liability Unit of any health insurance coverage and medical support court orders obtained for a child who is eligible for Nebraska Medicaid. When a non-custodial parent is ordered by the court to furnish health insurance or make payment for medical services, the provider may bill Medicaid for the services if the provider has not received payment from the health insurer or non-custodial parent within 30 days of the date of service. Medicaid will pay the claims and the Department will seek recovery from the health insurer or non-custodial parent.

005.13(A) BILLING WHEN A COURT ORDER EXISTS. To determine whether a court order exists, the provider may contact the Coordination of Benefits and Third Party Liability Unit. The provider is not required to continue to seek payment from the health insurer or non-custodial parent before billing Medicaid when there is court-ordered medical support.

005.13(B) SEEKING PAYMENT FROM THE NON-CUSTODIAL PARENT. Non-custodial parent medical support court orders may include an obligation by the non-custodial parent to pay a percentage of medical expenses after the health insurer has made payment. The provider is not required to seek payment from the non-custodial parent in these cases. If the provider receives a payment from a non-custodial parent, the provider will indicate this amount and the amount received from the health insurer as a prior payment or amount paid on the claim submitted to Medicaid. The provider must submit with the claim a copy of the documentation showing the non-custodial parent made the payment. If the provider receives payment from the non-custodial parent after Medicaid has paid the claim, the provider must refund Medicaid according to the requirements of this chapter.

005.13(C) HEALTH INSURER OBLIGATION WHEN THE NON-CUSTODIAL PARENT HAS A MEDICAL SUPPORT COURT ORDER. A health insurer cannot deny a child insurance coverage if the non-custodial parent has a court or administrative order for medical support. An insurer must provide the custodial parent information to file claims, allow the custodial parent or provider to file claims, and pay claims to the custodial parent, provider, or the Department, as required by Neb. Rev. Stat. § 44-3,149. If the provider receives a denial of insurance coverage for any of these reasons from an insurer and the client is a child, the provider must contact the Department.

005.14 PROVIDER REFUNDS TO THE DEPARTMENT. When a provider receives payment from a third party resource on a claim previously paid by Nebraska Medicaid, the provider must submit a refund to the Department. The provider must include the third party documentation with the refund. If the payment from the third party resource equals or exceeds the Nebraska Medicaid payment on the claim, the total payment must be refunded to the Department. If the payment from the third party resource is less than the Nebraska Medicaid payment on the claim, the total third party payment must be refunded to the Department.

005.15 BILLING THIRD PARTY RESOURCES AFTER NEBRASKA MEDICAID PAYMENT. If, after Nebraska Medicaid has paid, a provider learns of a third party resource which would have paid more for the service than Nebraska Medicaid, in cases where health insurance is the third party resource, the provider must supply the Department with the third party resource information, refund the Department the full Nebraska Medicaid payment, and then seek recovery from the third party resource. If a Medicaid client becomes retroactively eligible for Medicare, the provider must refund the Department the full Nebraska Medicaid payment and seek reimbursement from Medicare for payment unless Medicare filing time limits for dates of service on the claims have been exhausted. In cases where casualty insurance is the third party resource, the provider will not refund Nebraska Medicaid's payment and then seek recovery from a third party resource, unless the refund is requested by the Department.

005.15(A) DEPARTMENT REQUESTS FOR REFUNDS. When the Department receives information indicating the provider has received a third party resource payment on a Medicaid paid claim, the Department will request a refund from the provider. The provider has 30 days to submit a refund check, show the refund has already been made, document the refund request is in error, or appeal. Failure to comply with this request within 30 days is cause for the Department to withhold future provider payments until the situation is resolved or impose sanctions on the provider. The refund request constitutes notice of sanction.

005.16 CLIENT RIGHTS AND RESPONSIBILITIES.

005.16(A) CLIENT RIGHTS. A provider cannot refuse to furnish services to an individual who is eligible for Nebraska Medicaid because of a third party's potential liability for payment of service.

005.16(B) FAILURE TO COOPERATE. A Nebraska Medicaid client has the obligation to assist the provider and the Department in obtaining payment from all available third party resources. This may include complying with any requests from the insurer for additional information, ensuring the provider or the Department receives remittance advice, coordination of benefits, and payments from the insurer, or appearing in court in litigation situations. If the client fails to cooperate with the provider in securing third party resources, the provider may contact the Department. Failure by the client to cooperate may cause the client to lose Nebraska Medicaid eligibility. The client will be responsible for payment of the denied services.

005.16(C) CLIENT RESPONSIBILITY WHEN ENROLLED IN A HEALTH MAINTENANCE ORGANIZATION OR PREFERRED PROVIDER ORGANIZATION PLAN. Clients are required to utilize the services provided through and obtain all necessary prerequisites as set out by the health maintenance organization or preferred provider organization. Failure to do so is considered lack of cooperation and may result in loss of Medicaid eligibility. The client is responsible for the payment of the denied services.

005.16(D) CLIENT RESPONSIBILITY WHEN HEALTH INSURANCE PREMIUMS ARE PAID BY THE DEPARTMENT. If the Department determines it is cost effective to pay the premiums for a Medicaid eligible client to maintain his or her current commercial insurance coverage, the client must follow any preauthorization or referral provisions of the plan or utilization of specific providers in the network. Claims denied by third party resources because client did not utilize a network provider or obtain necessary authorizations or referrals will not be paid by Medicaid. The client will be responsible for payment of the denied services.

005.16(E) CLIENT RESPONSIBILITY WHEN CHOOSING TO ENROLL IN MEDICARE ADVANTAGE PLANS. Nebraska Medicaid will not pay claims denied by Medicare for Medicaid clients enrolled in Medicare Advantage plans who move out of the service area without complying with notification requirements or who do not utilize a network provider or obtain necessary authorizations and referrals. The client will be responsible for payment of the denied services.

005.17 COVERAGE INFORMATION REQUESTS. The Department may request coverage information from a licensed insurer or a self-funded insurer about a specific individual without the individual’s authorization to determine eligibility for state benefit programs or coordinate benefits with state benefit programs. The Department will specify the individual recipients for whom information is being requested.

005.17(A) RESPONSE TO REQUESTS. Self-funded insurers and licensed insurers must respond within 30 days of receipt of any request for coverage information from the Department. The information must be provided within thirty days after the date of the request unless good cause is shown.

005.17(B) FAILURE TO ACKNOWLEDGE AND RESPOND TO COVERAGE INFORMATION REQUESTS. If a self-funded insurer fails to acknowledge and respond to a request from the Department for coverage information about an individual, the Department may find this a violation of the requirements of this chapter and impose a civil money penalty.

005.17(C) CIVIL MONEY PENALTY. The Department may impose a civil money penalty of no more than $1,000 for each violation, not to exceed an aggregate penalty of $30,000, unless the violation by the self-funded insurer was committed flagrantly and in conscious disregard of the requirements of this chapter in which case the penalty will not be more than $15,000 for each violation, not to exceed an aggregate penalty of $150,000.

005.17(D) HEARING. A licensed insurer or a self-funded insurer’s request for a hearing to appeal an action by the Department must comply with Department regulations.

005.18 SERVICES REQUIRING PRIOR AUTHORIZATION. Services which require prior authorization for payment of claims, prior authorization requirements, and methods are listed in the chapter of the Nebraska Department of Health and Human Services Finance and Support Manual related to the specific type of service.

005.18(A) LIMITATIONS OF PRIOR AUTHORIZATION. Prior authorization is issued only if the client is eligible for Nebraska Medicaid for the period for which services are authorized. If the client becomes ineligible for Nebraska Medicaid during the authorization period, the authorization is invalid in the period of ineligibility. The authorizing agent will not submit a prior authorization request until eligibility for Nebraska Medicaid has been determined. Prior authorization is not transferable to other clients or other providers.

005.18(B) DUAL MEDICARE AND MEDICAID ELIGIBILITY. If the client is eligible for Medicare as well as Medicaid and the requested services are covered by Medicare, prior authorization is not issued. In some cases, as defined in the specific service policy, the provider must receive a denial of coverage from Medicare before a prior authorization is issued. The provider must submit a copy of the denial with the claim form to receive payment.

005.18(C) NOTIFICATION OF THE CLIENT. The provider or Department will notify the client of approval or denial of prior authorization according to the prior authorization procedures under the individual chapters of this Title.

006. COPAYMENTS .

006.01 COPAYMENT SCHEDULE. The Department has established the following schedule of copayments for Medicaid services:

| (A) Chiropractic Office Visits | $1 per visit | | --- | --- | | (B) Dental Services | $3 per specified service | | (C) Durable Medical Equipment | $3 per specified service | | (D) Drugs (except birth control) | | | (i) Generic drugs | $2 copay | | (ii) Brand name drugs | $3 copay | | (E) Eyeglasses | $2 per frames, lens, or frames with lens | | (F) Hearing Aids | $3 per hearing aid | | (G) Inpatient Hospital | $15 per admission | | (H) Mental Health/Substance Abuse Visits | $2 per specified service | | (I) Occupational Therapy (non-hospital based) | $1 per specified service | | (J) Optometric Office Visits | $2 per visit | | (K) Outpatient Hospital Services | $3 per visit | | (L) Physical Therapy (non-hospital based) | $1 per specified service | | (M) Physicians (M.D.'s and D.O.'s) Office Visits | $2 per visit | | (i) Excluding Primary Care Physicians Family Practice, General Practice, Pediatricians, Internists, and physician extenders, including physician assistants, nurse practitioners, and nurse midwives, who provide primary care services. | | | (N) Podiatrists Office Visits | $1 per visit | | (O) Speech Therapy (non-hospital based) | $2 per specified service |

006.02 EXCLUDED SERVICES. The following services are excluded from the above copayment requirement by federal regulations:

(A) Emergency services provided to treat an emergency medical condition in a hospital, clinic, office, or other facility equipped to provide the required care. An emergency condition is defined as a medical or behavioral condition, the onset of which is sudden, manifests itself by symptoms of sufficient severity, including but not limited to, severe pain, which a prudent layperson possessing an average knowledge of medicine and health could reasonably expect the absence of immediate medical attention to result in (a) placing the health of the person, or with respect to a pregnant woman, the health of the woman and her unborn child, afflicted with such condition in serious jeopardy or, in the case of a behavioral condition, placing the health of such persons or others in serious jeopardy, (b) serious impairment to such person's bodily functions, (c) serious impairment of any bodily organ or part of such person, or (d) serious disfigurement of such person; and (B) Family planning services, supplies, and drugs provided to individuals of child-bearing age.

006.03 COVERED PERSONS. All Medicaid-eligible adults age 19 or older listed below are subject to the copayment requirement:

(A) Adults eligible under the Aid to Aged, Blind, and Disabled program; (B) Adults eligible under the Refugee Resettlement Program; and (C) Individuals who are receiving extended assistance for former Department wards.

006.04 CHANGE IN CLIENT’S COPAYMENT STATUS DURING THE MONTH. The client's copayment status may change during the month. If the client's copayment status changes during the month, the provider may submit documentation regarding copayments made or collected erroneously and the Department will make the appropriate adjustments to the claim. The provider will refund the client when a copayment is erroneously collected. Providers can contact the Nebraska Medicaid Eligibility System or use the standard electronic Health Care Eligibility Benefit Inquiry and Response transaction to verify the client's copayment status.

006.05 EXEMPTED PERSONS. The following individuals are exempted from the copayment requirement:

(A) Individuals age 18 or younger; (B) Pregnant women through the immediate postpartum period, beginning on the last day of pregnancy and extending 60 days. The post-partum period ends on the last day of the month in which day 60 occurs; (C) Any individual who is an inpatient in a hospital, long term care facility, or other medical institution if the individual is required, as a condition of receiving services in the institution, to spend all but a minimal amount of his or her income required for personal needs for medical care costs; (D) Indians who receive items and services furnished directly by an Indian Health Care Provider or through referral from an Indian Health Care Provider under contract health services; (E) Individuals who are receiving waiver services, provided under a 1915(c) waiver, such as the Community-Based Waiver for Adults; the Home and Community-Based Waiver for Children; the Home and Community-Based Waiver for Aged Persons or Adults or Children with Disabilities or the Early Intervention Waiver; (F) Individuals with excess income, both before and after the obligation is met; (G) Individuals who receive assistance under the State Disability Program; (H) Individuals eligible for IV-E assistance; (I) Individuals in hospice care; (J) Individuals eligible in the Breast and Cervical Cancer category; (K) Family planning services and supplies; (L) Individuals approved for emergency services only; and (M) Individuals enrolled in managed care, though the managed care organization may assess copays as long as they offer at least the same exemptions listed in this section.

006.06 CLIENT RIGHTS AND RESPONSIBILITIES. Clients subject to copayments are required to pay the provider the applicable copayment amounts. If a client believes a provider has charged the client incorrectly, the client must continue to pay the copayments charged by the provider until the Department determines whether the copayment amounts are correct. The client has the right to appeal.

006.07 COLLECTION OF COPAYMENT. The provider will collect the copayment from the client when the service is provided. The provider cannot refuse to provide services to the client if the client is unable to pay the copayment amount at the time of the service. This does not alleviate the client's liability for the copayment amount nor does it prevent the provider from attempting to collect the copayment amount.

006.07(A) UNCOLLECTED COPAYMENTS. If it is the routine business practice of the provider to refuse service to any individual with uncollected debt, the provider may include uncollected copayments under this practice. Providers must give sufficient notice to the client before services can be denied.

006.07(B) PROVIDER BILLING FOR SERVICES SUBJECT TO COPAYMENT. Providers will bill their usual and customary charge regardless of whether the copayment has been collected. The provider will not enter the copayment as a prior payment or amount paid amount on the claim.

006.07(C) PROVIDER WAIVER OF COPAYMENT. A provider cannot establish a policy to automatically waive copayments or deductibles established by the Department. A provider cannot advertise or promote waiver of the collection of all or any portion of the required copayments or deductibles.

006.07(D) USUAL AND CUSTOMARY CHARGE. The provider cannot collect a copayment amount which exceeds the provider's usual and customary charge or the Nebraska Medicaid payment. Copayment collected from the client must be the lowest of the established copayment amount, the provider's usual and customary charge, or the Nebraska Medicaid payment.

006.08 THIRD PARTY LIABILITY. For Medicaid clients enrolled in commercial Health Maintenance Organization or Preferred Provider Organization plans, the Nebraska Medicaid copayment may apply.

006.09 MEDICARE. For Medicare and Medicaid dually eligible clients, the Nebraska Medicaid copayment applies. Nebraska Medicaid pays Medicare co-insurance and deductible amounts on Medicare-approved services less any Medicaid copayment.

History

• Effective 2022-06-06

Chapter 4 Ambulance Services

Neb. Admin. Code tit. 471, ch. 4 Ambulance Services {#sec-471-nac-4 omnilex-key=us-ne-regs-official--title-471--471 NAC 4}

001. SCOPE AND AUTHORITY . These regulations govern services provided under the Medical Assistance Act, Nebraska Revised Statute (Neb. Rev. Stat.) §§ 68-901 et seq.

002. DEFINITIONS . The following definitions apply:

002.01 ADVANCED LIFE SUPPORT (ALS) SERVICES. An emergency medical service that utilizes personnel that have been trained and licensed as advanced emergency medical technicians, emergency medical technician-intermediates, or paramedics and has equipment available commensurate with that level of training.

002.02 BASIC LIFE SUPPORT (BLS) SERVICES. An emergency medical service that utilizes personnel that have been trained and licensed, as a minimum, as emergency medical technicians and has equipment available commensurate with that level of training.

002.03 EMERGENCY TRANSPORT. Services provided after the sudden onset of a medical condition manifesting itself by acute symptoms of sufficient severity, including severe pain that the absence of immediate medical attention could reasonably be expected to result in:

(A) Placing the client's health in serious jeopardy;

(B) Serious impairment to bodily functions; or

(C) Serious dysfunction of any bodily organ or part.

002.04 LOADED MILEAGE. Miles traveled while the client is present in the ambulance vehicle.

003. PROVIDER REQUIREMENTS .

003.01 GENERAL PROVIDER REQUIREMENTS. Providers of ambulance services must comply with all applicable provider participation requirements codified in 471 Nebraska Administrative Code (NAC) 2 and 3. In the event that provider participation requirements in 471 NAC 2 or 3 conflict with requirements outlined in this chapter, the individual provider participation requirements in this chapter will govern.

004. SERVICE REQUIREMENTS .

004.01 GENERAL REQUIREMENTS.

004.01(A) MEDICAL NECESSITY OF THE SERVICE. Medical necessity is established when the client's condition is such that use of any other method of transportation is contraindicated. In any case in which some means of transportation other than an ambulance could be used without endangering the client's health, whether or not such other transportation is actually available, Medicaid will not make payment for ambulance service. Claims for ambulance services must include adequate documentation for determination of medical necessary.

004.01(B) SERVICES PROVIDED FOR CLIENTS ENROLLED IN NEBRASKA MEDICAID MANAGED CARE. See 471 NAC 1.

004.01(C) HEALTH CHECK SERVICES. See 471 NAC 33.

004.02 COVERED SERVICES. Medicaid covers medically necessary and reasonable ambulance services required to transport a client to obtain, or after receiving, a Medicaid covered service.

004.02(A) GROUND AMBULANCE SERVICES.

004.02(A)(i) BASIC LIFE SUPPORT (BLS) SERVICES. Medicaid covers basic life support (BLS) ambulance services.

004.02(A)(ii) ADVANCED LIFE SUPPORT (ALS) SERVICES. Medicaid covers advanced life support (ALS) ambulance services if:

(1) Ambulance personnel perform advanced life support (ALS) services during the transport;

(2) Advanced life support (ALS) personnel monitor the condition of a client during the transport, even if no advanced life support (ALS) services are provided during the transport; or

(3) Any ambulance service not covered under 004.02(A)(ii)(1) or 004.02(A)(ii)(2) covered as a basic life support (BLS) service.

004.02(A)(iii) MILEAGE. Loaded mileage is covered for total distances in excess of five loaded miles. Unloaded mileage, and the initial five loaded miles when the total distance is not in excess of five loaded miles, is covered as a part of the base rate.

004.02(A)(iv) WAITING OR STANDBY TIME. Waiting or standby time under normal circumstances is covered as a part of the base rate. Waiting or standby time, in excess of thirty minutes, but less than two hours, is covered only when necessary to stabilize a client’s condition. Waiting or standby time in excess of two hours is not covered.

004.02(B) AIR AMBULANCE. Medicaid covers medically necessary air ambulance services only when transportation by ground ambulance is contraindicated and:

(i) Great distances or other obstacles are involved in getting the client to the destination;

(ii) Immediate and rapid admission is essential; or

(iii) The point of pickup is inaccessible by land vehicle.

004.02(C) NON-EMERGENCY TRANSPORTS. Any ambulance transport that does not meet the definition of an emergency transport will be covered as a non-emergency transport, regardless of point of origin and destination. Sufficient documentation is required to support the medical necessity of a non-emergency transport.

004.02(C)(i) TRANSPORTS TO THE FACILITY WHICH MEETS THE NEEDS OF THE CLIENT. Medicaid covers services provided by the most appropriate ambulance and practitioner type that meets the needs of the client including:

(1) Medical care in a facility;

(2) Support from the client's community; or

(3) Care from the client's own physician or practitioner or a qualified physician, practitioner, or specialist.

004.02(C)(ii) TRANSPORTS TO A PHYSICIAN’S OFFICE. Non-emergency ambulance transports to a physician or practitioner's office, clinic or therapy center are covered when:

(1) The client is bed confined before, during, and after transport; and

(2) The services cannot or cannot reasonably be expected to be provided at the client's residence.

004.02(D) ROUND TRIP TRANSPORTS FOR HOSPITAL INPATIENTS. Ambulance services provided to a client receiving inpatient hospital services, where the client is transported to a separate facility for services, and the client is returned to the originating hospital for continuation of inpatient care, are covered as an ambulance service as opposed to a hospital service outlined in 471 NAC 10.

004.02(E) TRANSPORT OF MORE THAN ONE CLIENT. When more than one client is transported during a single trip, a base rate is covered for each client transported. The number of loaded miles and mileage charges must be prorated among the number of clients being billed.

004.02(F) TRANSPORT OF MEDICAL TEAMS. Transportation of a medical team resulting in an ambulance transport of the client, is covered as a part of the base rate. Transportation of a medical team without the client being in the ambulance is not covered.

004.02(G) TRANSPORT OF DECEASED CLIENTS. Ambulance services are covered if the client is pronounced dead while en route to or upon arrival at the hospital. Ambulance services are not covered if a client is pronounced dead before the client is transported.

004.02(H) HOSPITAL-BASED AMBULANCE SERVICE. Hospital-based ambulance services are regulated in 471 NAC 10.

005. BILLING AND PAYMENT FOR AMBULANCE SERVICES .

005.01 BILLING.

005.01(A) GENERAL BILLING REQUIREMENTS. Providers must comply with all applicable billing requirements codified in 471 NAC Chapter 3. In the event that individual billing requirements in 471 NAC 3 conflict with billing requirements outlined in this chapter 4, the individual billing requirements in this chapter 4 will govern.

005.01(B) SPECIFIC BILLING REQUIREMENTS.

005.01(B)(i) BILLING INSTRUCTIONS. The provider must bill Medicaid using the appropriate claim form or electronic format.

005.01(B)(ii) USUAL AND CUSTOMARY CHARGE. The provider or the provider's authorized agent must submit the provider's usual and customary charge for each procedure code listed on the claim. Healthcare Common Procedure Coding System (HCPCS) and Current Procedural Terminology (CPT) procedure codes used by Medicaid are listed in the Nebraska Medicaid Practitioner Fee Schedule.

005.02 PAYMENT.

005.02(A) GENERAL PAYMENT REQUIREMENTS. Medicaid will reimburse the provider for services rendered in accordance with the applicable payment regulations codified in 471 NAC 3. In the event that individual payment regulations in 471 NAC 3 conflict with payment regulations outlined in this chapter the individual payment regulations in this chapter will govern.

005.02(B) SPECIFIC PAYMENT REQUIREMENTS.

005.02(B)(i) BASE RATES. Ground ambulance base rates include all services, equipment, and other costs.

005.02(B)(ii) REIMBURSEMENT. Medicaid pays for covered ambulance services at the lower of:

(1) The provider's submitted charge; or

(2) The allowable amount for that procedure code in the Nebraska Medicaid Practitioner Fee Schedule in effect for that date of service.

005.02(B)(iii) AIR AMBULANCE. If a determination is made that ambulance transport is medically necessary, but ground ambulance would have been appropriate, payment for the air ambulance service is limited to the amount allowable for ground transport.

History

• Effective 2022-05-08

Chapter 5 Chiropractic Services

Neb. Admin. Code tit. 471, ch. 5 Chiropractic Services {#sec-471-nac-5 omnilex-key=us-ne-regs-official--title-471--471 NAC 5}

001. SCOPE AND AUTHORITY . These regulations govern services provided under the Medical Assistance Act, Nebraska Revised Statute (Neb. Rev. Stat.) §§ 68-901 et seq.

002. PROVIDER REQUIREMENTS .

002.01 GENERAL PROVIDER REQUIREMENTS. Providers of chiropractic services must comply with all applicable provider participation requirements codified in 471 Nebraska Administrative Code (NAC) 2 and 3. In the event that provider participation requirements in 471 NAC 2 or 3 conflict with requirements outlined in this chapter, the individual provider participation requirements in this chapter will govern.

002.02 SERVICE SPECIFIC PROVIDER REQUIREMENTS. If chiropractic services are provided outside of Nebraska, the chiropractor must be licensed in the state in which the services are provided.

003. SERVICE REQUIREMENTS .

003.01 GENERAL REQUIREMENTS.

003.01(A) MEDICAL NECESSITY. Medicaid incorporates the definition of medical necessity from 471 NAC 1 as is fully rewritten herein. Services and supplies that do not meet the 471 NAC 1 definition of medical necessity are not covered.

003.01(B) SERVICES PROVIDED FOR CLIENTS ENROLLED IN NEBRASKA MEDICAID MANAGED CARE. See 471 NAC 1.

003.01(C) HEALTH CHECK SERVICES. See 471 NAC 33.

003.02 COVERED SERVICES. Medicaid limits coverage of chiropractic services to:

(i) Certain spinal x-rays;

(ii) Manual manipulation of the spine;

(iii) Certain evaluation and management services;

(iv) Traction;

(v) Electrical stimulation;

(vi) Ultrasound; and

(vii) Certain therapeutic procedures, activities, and techniques designed and implemented to improve, develop, or maintain the function of the area treated.

003.02(A) CHIROPRACTIC TREATMENT. Covered services are only for the treatment of spinal subluxations for which treatment provides a direct therapeutic benefit, and is subject to the following limitations:

(i) For clients age 21 and older, chiropractic treatment is limited to those treatments deemed medically necessary;

(ii) For clients age 20 and younger, chiropractic treatment is limited to those treatments deemed medically necessary; and

(iii) No more than one treatment per client per day is covered.

003.02(B) SPINAL X-RAYS. Coverage of spinal x-rays is limited to one anteroposterior and one lateral view of the entire spine or one each of the following: thoracic, cervical, and lumbosacral for a client in a 12 month period. For spinal x-rays to be covered under Medicaid, at least one of the following criteria must be met:

(i) Recent acute or violent trauma where there may be a question concerning avulsion, fracture, or subluxation;

(ii) Chronic or long-standing ailments that have been treated by other practitioners without success and, if x-rays were already taken, they are not available;

(iii) When there is a pathology or malignancy previously diagnosed, precautionary x-rays are covered when medically necessary;

(iv) If there is any indication of existing pathology in the evaluation of the client, the treatment of which may cause additional discomfort;

(v) If the client has been under long-term treatment with no alleviation of symptoms; or

(vi) When specifically required by the Department's utilization review and for documentation of diagnosis and claims for services.

003.03 NON-COVERED SERVICES. Except for those services previously specified, Medicaid does not cover any other diagnostic or therapeutic service or supply provided by a chiropractor.

004. BILLING AND PAYMENT FOR CHIROPRACTIC SERVICES .

004.01 BILLING.

004.01(A) GENERAL BILLING REQUIREMENTS. Providers must comply with all applicable billing requirements codified in 471 NAC 3. In the event that individual billing requirements in 471 NAC 3 conflict with billing requirements outlined in this chapter, the individual billing requirements in this chapter will govern.

004.01(B) SPECIFIC BILLING REQUIREMENTS.

004.01(B)(i) BILLING INSTRUCTIONS. The provider must bill Medicaid, using the appropriate claim form or electronic format.

004.01(B)(ii) USUAL AND CUSTOMARY CHARGE. The provider, or the provider's authorized agent, must submit the provider's usual and customary charge for each procedure code listed on the claim. Healthcare Common Procedure Coding System (HCPCS) and Current Procedural Terminology (CPT) procedure codes used by Medicaid are listed in the Nebraska Medicaid Practitioner Fee Schedule.

004.01(B)(iii) CHIROPRACTIC TREATMENT. The chiropractor must list the following information on the claim when billing Medicaid:

(1) The diagnosis which includes the level of subluxation;

(2) The symptom(s) that directly relates to the diagnosis of subluxation; and

(3) The initial date of treatment billed to Medicaid for the reported diagnosis.

004.02 PAYMENT.

004.02(A) GENERAL PAYMENT REQUIREMENTS. Medicaid will reimburse the provider for services rendered in accordance with the applicable payment regulations codified in 471 NAC 3. In the event that individual payment regulations in 471 NAC 3 conflict with payment regulations outlined in this chapter, the individual payment regulations in this chapter will govern.

004.02(B) SPECIFIC PAYMENT REQUIREMENTS.

004.02(B)(i) REIMBURSEMENT. Medicaid pays for covered chiropractic services in the amount equal to the lesser of:

(1) The provider's submitted charge; and

(2) The allowable amount for that procedure code in the Nebraska Medicaid Practitioner Fee Schedule in effect for the date of service.

History

• Effective 2020-09-19

Chapter 6 Dental Services

Neb. Admin. Code tit. 471, ch. 6 Dental Services {#sec-471-nac-6 omnilex-key=us-ne-regs-official--title-471--471 NAC 6}

001. SCOPE AND AUTHORITY . These regulations govern services provided under the Medical Assistance Act, Nebraska Revised Statute (Neb. Rev. Stat.) §§ 68-901 et seq.

002. DEFINITIONS . The following definitions apply:

002.01 ADEQUATE OCCLUSION FOR PARTIAL DENTURES. Adequate occlusion for partial dentures is first molar to first molar, or a similar combination of anterior and posterior teeth on the upper or lower arch in occlusion.

002.02 DIAGNOSTIC RECORDS. A medical history, a dental and orthodontic history, clinical examination, plaster study models of the teeth, photographs of the patient’s face and teeth, a panoramic or other x-rays of all the teeth, a facial profile x-ray, and other appropriate x-rays.

002.03 HANDICAPPING MALOCCLUSION. A handicapping malocclusion is an improper alignment of the teeth due to one of two conditions:

(A) Craniofacial birth defect that is affecting the occlusion; or

(B) Mutilated and severe malocclusions.

002.04 OCCLUSAL ORTHOTIC DEVICE. Splints that are provided for treatment of temporomandibular joint dysfunction.

002.05 SPECIAL NEEDS. For the purposes of dental services, a client with special needs is a client who is unable to care for his or her mouth properly on his or her own because of a disabling condition.

002.06 TELEDENTISTRY. Teledentistry is the use of technology, including digital radiographs, digital photos and videos, and electronic health records, to facilitate delivery of oral healthcare and oral health education services from a provider in one location to a patient in a physically different location. Teledentistry is to be used for the purposes of evaluation, diagnosis, or treatment.

003. PROVIDER REQUIREMENTS .

003.01 GENERAL PROVIDER REQUIREMENTS. Providers of dental services must comply with all applicable provider participation requirements codified in 471 Nebraska Administrative Code (NAC) 2 and 3. In the event that provider participation requirements in 471 NAC 2 or 3 conflict with requirements outlined in this chapter, the individual provider participation requirements in this chapter will govern.

003.02 PROVIDER SPECIFIC REQUIREMENTS. If services are provided in another state, the dentist or dental hygienist must be licensed in that state, must practice within his or her scope of practice as defined by the licensing laws for that state, and must be enrolled in Medicaid by complying with the provider agreement requirements included in this chapter.

003.02(A) PROVIDER AGREEMENT. Providers of dental services must complete and sign Form MC-19, Service Provider Agreement, and submit the completed form to the Department for approval to participate in Medicaid.

004. SERVICE REQUIREMENTS .

004.01 GENERAL REQUIREMENTS.

004.01(A) MEDICAL NECESSITY. Medicaid incorporates the definition of medical necessity from 471 NAC 1 as if fully rewritten herein. Services and supplies that do not meet the 471 NAC 1 definition of medical necessity are not covered. Services may be subject to the specific limitations or prior authorization requirements as listed in this chapter.

004.01(A)(i) DOCUMENTATION OF MEDICAL NECESSITY. Documentation of medical necessity is required on all procedures. The documentation should be in the client’s dental chart which must be available to the Department upon request.

004.01(B) PRIOR AUTHORIZATION. Specific documentation must be submitted along with each prior authorization request. Submitted documentation that is inadequate, or does not otherwise meet the criteria for review, may be disapproved, or returned for additional information or correction. The provider must receive prior authorization before the following services:

(i) Crowns;

(ii) Periodontal scaling and root planning;

(iii) Periodontal maintenance procedure;

(iv) Complete, immediate, and interim dentures, maxillary and mandibular;

(iv) Partial resin base, maxillary and mandibular;

(v) Flipper partial dentures, maxillary and mandibular; and

(vi) Orthodontic treatment.

004.01(B)(i) REQUEST FOR PRIOR AUTHORIZATION. To request prior authorization for a proposed dental pre-treatment plan or covered service, the dentist must submit the request using one of the following options:

(1) Electronically using the standard Health Care Services Request for Review and Response; or

(2) Submission of a dental claim form and required documentation by mail to the Department.

004.01(B)(ii) ADULT EMERGENCY DENTAL SERVICES AND EXTENSIVE TREATMENT CIRCUMSTANCES. The request must clearly indicate that it is either an emergency services or extensive treatment circumstances request, and be accompanied by sufficient documentation to determine the emergent medical necessity. In the event that the service must be rendered immediately, the dental provider must submit a request for coverage, post treatment, with documentation of the emergent medical necessity, for payment review.

004.01(C) SERVICES FOR INDIVIDUALS AGE 21 AND OLDER. Dental coverage is limited to $750 per fiscal year. The annual limit is calculated at the Medicaid dental fee schedule rate for the treatment provided or on the all-inclusive encounter rate paid to Indian health service (IHS) facilities or federally qualified health centers (FQHC) facilities.

004.01(C)(i) PROVIDER RESPONSIBILITY AND CLIENT RESPONSIBILITY REGARDING THE YEARLY DENTAL LIMIT. Providers must inform a client before treatment is provided of the client’s obligation to pay for a service if the client’s annual limit has already been reached or if the amount of treatment proposed will cause the client’s annual limit to be exceeded.

004.01(C)(ii) EMERGENCY DENTAL SERVICES. Adult dental services provided in an emergency situation are not subject to the annual per fiscal year limits imposed in this chapter. Adult dental services provided in an emergency situation will be considered for coverage on a case-by-case basis. Only the most limited service(s) needed to correct the emergency condition will be covered. Medicaid will cover emergency dental services that were not prior authorized. The provider must submit a completed coverage request with supporting documentation of the emergent nature of the services provided. Medicaid considers the following conditions to be emergent:

(1) Extractions for the relief of:

(a) Severe and acute pain; or

(b) An acute infectious process in the mouth;

(2) Extractions and necessary treatment for repair of traumatic injury; and

(3) Full mouth extractions as necessary for catastrophic illness such as an organ transplant, chemotherapy, severe heart disease, intra-oral radiation workup, or other life threatening illnesses.

004.01(C)(iii) DENTURES AND EXTENSIVE TREATMENT CIRCUMSTANCES. Medicaid will review, and consider coverage of, services that cause the client to exceed the annual coverage limit, where the client is in need of dentures and extensive treatment in a hospital setting due to a disease or medical condition, or the client is disabled and it is in the best interest of the client’s overall health to complete the treatment in a single setting. A prior authorization request must be submitted with medical necessity documentation.

004.01(D) SERVICES PROVIDED TO CLIENTS ENROLLED IN NEBRASKA MEDICAID MANAGED CARE. See 471 NAC 1.

004.01(E) HEALTH CHECK SERVICES. See 471 NAC 33.

004.01(F) HOSPITALIZATION OR TREATMENT IN AN AMBULATORY SURGICAL CENTER. Dental services must be provided at the least expensive appropriate place of service.

004.01(G) MEDICAL AND SURGICAL SERVICES OF A DENTIST OR ORAL SURGEON. Medically necessary services of a dentist or oral surgeon not otherwise covered in this chapter, are covered and reimbursed as a physician’s service in accordance with the 471 NAC 18.

004.02 COVERED SERVICES. Medicaid does not cover all American Dental Association (ADA) procedure codes. Covered codes are listed in the Medicaid Dental Fee Schedule.

004.02(A) DIAGNOSTIC SERVICES.

004.02(A)(i) ORAL EVALUATIONS. Oral evaluations are covered for new patients, emergency treatment, second opinions and specialists. All oral examinations must be provided by a dentist. A single exam code is covered per date of service. Not to be billed with any other exam codes on the same date of service.

004.02(A)(i)(1) PERIODIC ORAL EVALUATIONS.

004.02(A)(i)(1)(a) AGE 20 AND YOUNGER. For clients age 20 and younger, periodic oral evaluation is covered once every 180 days.

004.02(A)(i)(1)(b) AGE 21 AND OLDER. For clients age 21 and older, periodic oral evaluation is covered once every 180 days.

004.02(A)(i)(1)(c) SPECIAL NEEDS AND DISABLED CLIENTS. Periodic oral evaluation is covered at the frequency determined appropriate by the treating dental provider.

004.02(A)(i)(1)(d) DOCUMENTATION REQUIREMENTS. Documentation of client’s special needs or disability is required.

004.02(A)(i)(2) LIMITED ORAL EVALUATION. Oral evaluation is limited to twice in a one year period for each client, and for treatment of a specific oral health problem or complaint. Documentation which specifies the medical necessity is required.

004.02(A)(i)(3) ORAL EVALUATION FOR INFANT. Oral evaluation is covered for clients age 3 and younger and includes counseling with the primary caregiver.

004.02(A)(i)(4) COMPREHENSIVE ORAL EVALUATION. Benefit is limited to one per three year period per client, per provider, and location. It is not payable in conjunction with emergency treatment visits, denture repairs, or similar appointments.

004.02(A)(i)(5) DETAILED AND EXTENSIVE ORAL EXAMINATION. Problem focused oral evaluation is a benefit limited to one per three year period per client. It is not payable in conjunction with emergency treatment visits, denture repairs or similar appointments.

004.02(A)(i)(6) RE-EVALUATION. Limited and problem focused benefit is limited to one per year per client.

004.02(A)(i)(7) COMPREHENSIVE PERIODONTAL EVALUATION. Comprehensive periodontal evaluation is a benefit limited to one per three year period per client.

004.02(A)(ii) RADIOGRAPHS. The maximum dollar amount covered is equal to the Medicaid fee paid for an intraoral complete series. A cephalometric film is not included in the maximum dollar amount. Medicaid covers a maximum dollar amount for any combination of the following radiographs:

(1) Intraoral complete series;

(2) Intraoral periapical films;

(3) Extraoral films, bitewings; or

(4) Panorex.

004.02(A)(iii) PERIODOCITY OF RADIOGRAPHS. Medicaid covers:

(1) A maximum of four bitewings per date of services;

(2) Intraoral complete series every three years;

(3) Panorex every three years. Covered more frequently if necessary for treatment. Documentation is required for more frequent panorex in dental chart; and

(4) Cephalometric film for clients age 20 and younger, as follows:

(a) Orthodontic treatment is covered if the client will qualify for Medicaid coverage of treatment as outlined in the orthodontic coverage criteria.

004.02(B) PREVENTIVE SERVICES.

004.02(B)(i) PROPHYLAXIS.

004.02(B)(i)(1) AGE 13 AND YOUNGER. For age 13 and younger, prophylaxis is covered one time every 180 days and billed as a child prophylaxis.

004.02(B)(i)(2) AGE 14 THROUGH 20. For age 14 through 20, prophylaxis is covered every 180 days and billed as an adult prophylaxis.

004.02(B)(i)(3) AGE 21 AND OLDER. For age 21 and older, prophylaxis is covered one time every 180 days.

004.02(B)(i)(4) SPECIAL NEEDS CLIENTS. Prophylaxis is covered at the frequency determined appropriate by the treating dental provider and is limited to one per date of service per client.

004.02(B)(i)(4)(a) DOCUMENTATION REQUIREMENTS. Documentation of client’s special needs or disability is required.

004.02(B)(ii) TOPICAL FLUORIDE AND FLUORIDE VARNISH. Topical fluoride and fluoride varnish are covered for adults and children at the frequency determined appropriate by the treating dental provider.

004.02(B)(iii) SEALANTS. Sealants are covered on permanent and primary teeth for clients ages 20 and younger. Sealants are covered once per tooth every 730 days.

004.02(B)(iv) SPACE MAINTAINERS, PASSIVE APPLIANCES. Space maintainers are covered for clients age 20 and younger, once every 365 days.

004.02(B)(v) RECEMENTATION OF SPACE MAINTAINERS. Recementation is covered for clients age 20 and younger, once every 365 days.

004.02(C) RESTORATIVE SERVICES. Tooth preparation, temporary restorations, cement bases, pulp capping, impressions, and local anesthesia are included in the restorative fee for each covered service.

004.02(C)(i) AMALGAM OR RESIN. Resin refers to a broad category of materials including but not limited to composites, and glass ionomers. Full labial veneers for cosmetic purposes are not covered.

004.02(C)(i)(1) DOCUMENTATION REQUIREMENTS. Documentation of carious lesions must be present.

004.02(C)(i)(2) MAXIMUM FEE. A maximum fee is covered per tooth for any combination of amalgam or resin restoration procedure codes. The maximum fee is equal to the Medicaid fee for a four or more surface restoration.

004.02(C)(ii) CROWNS. Crowns are covered for anterior and bicuspid teeth when other restoration is not possible. Crowns are covered for molar teeth that have been endodontically treated, and cannot be adequately restored with a stainless steel crown, amalgam, or resin restoration. Crowns are not covered for third molars. A replacement crown for the same tooth in less than 1,825 days, due to failure of the crown, is not covered and is the responsibility of the dentist who originally placed the crown.

004.02(C)(ii)(1) DOCUMENTATION REQUIREMENTS. Submit x-ray of anterior and bicuspids, or x-ray of molar that shows completed root canal. A request should not be submitted for unusual or exceptional situations not covered herein.

004.02(C)(iii) PREFABRICATED STAINLESS STEEL CROWNS. Prefabricated stainless steel crowns are covered for primary and permanent teeth.

004.02(C)(iv) PREFABRICATED STAINLESS STEEL CROWN WITH RESIN WINDOW. Prefabricated stainless steel crown with resin window is covered for primary anterior teeth.

004.02(C)(v) SEDATIVE FILLING. Sedative filling is covered once per tooth every 365 days.

004.02(C)(vi) UNSPECIFIED RESTORATIVE PROCEDURE, BY REPORT. This code is used for procedures that are not adequately described by another code. This code must not be used to claim an item that has an American Dental Association (ADA) code, but is not covered by Medicaid.

004.02(C)(vi)(1) DOCUMENTATION REQUIREMENTS. A description of treatment provided must be submitted with the claim. This service is reviewed prior to payment.

004.02(D) ENDODONTICS.

004.02(D)(i) THERAPEUTIC PULPOTOMY AND PUPAL THERAPY. Medicaid covers therapeutic pulpotomy and pupa therapy for primary teeth only, and is not covered for permanent teeth.

004.02(D)(ii) ROOT CANAL THERAPY AND RE-TREATMENT OF PREVIOUS ROOT CANALS. Root canal therapy and re-treatment are covered for permanent teeth. Root canal treatment includes a treatment plan, necessary appointments, clinical procedures, radiographic images and follow up care. Re-treatment of previous root canals may be covered if at least 365 days have passed since the original treatment, and failure has been demonstrated with x-ray documentation and narrative summary.

004.02(D)(ii)(1) LIMITATIONS. Root canal therapy and re-treatment of previous root canals are not covered for third molars.

004.02(D)(ii)(2) DOCUMENTATION REQUIREMENTS. Post-op x-ray of completed root canal must be available for review by Department upon request.

004.02(D)(iii) APICOECTOMY. Apicoectomy is covered on permanent anterior teeth.

004.02(D)(iv) EMERGENCY TREATMENT TO RELIEVE ENDODONTIC PAIN. Emergency treatment to relieve endodontic pain is covered as unspecified endodontic procedure, by report code. Tooth number must be identified on the claim submission. This is not to be submitted with any other definitive treatment codes on same tooth on same day of service.

004.02(E) PERIODONTICS.

004.02(E)(i) GINGIVECTOMY OR GINGIVOPLASTY. Medicaid covers gingivectomy or gingivoplasty per tooth or per quadrant.

004.02(E)(ii) PERIODONTAL SCALING AND ROOT PLANING. Medicaid covers four quadrants of scaling and root planing once every 365 days. Each quadrant is covered one time per client. The request for approval must be accompanied by the following:

(a) A periodontal treatment plan;

(b) A completed copy of a periodontic probe chart that exhibits pocket depths;

(c) A periodontal history, including home oral care; and

(d) Radiography.

004.02(E)(ii)(1) EXCLUSIONS. For scaling and root planing that requires the use of local anesthesia, Medicaid does not cover more than one half of the mouth in one day, except on hospital cases.

004.02(E)(ii)(2) DOCUMENTATION REQUIREMENTS. A treatment plan that demonstrates that curettage, scaling, or root planning is required in addition to a routine prophylaxis. Providers must submit the following documentation with prior authorization request:

(a) Periapical x-rays demonstrating subgingival calculus and loss of crestal bone; and

(b) Periodontal probe chart evidencing active periodontal disease and pocket depths of 4 millimeters (mm) or greater.

004.02(E)(iii) FULL MOUTH DEBRIDEMENT. Medicaid covers one full mouth debridement procedure every 365 days per client. Not covered on the same date of service as prophylaxis.

004.02(E)(iv) PERIODONTAL MAINTENANCE PROCEDURE. Medicaid covers periodontal maintenance procedure for clients that have had Medicaid approved periodontal scaling and root planing. Prior authorization must be renewed annually.

004.02(E)(iv)(1) DOCUMENTATION REQUIREMENTS. Providers must submit the following documentation with prior authorization request:

(a) Date the Medicaid approved scaling and root planing completed;

(b) Periodontal history; and

(c) Frequency the dental provider is requesting that the client must be seen for maintenance procedure.

004.02(F) PROSTHODONTICS. Coverage of prosthetic appliances includes all materials, fitting, and placement of the prosthesis, and all necessary adjustments for a period of 180 days following placement of the prosthesis. Medicaid covers the following prosthetic appliances, subject to service specific coverage criteria:

(1) Dentures that are immediate, replacement or complete, or interim or complete;

(2) Resin base partial dentures, including metal clasps;

(3) Flipper partials that are considered a permanent replacement of one to three anterior teeth only; and

(4) Cast metal framework with resin denture base partials, covered for clients age 20 and younger.

004.02(F)(i) REPLACEMENT. Medicaid covers a one-time replacement within the five year coverage limit for broken, lost, or stolen appliances. This one-time replacement is available once within each client’s lifetime, and a prior authorization request must be submitted and marked as a one-time replacement request. Replacement of any prosthetic appliance is covered once every five years when:

(1) The client's dental history does not show that previous prosthetic appliances have been unsatisfactory to the client;

(2) The client does not have a history of lost prosthetic appliances;

(3) A repair will not make the existing denture or partial functional;

(4) A reline will not make the existing denture or partial functional; or

(5) A rebase will not make the existing denture or partial functional.

004.02(F)(ii) COMPLETE DENTURES, MAXILLARY AND MANDIBULAR. Complete dentures, maxillary and mandibular, are covered 180 days after placement of interim dentures. Relines, rebases, and adjustments are not billable for 180 days after placement of the prosthesis.

004.02(F)(ii)(1) DOCUMENTATION REQUIREMENTS. Providers must submit the following documentation with prior authorization request:

(a) Date of previous denture placement;

(b) Information on condition of existing denture; and

(c) For initial placements, submit panorex or full mouth series radiographs.

004.02(F)(iii) IMMEDIATE DENTURE, MAXILLARY AND MANDIBULAR. An immediate denture, maxillary and mandibular, is considered a permanent denture. Relines or rebases are not billable for 180 days after placement of the prosthesis.

004.02(F)(iii)(1) DOCUMENTATION REQUIREMENTS. Providers must submit the following documentation with prior authorization request:

(a) Date and list of teeth to be extracted;

(b) Narrative documenting medical necessity; and

(c) Submit panorex or full mouth series radiographs.

004.02(F)(iv) PARTIAL RESIN BASE, MAXILLARY OR MANDIBULAR. Partial resin base, maxillary or mandibular, is covered if the client does not have adequate occlusion. Cast metal clasps are included on partial dentures. One to three missing anterior teeth should be replaced with a flipper partial which is considered a permanent replacement.

004.02(F)(iv)(1) DOCUMENTATION REQUIREMENTS. Providers must submit the following documentation with prior authorization request:

(a) Chart or list of missing teeth and teeth to be extracted;

(b) Age and condition of any existing partial, or a statement identifying the prosthesis as an initial placement;

(c) Narrative documenting how there is not adequate occlusion; and

(d) For initial placements, radiographs of remaining teeth are required.

004.02(F)(v) PARTIAL CAST METAL BASE, MAXILLARY OR MANDIBULAR. Partial cast metal base, maxillary or mandibular is covered for clients age 20 and younger only. More than one posterior tooth must be missing for partial placement. One to three missing anterior teeth should be replaced with a flipper partial which is considered a permanent replacement.

004.02(F)(vi) ADJUSTMENTS TO DENTURES AND PARTIALS. Adjustments to dentures and partials are not covered for 180 days following placement of a new prosthesis. Adjustments after 180 days are billable as needed to make prosthesis wearable.

004.02(F)(vii) REPAIRS TO DENTURES AND PARTIALS. Medicaid covers two repairs per prosthesis every 365 days.

004.02(F)(viii) REBASE OF DENTURES AND PARTIALS. Rebase of dentures and partials are covered following the placement of a new prosthesis after 180 days have passed and, covered once per prosthesis every 365 days. Chair side and lab rebases are covered, but only one can be provided within the 365 day period.

004.02(F)(ix) RELINE OF DENTURES AND PARTIALS. Reline of dentures and partials are covered following the placement of a new prosthesis after 180 days have passed. Covered once per prostheses every 365 days. Chair side and lab relines are covered, but only one can be provided within the 365 day period.

004.02(F)(x) INTERIM COMPLETE DENTURES, MAXILLARY AND MANDIBULAR. Interim dentures can be replaced with a complete denture 180 days after placement of the interim denture. Complete dentures require prior authorization in accordance with this chapter.

004.02(F)(x)(1) DOCUMENTATION REQUIREMENTS. Providers must submit the following documentation with prior authorization request:

(a) Date and list of teeth to be extracted;

(b) Narrative documenting medical necessity; and

(c) Submit panorex or full mouth series radiographs.

004.02(F)(xi) FLIPPER PARTIAL DENTURES, MAXILLARY AND MANDIBULAR. Flipper partial dentures, maxillary and mandibular are considered a permanent replacement for one to three anterior teeth. It is not covered for temporary replacement of missing teeth. Relines, rebases, and adjustments are not billable for 180 days after placement of the prosthesis.

004.02(F)(xi)(1) DOCUMENTATION REQUIREMENTS. Providers must submit the following documentation with prior authorization request:

(a) Chart or list missing teeth and teeth to be extracted;

(b) Age and condition of existing partials, or a statement identifying the prosthesis as an initial placement; and

(c) Radiographs.

004.02(F)(xii) TISSUE CONDITIONING. Covered one time during the first 180 days following placement of a prosthetic appliance. Following the initial 180 days, necessary tissue conditioning may be covered two times per prosthesis every 365 days, with documentation in the dental record.

004.02(G) ORAL AND MAXILLOFACIAL SURGERY.

004.02(G)(i) EXTRACTIONS ROUTINE AND SURGICAL. Medicaid covers necessary extraction of teeth when there is documented medical need for the extraction. The Medicaid fee for extractions includes local anesthesia, suturing if needed, and routine postoperative care.

004.02(G)(i)(1) DOCUMENTATION REQUIREMENTS. Providers must document the medical reason for extractions in the dental chart.

004.02(G)(ii) TOOTH REIMPLANTATION AND STABILIZATION OF AN ACCIDENTALLY AVULSED OR DISPLACED TOOTH OR ALVEOLUS. The Medicaid fee includes splinting and stabilization.

004.02(G)(iii) SURGICAL EXPOSURE OF IMPACTED OR UNERUPTED TOOTH FOR ORTHODONTIC REASONS. The Medicaid fee includes the orthodontic attachment.

004.02(G)(iv) BIOPSY OF ORAL TISSUE, HARD OR SOFT. The Medicaid fee is for the professional component only. The lab must bill the specimen charge.

004.02(G)(v) ALVEOLOPLASTY. The Medicaid fee for extractions includes routine recontouring of the ridge and suturing as necessary. It is not a separate billable procedure.

004.02(G)(v)(1) ALVEOLOPLASTY IN CONJUNCTION WITH EXTRACTIONS. The Medicaid fee covers alveoloplasty in conjunction with extractions, per quadrant as a separate procedure, when it is necessary beyond routine recontouring to prepare the ridge for a prosthetic appliance.

004.02(G)(vi) EXCISIONS. Excision is the surgical removal, act of cutting out, a part or all gingival and or alveolar structure within the oral cavity. The Medicaid fee is for the excision. The lab must bill the specimen charge.

004.02(G)(vii) OCCLUSAL ORTHOTIC DEVICE, BY REPORT. The fee includes any necessary adjustments. For treatment of bruxism or for minor occlusal problems, see occlusal guard in this chapter.

004.02(G)(vii)(1) DOCUMENTATION REQUIREMENTS. Providers must document the type of appliance made, and medical necessity.

004.02(H) ORTHODONTICS. Medicaid covers prior authorized orthodontic treatment for clients who are age 20 or younger, and have a handicapping malocclusion.

004.02(H)(i) COVERAGE CRITERIA FOR DIAGNOSTIC MODELS AND RADIOGRAPHS. Diagnostic records are not covered by Medicaid unless the case will qualify for Medicaid coverage as outlined in this chapter. Diagnostic records for minor malocclusions are not covered by Medicaid. For auditing purposes, Medicaid may request end of treatment diagnostic models and x-rays. Payment for the end of treatment records will be included in the dollar amount prior authorized. The end of treatment records must be submitted to the Department for review.

004.02(H)(ii) FORMS. Medicaid uses the Nebraska Index of Orthodontic Treatment Need (NIOTN) form to determine whether coverage is appropriate based on a handicapping malocclusion. A score of 28 or greater being necessary to qualify for Medicaid coverage of orthodontic treatment. The Nebraska Index of Orthodontic Treatment Need (NIOTN) form must be used to pre-screen orthodontic cases.

004.02(H)(iii) ORTHODONTIC TREATMENT. To be eligible for orthodontic treatment, a client must be age 20 or younger when treatment is authorized, and have a handicapping malocclusion, which includes one or more of the following five documented conditions:

(a) Accident causing a severe malocclusion;

(b) Injury causing a severe malocclusion;

(c) Condition that was present at birth causing a severe malocclusion;

(d) Medical condition causing a severe malocclusion; and

(e) Facial skeletal condition causing a severe malocclusion.

004.02(H)(iii)(1) SURGICAL CORRECTION. When the individual has had a surgical correction of a cleft lip or palate, or orthognathic correction, the monthly adjustment procedure is reimbursed at a higher fee. The pre-treatment request must contain documentation of the client’s medical condition, or surgical correction.

004.02(H)(iii)(2) AUTHORIZATION. Treatment is prior authorized and paid on a single procedure code. The authorized code will be on the Form MC-9D, Dental Authorization and Treatment. In order for Medicaid clients to receive timely treatment, the request for approval will constitute the providers acceptance of the Medicaid fee, and a commitment to complete care.

004.02(H)(iii)(3) DOCUMENTATION REQUIREMENTS. The following documentation must be submitted with the prior authorization request:

(a) A pre-treatment request form that outlines treatment and the Nebraska Index of Orthodontic Treatment Need (NIOTN) form;

(b) Diagnostic records including:

(i) Diagnostic casts and oral or facial photographic images;

(ii) Full mouth radiographs and panoramic x-ray; and

(iii) Cephalometric x-ray;

(c) A narrative description of the diagnosis, and prognosis; and

(d) On surgical cases, include a description of the procedure to be completed. Following completed surgery, a surgical letter of documentation is required accompanying an additional prior authorization request for the added surgical fee.

004.02(H)(iv) INTERCEPTIVE ORTHODONTIC TREATMENT OF TRANSITIONAL DENTITION. The interceptive orthodontic treatment of transitional dentition is covered if it is the cost effective method to lessen the severity of a malformation such that extensive treatment is not required.

004.02(H)(v) REMOVABLE AND FIXED APPLIANCE FOR THUMB SUCKING AND TONGUE THRUST. Removable and fixed appliance for thumb sucking and tongue thrust is covered for clients age 20 and younger, and includes adjustments.

004.02(H)(vi) REPAIR OF ORTHODONTIC APPLIANCES. Repair is covered for clients age 20 and younger.

004.02(H)(vi)(1) DOCUMENTATION REQUIREMENTS. Documentation must include a description of the repair on the dental claim, and in the dental chart.

004.02(H)(vii) ORTHODONTIC RETAINERS, REPLACEMENT. Retainers are covered for clients age 20 and younger if the client is compliant with wearing the appliance.

004.02(H)(viii) REPAIR OF BRACKET AND STANDARD FIXED ORTHODONTIC APPLIANCES. Repair is covered for clients age 20 and younger, when repairs exceed routine repairs associated with orthodontic treatment.

004.02(I) ADJUNCTIVE GENERAL SERVICES.

004.02(I)(i) PALLIATIVE TREATMENT. Palliative treatment is covered once per date of service per location. Palliative treatment on a specific tooth is not covered if definitive treatment was provided on the same tooth for the same date of service.

004.02(I)(i)(1) DOCUMENTATION REQUIREMENTS. Providers must document the palliative treatment provided on or in the dental claim, and in the dental chart.

004.02(I)(ii) GENERAL ANESTHESIA. General anesthesia administered in the provider’s office is covered when it is medically necessary to treat the client. Administration of general anesthesia must be performed in full compliance with Neb. Rev. Stat. §38-101 to §38-1142.

004.02(I)(ii)(1) DOCUMENTATION REQUIREMENTS. Providers must document in the dental chart the medical necessity for the anesthesia. An appropriate sedation record must be maintained, including the names of all drugs administered, including local anesthetics, dosages, and monitored vital signs.

004.02(I)(iii) ANALGESIA, ANXIOLYSIS, AND INHALATION OF NITROUS OXIDE. Analgesia, anxiolysis, and inhalation of nitrous oxide is covered when medically necessary to treat the client.

004.02(I)(iv) INTRAVENOUS SEDATION AND ANALGESIA. Intravenous sedation and analgesia administered in the provider’s office or location is covered when it is medically necessary to treat the client.

004.02(I)(iv)(1) DOCUMENTATION REQUIREMENTS. Providers must document in the dental chart the medical need for the anesthesia. An appropriate sedation record must be maintained, including the names of all drugs administered, including local anesthetics, dosages, and monitored vital signs.

004.02(I)(v) NON-INTRAVENOUS CONSCIOUS SEDATION. Non-intravenous conscious sedation administered in the provider’s office is covered when it is medically necessary to treat the client. The use of oral medications require monitoring.

004.02(I)(v)(1) DOCUMENTATION REQUIREMENTS. Providers must document in the dental chart the medical need for the anesthesia. An appropriate sedation record must be maintained, including the names of all drugs administered, local anesthetics, dosages, and monitored vital signs.

004.02(I)(vi) HOUSE CALL, NURSING FACILITY CALL, HOSPITAL CALL, AND AMBULATORY SURGICAL CENTER (ASC) CALL. House call, nursing facility call, hospital call, and ambulatory surgical center call is covered one per day per facility regardless of the number of patients seen.

004.02(I)(vi)(1) DOCUMENTATION REQUIREMENTS. Providers must document on or in the dental claim the name of the facility, or home address where treatment was provided.

004.02(I)(vii) OFFICE VISIT AFTER REGULARLY SCHEDULED HOURS. Office visit after regularly scheduled hours is covered in addition to an exam and treatment provided, when treatment is provided after normal office hours.

004.02(I)(viii) OCCLUSAL GUARD. Occlusal guard is covered once every 1095 days to minimize the effects of bruxism and other occlusal factors. Occlusal guards are removable appliances. Athletic guards are not covered.

004.02(I)(viii)(1) DOCUMENTATION REQUIREMENTS. Providers must document the medical necessity for the occlusal guard in the dental chart. Documentation should support evidence of significant loss of tooth enamel or tooth chipping, or the medical documentation supports headaches and jaw pain.

004.03 NON-COVERED SERVICES. Medicaid does not cover any service that is:

(A) Cosmetic;

(B) More costly than another, equally effective available service;

(C) Not within the coverage criteria of these regulations;

(D) Determined not medically necessary by the Department; or

(E) Experimental, investigational, or non-Food and Drug Administration (FDA) approved.

005. BILLING AND PAYMENT FOR DENTAL SERVICES .

005.01 BILLING.

005.01(A) GENERAL BILLING REQUIREMENTS. Providers must comply with all applicable billing requirements codified in 471 NAC 3. In the event that billing requirements in 471 NAC 3 conflict with billing requirements outlined in this chapter, the billing requirements in this chapter will govern.

005.01(B) SPECIFIC BILLING REQUIREMENTS.

005.01(B)(i) BILLING INSTRUCTIONS. The provider must bill Medicaid using the procedure codes outlined in the Nebraska Medicaid Dental Fee Schedule and in accordance with the billing instructions. The fees listed on the dental claim must be the dentist’s usual and customary charge for each procedure code.

005.02 PAYMENT.

005.02(A) GENERAL PAYMENT REQUIREMENTS. Medicaid will reimburse the provider for services rendered in accordance with the applicable payment regulations codified in 471 NAC 3. In the event that individual payment regulations in 471 NAC 3 conflict with payment regulations outlined in this chapter, the individual payment regulations in this chapter will govern.

005.02(B) SPECIFIC PAYMENTS REQUIREMENTS.

005.02(B)(i) REIMBURSEMENT. Medicaid pays for covered dental services at the lower of:

(1) The provider's submitted charge; or

(2) The allowable amount for that procedure code in the Nebraska Medicaid Practitioner Fee Schedule in effect for that date of service.

005.02(B)(ii) RESTORATIVE SERVICES RATES. Operative dentistry fee includes local anesthetic, bases, or insulation and other procedures necessary to complete the case. Pins are billed separately.

005.02(B)(iii) PAYMENT FOR INTERCEPTIVE AND COMPREHENSIVE ORTHODONTIC TREATMENT. Payment for authorized orthodontic treatment is made upon approval of the treatment plan and submittal of a dental claim.

005.02(B)(iii)(1) TRANSFER OF INTERCEPTIVE AND COMPREHENSIVE ORTHODONTIC CASES. If the client transfers to another dentist, the dentist who obtained the original authorization and initiated orthodontic treatment, must refund to Medicaid the portion of the amount paid by Medicaid that applies to the treatment not completed. The transfer request must be submitted and reviewed by the Department to determine the amount to be refunded. Transfers are only allowed under hardship circumstances.

005.02(B)(iii)(2) INTERCEPTIVE AND COMPREHENSIVE ORTHODONTIC TREATMENT NOT COMPLETED. If prior authorized orthodontic treatment is not completed, the dentist who obtained the original authorization and initiated the treatment must refund to Medicaid the portion of the amount paid by Medicaid that applies to the treatment not completed. The request to discontinue treatment must be submitted and reviewed by the Department to determine the amount to be refunded.

005.02(B)(iv) AUDIT RECORDS. Medicaid may request end of treatment diagnostic models and x-rays in accordance with this chapter. Payment for the end of treatment records is included in the dollar amount prior authorized.

006. TELEDENTISTRY .

006.01 GENERAL REQUIREMENTS. Teledentistry follows the requirements of telehealth in accordance with 471 NAC 1. Services requiring hands on professional care are excluded.

History

• Effective 2021-06-26

Chapter 7 Durable Medical Equipment, Prosthetics, Orthotics, and Medical Supplies (dmepos)

Neb. Admin. Code tit. 471, ch. 7 Durable Medical Equipment, Prosthetics, Orthotics, and Medical Supplies (dmepos) {#sec-471-nac-7 omnilex-key=us-ne-regs-official--title-471--471 NAC 7}

001. SCOPE AND AUTHORITY . These regulations govern services provided under the Medical Assistance Act, Nebraska Revised Statute (Neb. Rev. Stat.) §§ 68 901 et seq.

002. DEFINITIONS . The following definitions apply.

002.01 APPARENT LIFE-THREATENING EVENT (ALTE). Apparent life threatening events (ALTE) are episodes that are frightening to the observer and characterized by some combination of central or obstructive apnea, color change, marked change in muscle tone, choking, or gagging.

002.02 AUGMENTATIVE COMMUNICATION DEVICES. Augmentative communication devices are any modes of communication other than speech.

002.03 AUTHORIZED DURABLE MEDICAL EQUIPMENT, PROSTHETICS, ORTHOTICS, AND MEDICAL SUPPLIES (DMEPOS) PROVIDER. Providers authorized to prescribe durable medical equipment, prosthetics, orthotics, and medical supplies (DMEPOS) include physicians, nurse practitioners, clinical nurse specialists, or physician assistants.

002.04 BED-CONFINED. The client's condition is such that the client is confined to bed, although not necessarily all of the time.

002.05 CUSTOM FABRICATED. Made for a specific client from his or her individualized measurements.

002.06 CUSTOM FITTED. Substantial adjustments are made to a prefabricated item by a specially trained professional to meet the needs and unique shape of an individual client.

002.07 DURABLE MEDICAL EQUIPMENT. Equipment which:

(A) Withstands repeated use; (B) Is primarily and customarily used to serve a medical purpose; (C) Is not useful to a person in the absence of an illness or injury; and (D) Is appropriate for use in the client's home.

002.08 FACILITY. A nursing facility (NF) regulated by 471 Nebraska Administrative Code (NAC) 12 or intermediate care facility for individuals with developmental disabilities (ICF/DD) regulated by 471 NAC 31.

002.09 MEDICAL SUPPLIES. Expendable or reusable supplies required for care of a medical condition in the client's home. This does not include personal care items or oral or injectable over the counter drugs and medications.

002.10 ORTHOSIS. A type of brace which either prevents or assists movement of a limb or the spine.

002.11 ORTHOTICS. Rigid or semi rigid devices which prevent or correct physical deformity or malfunction, to support a weak or deformed part of the body or eliminate motion.

002.12 PROSTHESES AND PROSTHETICS. An artificial device which replaces a missing body part lost through trauma, disease, or congenital conditions.

002.13 REGISTERED NURSE. A licensed registered nurse in the employment of a durable medical equipment, prosthetics, orthotics, and medical supplies (DMEPOS) provider.

002.14 UTILIZATION MANAGEMENT ORGANIZATION. An organization under contract with the Department to review and approve prior authorization requests.

003. PROVIDER REQUIREMENTS .

003.01 GENERAL PROVIDER REQUIREMENTS. Providers of durable medical equipment, prosthetics, orthotics, and medical supplies (DMEPOS) must comply with all applicable provider participation requirements codified in 471 NAC 2 and 3. In the event that provider participation requirements in 471 NAC 2 or 3 conflict with requirements outlined in this chapter, the individual provider participation requirements in this chapter will govern.

003.02 SERVICE SPECIFIC PROVIDER REQUIREMENTS. To participate in Medicaid, providers must be enrolled as a rental and retail supplier with the appropriate primary specialty type as outlined on the Form MC-19, Service Provider Agreement. Providers must meet any applicable state and federal laws governing the provision of their services.

004. SERVICE REQUIREMENTS .

004.01 GENERAL SERVICE REQUIREMENTS. Medicaid covers medically necessary durable medical equipment, prosthetics, orthotics, and medical supplies (DMEPOS) when prescribed by an authorized durable medical equipment, prosthetics, orthotics, and medical supplies (DMEPOS) provider.

004.01(A) MEDICAL NECESSITY. The provider must obtain written documentation from the prescribing authorized durable medical equipment, prosthetics, orthotics, and medical supplies (DMEPOS) provider which justifies the medical necessity for durable medical equipment, prosthetics, orthotics, and medical supplies (DMEPOS). The original documentation of medical necessity must be kept on file by the provider. In addition to meeting the requirements outlined in 471 NAC 1 the documentation must:

(1) Be signed by the authorized durable medical equipment, prosthetics, orthotics, and medical supplies (DMEPOS) provider’s own hand and dated, using the date the documentation is signed; (2) Specify the start date of the order; (3) Include the authorized durable medical equipment, prosthetics, orthotics, and medical supplies (DMEPOS) provider’s name, address, and telephone number; (4) Include the diagnosis and an estimate of the total length of time the item will be needed; (5) Be sufficiently detailed, including all options or additional features which will be separately billed or will require an upgraded procedure code; (6) Describe the ordered item(s) using either a narrative description or a brand name and model number, including all options or additional features; (7) For supplies, include appropriate information on the quantity used, frequency of change, and duration of need; and (8) Include information substantiating that all Medicaid coverage criteria for the item(s) are met.

004.01(A)(i) MEDICAID CERTIFICATION OF MEDICAL NECESSITY FORMS. Use of the following Medicaid Certification of Medical Necessity (CMN) forms are required:

(1) Form MS 78, Augmentative Communication Device Selection Report; (2) Form MS 79, Wheelchair and Wheelchair Seating System Selection Report; or (3) Form MS 80, Air Fluidized and Low Air Loss Bed Certification of Medical Necessity.

004.01(A)(ii) MEDICARE CERTIFICATION OF MEDICAL NECESSITY FORMS. Use of the following Medicare Certification of Medical Necessity (CMN) form is required: Medicare Attending Physician's Certificate of Medical Necessity for Home Oxygen form.

004.01(A)(iii) RECERTIFICATION OF MEDICAL NECESSITY. Documentation of medical necessity must be updated annually or when the authorized durable medical equipment, prosthetics, orthotics, and medical supplies (DMEPOS) provider’s estimated quantity, frequency, or duration of the client's need has expired, whichever occurs first.

004.01(B) PRIOR AUTHORIZATION REQUIREMENTS. Prior authorization is required for coverage of the following items:

(1) Augmentative communication devices with related equipment and software; (2) Spinal orthosis seating systems and back modules incorporated in or attached to a wheelchair base; (3) Transcutaneous electrical nerve stimulators (TENS); (4) Ultraviolet light therapy systems; (5) All wheelchairs and wheelchair accessories, options, and components; (6) Whirlpools; and (7) Not otherwise classified (NOC) durable medical equipment, prosthetics, orthotics, and medical supplies (DMEPOS).

004.01(B)(i) REQUESTS FOR PRIOR AUTHORIZATION. The provider will electronically submit requests for prior authorization to the Department or the appropriate utilization management organization using the standard electronic transaction or by completing and submitting Form MS 77, Request for Prior Authorization, according to the form instructions. Documentation supporting the medical necessity of the durable medical equipment, prosthetics, orthotics, and medical supplies (DMEPOS) must be submitted with each prior authorization request. The provider will receive notification from the utilization management organization on the status of the request. A copy of this document should be submitted with the payment request.

004.01(B)(ii) PRIOR AUTHORIZATION LIMITATIONS. Approved prior authorizations are valid only when:

(1) The prior authorization is requested before the services are provided; (2) The client is Medicaid eligible at the time services are provided; (3) The provider is enrolled as a Medicaid provider in accordance with this chapter at the time the services are provided; (4) The Managed Care Organization (MCO) or the Department has approved the prior authorization; and (5) For the initial order of durable medical equipment, prosthetics, orthotics, and medical supplies (DMEPOS), a face-to-face encounter must occur within six months before or 30 days after the durable medical equipment, prosthetics, orthotics, and medical supplies (DMEPOS) order is written. The encounter must be documented and the document maintained by the authorized durable medical equipment, prosthetics, orthotics, and medical supplies (DMEPOS) provider.

004.01(C) SUPPLIES AND ACCESSORIES. Purchase or rental of durable medical equipment, prosthetics, orthotics, and medical supplies (DMEPOS) includes all items, supplies, and accessories necessary for proper and effective use of the durable medical equipment, prosthetics, orthotics, and medical supplies (DMEPOS). Additional items, supplies, and accessories are only provided for client owned durable medical equipment, prosthetics, orthotics, and medical supplies (DMEPOS).

004.01(C)(i) MAXIMUM QUANTITY FOR SUPPLIES. The maximum allowable quantity of supplies that may be dispensed is limited to a three month supply, unless otherwise specified in this chapter or in the Nebraska Medicaid Practitioner Fee Schedule.

004.01(D) MULTIPLE OR DUPLICATE ITEMS. Medicaid does not cover purchase, rental or repair of multiple durable medical equipment, prosthetics, orthotics, and medical supplies (DMEPOS) used for the same or similar purposes. Medicaid does not cover back up equipment. Back up equipment may be supplied by the provider, but the provider may not bill Medicaid.

004.01(E) REPLACEMENT. Replacement of Medicaid covered durable medical equipment, prosthetics, orthotics, and medical supplies (DMEPOS) items owned by the client is covered if needed due to change in the client's medical condition, wear, loss, or irreparable damage.

004.01(F) REPAIR. Medicaid covers repairs required for the effective use of Medicaid covered durable medical equipment, prosthetics, orthotics, and medical supplies (DMEPOS) when the item is owned by the client and the client meets the coverage criteria for the item. Repairs must meet the following requirements:

(1) The cost must not exceed 80 percent of the Medicaid allowable purchase price for the item; (2) All manufacturers and provider warranties must be pursued; and (3) The provider must indicate if the item is owned by the client.

004.01(F)(i) EXCEPTION. Damage to durable medical equipment, prosthetics, orthotics, and medical supplies (DMEPOS) items, due to misuse by the client or caregivers, will require a prior authorization request be submitted to either the Managed Care Organization (MCO) or the Department before repair work begins.

004.01(F)(ii) RENTAL DURING REPAIR. Medicaid covers rental of covered durable medical equipment, prosthetics, orthotics, and medical supplies (DMEPOS) for a maximum of three months during which time the client owned equipment is being repaired. If the provider's usual business practice is to provide loaner equipment at no charge, the provider will not bill Medicaid for rental during that period.

004.01(G) SUPPLIES AND ACCESSORIES FOR DURABLE MEDICAL EQUIPMENT, PROSTHETICS, ORTHOTICS, AND MEDICAL SUPPLIES (DMEPOS). Items required for the proper functioning and effective use of Medicaid eligible durable medical equipment, prosthetics, orthotics, and medical supplies (DMEPOS) are covered. Supplies and accessories for rented Medicaid durable medical equipment, prosthetics, orthotics, and medical supplies (DMEPOS) are included in the Medicaid allowable payment unless stated.

004.01(H) RENTAL. Items with a purchase price under one hundred fifty ($150) may be purchased rather than rented, unless the authorized durable medical equipment, prosthetics, orthotics, and medical supplies (DMEPOS) provider’s estimated duration of need is less than six months. Items with a purchase price of one hundred fifty ($150) or greater must be rented, unless the authorized durable medical equipment, prosthetics, orthotics, and medical supplies (DMEPOS) provider’s estimated duration of need is 12 months or greater. The Department is not responsible for lost, stolen, or damaged rental items.

004.01(H)(i) RENTAL OPTION TO PURCHASE. All rentals must provide an option to purchase the durable medical equipment, prosthetics, orthotics, and medical supplies (DMEPOS) item, and meet the following criteria:

(1) Providers will cease submitting payment requests for rental items when the Medicaid allowable is reached or after 12 monthly rental payments, whichever comes first; (2) When converting a rental item to purchase before 12 months of rental, all rental monies paid to the provider will be applied to the Medicaid allowable purchase price; and (3) When the conversion to purchase is completed, the item becomes the property of the client.

004.01(H)(ii) EXCEPTIONS. The following items remain the property of the provider, and may be rented on a monthly basis:

(1) Oxygen delivery equipment; (2) Ventilators; (3) Air fluidized bed units; (4) Apnea monitors; (5) Compressors, including air power sources for equipment which is not self-contained or cylinder driven; (6) Low air loss bed units; and (7) Oximeters.

004.01(I) USED EQUIPMENT. The durable medical equipment, prosthetics, orthotics, and medical supplies (DMEPOS) provider must ensure that used durable medical equipment, prosthetics, orthotics, and medical supplies (DMEPOS) items meet the same standard of quality as new durable medical equipment, prosthetics, orthotics, and medical supplies (DMEPOS) items, and must provide comparable warranty, servicing and return policies as those which are available with new durable medical equipment, prosthetics, orthotics, and medical supplies (DMEPOS).

004.01(J) SERVICES PROVIDED FOR CLIENTS ENROLLED IN NEBRASKA MEDICAID MANAGED CARE. See 471 NAC 1.

004.01(K) HEALTH CHECK SERVICES. See 471 NAC 33.

004.01(L) DOCUMENTATION REQUIREMENTS. In addition to all other documentation requirements outlined in this chapter, the provider must:

(i) Maintain documentation which substantiates all conditions for coverage are met; and (ii) Maintain documentation that states the client or caregiver is capable of being trained to use the particular device prescribed in an appropriate manner.

004.02 COVERED SERVICES.

004.02(A) COVERED SERVICES FOR CLIENTS RESIDING IN NURSING FACILITY (NF) OR INTERMEDIATE CARE FACILITY FOR INDIVIDUALS WITH DEVELOPMENTAL DISABILITIES (ICF/DD). Medicaid will reimburse durable medical equipment, prosthetics, orthotics, and medical supplies (DMEPOS) providers directly for the following items for clients residing in nursing facility (NF) or intermediate care facility for individuals with developmental disabilities (ICF/DD):

(1) Orthotics, including lower and upper limb, foot, and spinal, as defined in this chapter; (2) Prosthetics, including breast, eye, and lower and upper limb, as defined in this chapter; and (3) All other items, necessary for the care of clients residing in nursing facility (NF) or intermediate care facility for individuals with developmental disabilities (ICF/DD), are included in payments to the facility and cannot be billed directly by a durable medical equipment, prosthetics, orthotics, and medical supplies (DMEPOS) provider.

004.02(A)(i) COVERED SERVICES REIMBURSED DIRECTLY TO NURSING FACILITES (NF) OR INTERMEDIATE CARE FACILITY FOR INDIVIDUALS WITH DEVELOPMENTAL DISABILITIES (ICF/DD). The following items will be reimbursed directly to the nursing facility (NF) or intermediate care facility for individuals with developmental disabilities (ICF/DD):

(1) Air fluidized beds; (2) Non-standard wheelchairs; (3) Wheelchair accessories, options, and components; (4) Power operated vehicles; and (5) Negative pressure wound therapy.

004.02(A)(ii) TRANSFER OR DISCHARGE. At the time of the client's transfer or discharge, the following items specifically purchased for and used by the client will be transferred with the client:

(1) Any non-standard wheelchair and wheelchair accessories, options, and components; (2) Augmentative communication devices with related equipment and software; (3) Supports; and (4) Custom fitted or custom fabricated items.

004.02(B) SERVICES PROVIDED TO HOSPITAL PATIENTS. Medicaid covers durable medical equipment, prosthetics, orthotics, and medical supplies (DMEPOS), including fittings, provided to hospital patients, as defined in 471 NAC 10. Payment is not made separately to the durable medical equipment, prosthetics, orthotics, and medical supplies (DMEPOS) provider. In the event a customized wheelchair for primary use in other than the hospital setting is needed for training purposes while the client is a hospital inpatient, the non hospital supplier or provider may deliver the wheelchair to the client during the inpatient stay and bill Medicaid. This exception does not apply to other items provided for use in the hospital setting.

004.02(C) AIR FLUIDIZED AND LOW AIR LOSS BED UNITS. Air fluidized and low air loss bed units are covered on a rental basis for active healing and treatment to assure progressive and consistent wound healing occurs.

004.02(C)(i) DOCUMENTATION PRIOR TO PLACEMENT. The following conditions must be met and documented prior to placement of an air fluidized or low air loss bed unit:

(1) Comprehensive client assessment and evaluation by the authorized durable medical equipment, prosthetics, orthotics, and medical supplies (DMEPOS) provider has occurred; (2) Treatment has been tried without success; (3) Caregiver training on use of the bed by a registered nurse employed by the provider has occurred; and (4) Initial dietary consult has occurred, which includes recommended caloric intake and serum albumin level at or near the time of placement.

004.02(C)(ii) DOCUMENTATION DURING USAGE. The following conditions must be met and documented during use of air fluidized or low air loss bed units:

(1) A trained adult caregiver is available to assist the client with activities of daily living, fluid balance, skin care, repositioning, recognition, and management of altered mental status, dietary needs, prescribed treatments and management and support of the bed; (2) Wound healing must begin within 14 days of placement on the bed unit. If progressive, consistent wound healing ceases during use of the bed, a new wound healing care plan must be reestablished within 14 days; (3) The client must remain on the bed unit at all times except for a maximum of one hour per day and when receiving medical treatment; (4) On-site client evaluation and wound care consultation by a registered nurse occurs weekly; (5) Changes in the client's status, treatment, and diet is monitored and documented; and (6) A written plan of care must be established within four weeks of placement of the bed unit. The plan of care must address skin care, pressure reducing devices and protocol, and dietary needs after use of bed unit has been discontinued.

004.02(C)(iii) ADDITIONAL DOCUMENTATION REQUIREMENTS. Form MS 80, Air Fluidized and Low Air Loss Bed Certification of Medical Necessity, must be completed on a monthly basis by a registered nurse, signed by the authorized durable medical equipment, prosthetics, orthotics, and medical supplies (DMEPOS) provider and kept on file with the provider and submitted to the health plans upon request.

004.02(D) APNEA MONITORS. Apnea monitors are covered on a rental basis for infants up to one year of age who meet at least one of the following criteria:

(1) Infants with one or more apparent life-threatening events (ALTEs) requiring mouth to mouth resuscitation or vigorous stimulation; (2) Symptomatic preterm infants; (3) Siblings of one or more sudden infant death syndrome (SIDS) victims; or (4) Infants with certain diseases or conditions, such as central hyperventilation, bronchopulmonary dysplasia, infants with tracheostomies, infants with substance abusing mothers, or infants with less severe apparent life-threating events (ALTEs).

004.02(D)(i) ADDITIONAL CRITERIA. Criteria for discontinuing apnea monitoring must be based on the infant's clinical condition. A monitor may be discontinued when apparent life-threating event (ALTE) infants have had two to three months free of significant alarms or apnea requiring vigorous stimulation or resuscitation. Pneumocardiograms are covered for diagnostic or evaluation purposes and when required to determine when the infant may be removed from the monitor. Payment does not include analysis and interpretation.

004.02(D)(ii) COVERAGE CONDITIONS. The following conditions must be met prior to initiation of home apnea monitoring:

(1) History and physical assessment by the infant's authorized durable medical equipment, prosthetics, orthotics, and medical supplies (DMEPOS) provider; and (2) Parent or caregiver have successfully completed training on use of the equipment and any other authorized durable medical equipment, prosthetics, orthotics, and medical supplies (DMEPOS) provider recommended training.

004.02(D)(iii) DOCUMENTATION REQUIREMENTS. Apnea monitor rental exceeding two months requires an authorized durable medical equipment, prosthetics, orthotics, and medical supplies (DMEPOS) provider’s narrative report of client progress to be kept on file with the provider. A progress report is required every two months, and must include:

(1) The number of apnea episodes during the previous two month period of use; (2) Tests and results of tests performed during the previous two month period of use; (3) Estimated additional length of time the monitor will be needed; and (4) Any additional pertinent information the authorized durable medical equipment, prosthetics, orthotics, and medical supplies (DMEPOS) provider may wish to provide.

004.02(E) BATH AND TOILET AIDS. Bathtub patient lifts and rehabilitation shower chairs are covered for clients with severe conditions who, without use of the equipment, would be unable to bathe or shower. The client must be unable to use a stationary tub stool or bench, rails, or similar equipment. Covered bath and toilet aids include the following durable medical equipment, prosthetics, orthotics, and medical supplies (DMEPOS):

(i) Bath and toilet rails; (ii) Raised toilet seats; (iii) Tub stools and benches; (iv) Transfer tub benches and attachments; and (v) Bath support chairs.

004.02(F) BED SIDE RAILS. Bed side rails are covered for clients who are at risk for injury due to one of the following conditions:

(i) Disorientation; (ii) Vertigo; or (iii) A neurological disorder resulting in convulsive seizures.

004.02(G) BED WEDGES. Bed wedges are covered for clients that require the head of the bed to be elevated more than 30 degrees due to congestive heart failure, chronic pulmonary disease, or problems with aspiration. Standard bed pillows must have been tried and failed.

004.02(H) BEDPANS AND URINALS. Bedpans and urinals are covered for clients who are determined by their authorized durable medical equipment, prosthetics, orthotics, and medical supplies (DMEPOS) provider to be bed confined.

004.02(I) BLOOD GLUCOSE MONITORS. Blood glucose monitors are covered for clients with insulin-treated diabetes, non-insulin-treated diabetes, and gestational diabetes.

004.02(I)(i) DOCUMENTATION REQUIRMENTS. The authorized durable medical equipment, prosthetics, orthotics, and medical supplies (DMEPOS) provider must retain documentation stating the client or caregiver is capable of being trained to use the particular device prescribed in an appropriate manner.

004.02(I)(ii) ADDITIONAL FEATURES. Medicaid covers blood glucose monitors with additional features such as:

(a) Voice synthesizers; (b) Automatic timers; and (c) Specially designed arrangements of supplies and materials to enable clients with visual impairments to use the equipment without assistance.

004.02(I)(ii)(1) DOCUMENTATION REQUIREMENTS. An authorized durable medical equipment, prosthetics, orthotics, and medical supplies (DMEPOS) provider must certify the client has a visual impairment and requires use of a blood glucose monitor with additional features. The certification must identify the additional features are necessary.

004.02(J) BLOOD PRESSURE MONITORS. Blood pressure monitors are covered for clients with a hypertension diagnosis that must be self monitored at home. An electronic blood pressure monitor is covered only if the client is unable to use a standard cuff and stethoscope due to medical conditions.

004.02(J)(i) ACCESSORIES. Accessories are covered only as replacement for use with client owned monitors for clients whose condition meets the criteria for coverage of the monitor.

004.02(J)(ii) DOCUMENTATION REQUIREMENTS. The documentation must specify the cuff size, that the authorized durable medical equipment, prosthetics, orthotics, and medical supplies (DMEPOS) provider will be monitoring its use in connection with the client's continuing course of treatment, and that the client or caregiver will be instructed in use of the equipment by the authorized durable medical equipment, prosthetics, orthotics, and medical supplies (DMEPOS) provider, their office staff, or other qualified health professional.

004.02(K) EXTERNAL BREAST PROSTHESES AND SUPPLIES. Breast prostheses and supplies are covered for clients who have had a mastectomy.

004.02(L) BREAST PUMPS. Breast pumps are covered for clients who are breast feeding if one or more of the following conditions are met for either short term or long term rental. Hospital grade breast pumps are covered only on a rental basis.

004.02(L)(i) SHORT TERM RENTAL. Short term rental of breast pumps for up to two months is covered in the following instances:

(1) Infant or neonate with abnormal weight loss; (2) Hyperbilirubinemia; (3) Inadequate milk supply; (4) Mastitis; (5) Acutely ill infant; (6) Infant food allergy; (7) Medical condition of mother that precludes feeding infant at breast; or (8) Maternal post-partum complications.

004.02(L)(ii) LONG TERM RENTAL. Long term rental of breast pumps is covered for up to six months, with one additional six month period in the following instances:

(1) Congenital abnormality of the infant that impedes the infant’s ability to suck or swallow; (2) Neurologic abnormality of the infant; (3) Prematurity; or (4) Latch difficulties.

004.02(M) CANES AND CRUTCHES. Canes and crutches are covered for clients with conditions that impair ambulation.

004.02(N) CAR SEATS. Car seats are covered for clients age 20 and younger with physical disabilities when required for positioning during transportation when standard seat belts and car seats are not appropriate.

004.02(O) COMMODES. Commodes are covered for clients who are confined to bed, to a room or to a home without accessible bathroom facilities. A commode chair with detachable arms is covered when medically necessary.

004.02(P) COMMUNICATION DEVICES, AUGMENTATIVE. Communication devices are covered for clients who are unable to use natural oral speech as a primary means of communication. Non portable devices may be covered only if required for visual enhancement or accommodated by a portable device. The specific device recommended and all accessories required for use of the device must be identified and medically necessary. Communication boards, dedicated speech-generating devices, and related accessories are durable medical equipment (DME). Artificial larynx, voice amplification, and related devices are prostheses.

004.02(P)(i) EVALUATION. A licensed speech-language pathologist must evaluate the client’s communication needs. The evaluation must identify the client’s:

(1) Medical diagnosis: (2) Speech-language diagnosis; (3) Physical status; (4) Communication abilities; (5) Vision and hearing acuity; and (6) Other skills required for use of the specific device selected.

004.02(P)(ii) DOCUMENTATION REQUIREMENTS. Form MS-78, Augmentative Communication Device Selection Report, must be completed and signed by the evaluating speech language pathologist and the authorized durable medical equipment, prosthetics, orthotics, and medical supplies (DMEPOS) provider. Form MS 78 is submitted with the request for prior authorization. Documentation from the speech-language pathologist must show that the device meets the client’s communication needs, the client has the ability to use the device and the device meets the functional communication goals established by the speech-language pathologist.

004.02(P)(ii)(1) TRIAL PERIOD. The provider must maintain documentation showing the results of the selected device during a trial period lasting a minimum of one month.

004.02(Q) CONTINUOUS GLUCOSE MONITORS (CGM). Continuous glucose monitors (CGM) are covered for eligible beneficiaries who have Diabetes mellitus, use multiple daily doses of insulin or are on an insulin pump, are being assessed at least every six months by the healthcare practitioner for this condition, and for whom the treatment is medically indicated and appropriate. The continuous glucose monitor (CGM) is used for diagnostic and therapeutic purposes when medically necessary. The initial authorization period for the therapeutic continuous glucose monitor (CGM) is six months and the renewal authorization period is 12 months. For therapeutic continuous glucose monitors (CGM), beneficiaries must be able to hear and view the continuous glucose monitor (CGM) alerts and respond accordingly or have a caregiver who is able to do so.

004.02(R) CONTINUOUS PASSIVE MOTION. Continuous passive motion devices are covered for clients who have received a total knee replacement. Coverage is limited to the first three weeks following surgery.

004.02(R)(i) DOCUMENTATION. The provider must retain documentation showing the device was provided to the client within two days following surgery.

004.02(S) CONTINUOUS POSITIVE AIRWAY PRESSURE SYSTEMS (CPAP). Continuous positive airway pressure systems (CPAP) are covered for clients with moderate or severe obstructive sleep apnea for whom surgery is a likely alternative to continuous positive airway pressure systems (CPAP). Intermittent assist devices with a continuous positive airway pressure systems (CPAP) are covered for clients who, after trial use with continuous positive airway pressure systems (CPAP), cannot tolerate use of continuous positive airway pressure systems (CPAP) without the intermittent assist devices. Humidifiers for use with continuous airway pressure systems (CPAP) are covered for clients who require supplemental humidification with continuous airway pressure systems (CPAP).

004.02(S)(i) DOCUMENTATION REQUIREMENTS. The provider must maintain documentation showing authorized durable medical equipment, prosthetics, orthotics, and medical supplies (DMEPOS) provider approval of intermittent assist devices and humidifiers.

004.02(T) DRESSINGS. Dressings are covered for clients that require treatment of a wound or surgical incision.

004.02(U) ELECTROMYOGRAPHY BIODFEEDBACK DEVICES. Electromyography biofeedback devices are covered for muscle re education of specific muscle groups or for treating pathological muscle spasm, or weakness.

004.02(V) ENTERAL AND PARENTERAL NUTRITION, AND NUTRITIONAL SUPPLEMENTS. Enteral nutritional supplements are covered for clients with normal gastrointestinal absorptive capacity who, due to permanent or temporary non-function or disease of the structures which normally permit food to reach the small bowel and requires tube feeding to provide sufficient nutrients.

004.02(V)(i) PARENTERAL NUTRITION. Parenteral nutritional supplements are covered for clients with disease of the gastrointestinal tract which prevents absorption of sufficient nutrients. No more than one month supply of parenteral nutrients, equipment, or supplies may be provided in advance.

004.02(V)(ii) NUTRITIONAL SUPPLEMENTS. Nutritional supplements are covered for clients who require nutritional supplementation to maintain weight and strength commensurate with the client's general condition.

004.02(V)(iii) CLIENTS ELIGIBLE FOR SUPPLEMENTAL FEEDING AND NUTRITION PROGRAM. Clients eligible for Supplemental Feeding and Nutrition Program for Women, Infants, and Children (WIC), enteral nutrients are covered if the product is not covered by Women, Infants, and Children (WIC) or to the extent the quantity required exceed the maximum quantity provided by Women, Infants, and Children (WIC).

004.02(V)(iv) DOCUMENTATION REQUIREMENTS. Authorized durable medical equipment, prosthetics, orthotics, and medical supplies (DMEPOS) provider approval must be documented for:

(1) Use of a pump; and (2) Clients age 20 and younger with special delivery needs.

004.02(W) EYE PROSTHESES. Eye prostheses are covered for clients with absence or shrinkage of an eye due to birth defect, trauma, or surgical removal.

004.02(X) FAMILY PLANNING SUPPLIES. Prescribed family planning supplies are covered when medically necessary and required to prevent or delay pregnancy.

004.02(Y) FOOT ORTHOSES. Foot orthoses are covered when required to support a weak or deformed foot or leg, or to restrict or eliminate motion in a foot or leg. Coverage of orthopedic shoes is limited to one pair in a one-year period, except when documentation indicates excessive wear or size change is necessary due to growth.

004.02(Z) HEARING AID BATTERIES. Hearing aid batteries are covered for clients who use hearing aids.

004.02(AA) HEAT AND COLD APPLICATION DEVICES. Heat and cold application devices are covered for clients with medical conditions requiring heat or cold therapy.

004.02(BB) HOSPITAL BEDS. Fixed height, variable height, and semi-electric hospital beds are covered for clients who:

(1) Require positioning of the body due to a medical condition or pain which is expected to last at least one month; (2) Require the head of the bed to be elevated most of the time, due to a medical condition; (3) Require equipment which can only be attached to a hospital bed; (4) Require a bed height different from the height provided by a fixed height bed in order to permit transfer to a chair, wheelchair, or standing position; or (5) Require frequent changes in body position.

004.02(BB)(i) SUPPLIES AND ACCESSORIES. Medicaid covers supplies and accessories including:

(1) An innerspring or foam rubber mattress; (2) Side rails; (3) Trapeze bar; and (4) Bed cradle.

004.02(CC) IMPOTENCE TREATMENT DEVICES. Impotence treatment devices are covered for clients with organic impotence and without conditions that contraindicate use of the device.

004.02(DD) INCONTINENCE APPLIANCES AND CARE SUPPLIES. Incontinence appliances and care supplies are covered for clients without control over bladder or bowel function. Incontinence diapers or briefs and liners are not covered for clients under age three.

004.02(EE) INSULIN INFUSION PUMPS, EXTERNAL. External continuous subcutaneous insulin infusion (CSII) pumps are covered for clients with conditions which require administration of parenteral medication when reasonable and necessary.

004.02(EE)(i) DOCUMENTATION REQUIREMENTS. The provider will obtain written documentation from the prescribing authorized durable medical equipment, prosthetics, orthotics, and medical supplies (DMEPOS) provider which includes at minimum, the following:

(1) Diabetes team evaluation summary, which addresses:

(a) Diagnosis; (b) Complications and compounding issues; (c) Failure of adequate blood glucose control in spite of demonstrated compliance with multiple daily injections; (d) Hemoglobin (Hgb) A1c levels; and (e) Patient's ability and motivation to use the pump; and

(2) Treatment plan, which includes:

(a) Inpatient initiation of continuous subcutaneous insulin infusion (CSII) pump or rationale for outpatient initiation with all policies and procedures involved; (b) Client and family diabetes education plan; and (c) Monitoring plan post-initiation of continuous subcutaneous insulin infusion (CSII) pump.

004.02(FF) INTERMITTENT POSITIVE PRESSURE BREATHING (IPPB) MACHINES. Intermittent positive pressure breathing (IPPB) machines are covered for clients who require respiratory therapy treatment for hypoventilation.

004.02(GG) PATIENT LIFTS. Patient lifts are covered for clients when assistance is required for transfers in the residence.

004.02(GG)(i) DOCUMENTATION REQUIREMENTS. Documentation must verify:

(1) The home can accommodate the lift; (2) The caregiver is able and willing to use the equipment; and (3) The client can tolerate using the equipment.

004.02(HH) LOWER AND UPPER LIMB ORTHOSES. Lower and upper limb orthoses are covered when required to support a weak or deformed arm or segments of the lower or upper limb.

004.02(II) LOWER AND UPPER LIMB PROSTHESES. Medicaid covers lower and upper limb prostheses for clients to replace a missing body part.

004.02(JJ) MEDICAL AND SURGICAL SUPPLIES. Medical and surgical supplies are covered for clients who require home treatment of a specific medical condition, protection or support of a wound, surgical incision, or diseased or injured body part.

004.02(KK) NEBULIZERS AND COMPRESSORS. Medicaid provides coverage of nebulizers and compressors in the following situations:

(1) When the client's ability to breathe is severely impaired; (2) To administer aerosol therapy when a metered dose inhaler is not adequate or appropriate; (3) When required for use in connection with durable medical equipment, prosthetics, orthotics, and medical supplies (DMEPOS) for purposes of moisturizing oxygen; or (4) For clients who require heated nebulizers with tracheostomies.

004.02(KK)(i) DOCUMENTATIOIN REQUIREMENTS. Authorized durable medical equipment, prosthetics, orthotics, and medical supplies (DMEPOS) provider approval must be documented for portable compressors with internal battery features and ultrasonic nebulizers when other means of nebulization is ineffective.

004.02(LL) NEUROMUSCULAR ELECTRICAL STIMULATORS (NMES). Neuromuscular electrical stimulators (NMES) are covered for treatment of disuse atrophy where nerve supply to the muscle is intact, including brain, spinal cord and peripheral nerves, and other non neurological reasons for disuse are causing atrophy.

004.02(LL)(i) SUPPLIES AND ACCESSORIES. Supplies and accessories for rented neuromuscular electrical stimulators (NMES) units, the lead wires, and supplies must be billed on the same claim as the neuromuscular electrical stimulators (NMES) rental.

004.02(LL)(ii) DOCUMENTATION REQUIREMENTS. Authorized durable medical equipment, prosthetics, orthotics, and medical supplies (DMEPOS) provider approval must be documented for a conductive garment.

004.02(MM) OSTEOGENIC STIMULATORS. Osteogenic stimulators are covered for clients with at least one of the following indications:

(i) Non-union of long bone fractures lasting six or more months; (ii) Failed fusion lasting six or more months without healing of the fusion; and (iii) Congenital pseudo arthrosis.

004.02(NN) OSTOMY SUPPLIES. Ostomy supplies are covered for clients with an ostomy.

004.02(NN)(i) DOCUMENTATION REQUIREMENTS. Authorized durable medical equipment, prosthetics, orthotics, and medical supplies (DMEPOS) provider approval must be documented for skin moisturizers, protectants, and sealants for clients with ostomies.

004.02(OO) OXIMETERS, EAR, AND PULSE. Oximeters are covered on a rental basis for clients who require a minimum of daily monitoring of arterial blood oxygen saturation levels for evaluation and regulation of home oxygen therapy. Coverage for other indications will be determined on a case-by-case basis.

004.02(OO)(i) DOCUMENTATION REQUIREMENTS. A monthly updated certification of medical necessity is required when the oximeter is required for evaluation and regulation of home oxygen therapy. The documentation submitted by the authorized durable medical equipment, prosthetics, orthotics, and medical supplies (DMEPOS) provider must specify the client’s medical condition which substantiates the need for in-home use of oximeter, estimated length of need for monitoring and frequency of monitoring required.

004.02(PP) OXYGEN AND OXYGEN EQUIPMENT. Portable oxygen systems alone or to complement a stationary oxygen system will be covered if the client is mobile within the residence. Oxygen and oxygen equipment are covered for clients with significant hypoxemia in the chronic stable state, when the following conditions are met:

(1) The authorized durable medical equipment, prosthetics, orthotics, and medical supplies (DMEPOS) provider has determined that the client suffers severe lung disease or hypoxia related symptoms that might be expected to improve with oxygen therapy; (2) The client's blood gas levels indicate the need for oxygen therapy; and (3) The client has appropriately tried other alternative treatment measures without complete success.

004.02(PP)(i) STATIONARY AND PORTABLE SYSTEM RENTAL. When both a stationary and portable system is being rented, the Medicaid allowable for all contents is included in the Medicaid allowable for the stationary system. Stationary contents are covered only when the client owns the gaseous or liquid stationary system. Portable contents are covered only when the client uses a portable system only.

004.02(PP)(ii) OXYGEN THERAPY. Oxygen therapy is covered for clients with significant hypoxemia evidenced by the following:

(1) An arterial partial pressure of oxygen (PO2) at or below 55 millimeters of mercury (mm Hg), or an arterial oxygen saturation at or below 88 percent, taken:

(a) At rest; (b) During sleep for a client who demonstrates an arterial partial pressure of oxygen (PO2) at or above 56 millimeters of mercury (mm Hg);

(i) An arterial oxygen saturation at or above 89 percent, while awake; or (ii) A greater than normal fall in oxygen level during sleep:

(1) A decrease in arterial partial pressure of oxygen (PO2) more than 10 millimeter of mercury (mm Hg); or (2) A decrease in arterial oxygen saturation more than five percent associated with symptoms or signs reasonably attributable to hypoxemia. In either of these cases, coverage is provided only for nocturnal use of oxygen; or

(c) During exercise:

(i) For a client who demonstrates an arterial partial pressure of oxygen (PO2) at or above 56 millimeters of mercury (mm Hg); or (ii) An arterial oxygen saturation at or above 89 percent, during the day while at rest. In this case, supplemental oxygen is provided for during exercise if it is documented that the use of oxygen improves the hypoxemia which was demonstrated during exercise when the client was breathing without assistance; or

(2) An arterial partial pressure of oxygen (PO2) of 56 to 59 millimeter of mercury (mm Hg); or an arterial blood oxygen saturation of 89 percent if any of the following are documented:

(a) Dependent edema suggesting congestive heart failure; (b) Pulmonary hypertension or cor pulmonale, determined by measurement of pulmonary artery pressure, gated blood pool scan, echocardiogram, "P" pulmonale of electrocardiogram; or (c) Erythrocythemia with a hematocrit greater than 56 percent.

004.02(PP)(iii) DOCUMENTATION REQUIREMENTS. The authorized durable medical equipment, prosthetics, orthotics, and medical supplies (DMEPOS) provider must provide documentation that shows the conditions outlined in this chapter have been met. Documentation for oxygen therapy must include:

(a) The results of a blood gas study that has been ordered and evaluated by the authorized durable medical equipment, prosthetics, orthotics, and medical supplies (DMEPOS) provider; or (b) A measurement of pulse arterial oxygen saturation when ordered and evaluated by the authorized durable medical equipment, prosthetics, orthotics, and medical supplies (DMEPOS) provider and performed under his or her supervision or when performed by a qualified provider or supplier of laboratory services.

004.02(PP)(iii)(1) ADDITIONAL DOCUMENTATION REQUIREMENTS. A durable medical equipment, prosthetics, orthotics, and medical supplies (DMEPOS) supplier is not considered a qualified provider or supplier of laboratory services for purposes of these guidelines. When a client's initial certification for oxygen is approved based on an arterial partial pressure of oxygen (PO2) of 56 millimeter of mercury (mm Hg) or greater or an oxygen saturation of 89 percent or greater, retesting between the 61st and 90th day of home oxygen therapy is required in order to establish continued medical necessity.

004.02(QQ) PACEMAKER MONITORS, SELF-CONTAINED. Pacemaker monitors are covered for clients with cardiac pacemakers.

004.02(RR) PARAFFIN BATH UNITS, PORTABLE. Paraffin bath units are covered for clients who have undergone a successful trial period of paraffin therapy.

004.02(RR)(i) DOCUMENTATION REQUIREMENTS. The authorized durable medical equipment, prosthetics, orthotics, and medical supplies (DMEPOS) provider must provide documentation of successful trial period of paraffin therapy.

004.02(SS) PEAK FLOW METERS. Peak flow meters are covered for clients with chronic asthma.

004.02(TT) PERCUSSORS. Percussors are covered for mobilizing respiratory tract secretions in clients with cystic fibrosis, chronic obstructive lung disease, chronic bronchitis, or emphysema.

004.02(TT)(i) DOCUMENTATION REQUIREMENTS. The authorized durable medical equipment, prosthetics, orthotics, and medical supplies (DMEPOS) provider must provide documentation showing the client or operator of powered percussor has received appropriate training by an authorized durable medical equipment, prosthetics, orthotics, and medical supplies (DMEPOS) provider or therapist when no one else competent to administer manual therapy is available.

004.02(UU) PHOTOTHERAPY SERVICES. Phototherapy is covered on a rental basis for infants who meet the following criteria:

(1) Neonatal hyperbilirubinemia; (2) Bilirubin level at initiation of phototherapy is 14 18 milligrams (mgs) per deciliter. Home phototherapy is not covered if the bilirubin level is less than 12 milligrams (mgs) at 72 hours of age or older; or (3) Direct bilirubin level is less than two milligrams (mgs) per deciliter.

004.02(UU)(i) PHOTOTHERAPY HOME TREATMENT. The following conditions must be met prior to initiation of home phototherapy:

(1) History and physical assessment by the infant's authorized durable medical equipment, prosthetics, orthotics, and medical supplies (DMEPOS) provider has occurred; (2) Required laboratory studies have been performed, including, complete blood count (CBC), blood type on mother and infant, direct Coombs, direct and indirect bilirubin; (3) The authorized durable medical equipment, prosthetics, orthotics, and medical supplies (DMEPOS) provider certifies that the parent or caregiver is capable of administering home phototherapy; (4) Parent or caregiver has successfully completed training on use of the equipment; and (5) Equipment must be delivered and set up within four hours of discharge from the hospital or notification of the provider, whichever is more appropriate. There must be a 24 hour per day repair and replacement service available.

004.02(UU)(ii) DOCUMENTATION REQUIREMENTS. An authorized durable medical equipment, prosthetics, orthotics, and medical supplies (DMEPOS) provider’s narrative report outlining the client's progress and the circumstances necessitating extended therapy must be submitted with the claim when billing for home phototherapy exceeding three days.

004.02(VV) PNEUMATIC COMPRESSORS AND APPLIANCES. Pneumatic compressors and appliances are covered for clients with intractable edema of the extremities and are intended for single person use only.

004.02(WW) POSTURAL DRAINAGE BOARDS. Postural drainage boards are covered for clients with chronic pulmonary conditions.

004.02(XX) POWER-OPERATED VEHICLE (POV). A power operated vehicle (POV) is covered instead of a standard wheelchair when all of the following criteria are met:

(1) The client has a diagnosed medical condition which impairs their ability to walk; (2) The client requires a power-operated vehicle (POV) for the purpose of:

(a) Increasing their independence with mobility, resulting in significant difference in their ability to perform major life activities; or (b) Providing assisted mobility for clients who show no means of safe independent mobility;

(3) The client has significant limitation of limb function such that the client is not able to propel a manual wheelchair. Compared to their use of a manual wheelchair, the client's use of a power-operated vehicle (POV) must result in a significant improvement in independent mobility and ability to perform major life activities; and (4) The client has demonstrated, through a trial period with a similar power-operated vehicle (POV):

(a) The ability to safely and independently operate the controls of a power-operated vehicle (POV); (b) The ability to transfer safely in and out of a power-operated vehicle (POV); and (c) Adequate trunk stability to be able to safely ride in the power-operated vehicle (POV).

004.02(XX)(i) DOCUMENTATION REQUIREMENTS. The authorized durable medical equipment, prosthetics, orthotics, and medical supplies (DMEPOS) provider must complete Form MS 79, Wheelchair and Wheelchair Seating System Selection Report, and must:

(1) Justify the type of wheelchair seating system; and (2) Provide evidence of a coordinated assessment, which includes communication between the client, caregiver(s), authorized durable medical equipment, prosthetics, orthotics, and medical supplies (DMEPOS) provider, physical or occupational therapist, and equipment supplier. The assessment should address:

(a) Physical; (b) Functional; (c) Cognitive issues; (d) Accessibility; and (e) Cost effectiveness of equipment.

004.02(XX)(ii) PRIOR AUTHORIZATION. All power-operated vehicles (POVs) and power-operated vehicle (POV) accessories require prior authorization before items are provided to the client.

004.02(YY) PRESSURE REDUCING SUPPORT SURFACES. Pressure reducing support surfaces are covered for clients who meet one of the following conditions:

(1) Completely immobile; (2) Limited mobility; (3) Any stage pressure ulcer on the trunk or pelvis; or (4) Pressure reducing cushions are covered for clients with or highly susceptible to decubiti.

004.02(YY)(i) ADDITIONAL CRITERIA. If the client meets criteria two or three above, he or she must also meet at least one of the following criteria:

(1) Impaired nutritional status; (2) Fecal or urinary incontinence; (3) Altered sensory perception; or (4) Compromised circulatory status.

004.02(YY)(ii) REPLACEMENTS. Replacements are covered when the anticipated length of need is at least one year or the original pressure reducing mattress is not supportive enough for the client.

004.02(YY)(iii) DOCUMENTATION REQUIREMENTS. The authorized durable medical equipment, prosthetics, orthotics, and medical supplies (DMEPOS) provider must provide an approved care plan. Adherence to the care plan or treatment is not to be construed as elements for coverage criteria. Authorized durable medical equipment, prosthetics, orthotics, and medical supplies (DMEPOS) provider supervision during the use in connection with the client’s course of treatment must be documented. The care plan must include the following:

(1) Education of the client and caregiver on the prevention and management of decubiti; (2) Regular assessment by a licensed health healthcare practitioner; (3) Appropriate turning and positioning; (4) Appropriate wound care for stage II, III, or IV ulcer; (5) Moisture and incontinence control needed; and (6) Nutritional assessment and intervention consistent with the overall plan of care if there is impaired nutritional status.

004.02(ZZ) SEAT LIFTS. Seat lifts are covered if all of the following criteria are met:

(1) The client must have severe arthritis of the hip or knee or have a severe neuromuscular disease; (2) The seat lift chair must be a part of the authorized durable medical equipment, prosthetics, orthotics, and medical supplies (DMEPOS) provider’s course of treatment and be prescribed to effect improvement, or arrest or hinder deterioration in the client's condition; (3) The client must be completely incapable of standing up from a regular armchair or Any chair in their home; and (4) Once standing, the client must have the ability to ambulate.

004.02(ZZ)(i) ADDITIONAL CRITERIA. Coverage is limited to seat lifts which:

(1) Provide smooth transition in movement of the client; (2) Can be controlled by the client; and (3) Effectively assist a client in standing up and sitting down without other assistance.

004.02(ZZ)(ii) DOCUMENTATION REQUIREMENTS. The authorized durable medical equipment, prosthetics, orthotics, and medical supplies (DMEPOS) provider must provide documentation that shows the criteria outlined in this chapter have been met.

004.02(ZZ)(iii) MEDICARE AND MEDICAID CLIENTS. For clients eligible for both Medicare and Medicaid, the seat portion of the seat lift chair will be covered by Medicaid if the seat lift mechanism has been approved by Medicare. Prior authorization of payment is not required. Documentation of Medicare coverage must be submitted on or with the Medicaid claim when billing for the chair portion.

004.02(AAA) SITZ BATHS. Sitz baths are covered for clients with infection or injury of the perineal area.

004.02(AAA)(i) DOCUMENTATION REQUIREMENTS. Documentation must have an authorized durable medical equipment, prosthetics, orthotics, and medical supplies (DMEPOS) provider ordered plan of care in the client’s residence.

004.02(BBB) SPINAL ORTHOSES. Spinal orthoses are covered for clients who require a wheelchair seating system for one of the following reasons:

(1) Supporting the client in a position that minimizes the development or progression of musculoskeletal impairment; (2) Relieving pressure; or (3) Providing support in a position that improves the client's ability to perform functional activities.

004.02(BBB)(i) DOCUMENTATION REQUIREMENTS. Documentation must be provided using Form MS 79, Wheelchair and Wheelchair Seating System Selection Report, which:

(1) Justifies the type of wheelchair seating system; and (2) Provides evidence of a coordinated assessment. A coordinated assessment includes communication between the client, caregiver(s), authorized durable medical equipment, prosthetics, orthotics, and medical supplies (DMEPOS) provider, physical or occupational therapist, and equipment supplier. The assessment should address:

(a) Physical; (b) Functional; (c) Cognitive issues; (d) Accessibility; and (e) Cost effectiveness of equipment.

004.02(BBB)(ii) PRIOR AUTHORIZATION. All wheelchair and wheelchair accessories require prior authorization before items are provided to the client.

004.02(CCC) SUCTION PUMPS. Suction pumps are covered for clients who have difficulty raising and clearing secretions caused by:

(i) Cancer or surgery of the throat or mouth; (ii) Dysfunction of the swallowing muscles; (iii) Unconsciousness or obtunded state; or (iv) Tracheostomy.

004.02(DDD) SUPPORTS. Support items include elastic supports, elastic surgical stockings, slings, and trusses. Supports are covered for post-surgical clients, and clients with intractable edema of the lower extremities or other circulatory disorders.

004.02(EEE) TRACHEOSTOMY CARE SUPPLIES. Tracheostomy care supplies are covered for clients with an open surgical tracheostomy. A tracheostomy care or cleaning starter kit is covered following an open surgical tracheostomy for a two week post operative period. An artificial larynx is covered for clients that have had a laryngectomy or whose larynx is permanently inoperable. Artificial larynx and tracheostomy speaking valves are prostheses.

004.02(FFF) TRACTION EQUIPMENT. Traction equipment is covered for clients with orthopedic impairments requiring traction equipment that prevents ambulation during the period of use. Cervical pillows are covered only when required for use with traction equipment.

004.02(GGG) TRANSCUTANEOUS ELECTRICAL NERVE STIMULATORS (TENS). Transcutaneous electrical nerve stimulators are covered for clients with chronic, intractable pain, or acute post operative pain. The presumed etiology of the pain must be a type which is accepted as responding to transcutaneous electrical nerve stimulators (TENS) therapy.

004.02(GGG)(i) ACUTE POST-OPERATIVE PAIN. For acute post operative pain, a transcutaneous electrical nerve stimulator (TENS) unit is generally covered for no more than one month following the day of surgery. Approval for more than one month will be determined on a case-by-case basis, based on the documentation provided by the authorized durable medical equipment, prosthetics, orthotics, and medical supplies (DMEPOS) provider, and submitted with the prior authorization request. A four-lead transcutaneous electrical nerve stimulator (TENS) unit may be used with either two lead or four leads, depending on the character of the patient’s pain.

004.02(GGG)(ii) DOCUMENTATION REQUIREMENTS. Documentation for a transcutaneous electrical nerve stimulator (TENS) must show:

(a) The pain is present for at least three months; (b) Other appropriate treatment modalities have been unsuccessful; (c) Names of treatment modalities and length of time each treatment modality was used; (d) Results of the treatment modalities; (e) Trial basis of one month the transcutaneous electrical nerve stimulator (TENS) unit was used; (f) Monitor report from the authorized durable medical equipment, prosthetics, orthotics, and medical supplies (DMEPOS) provider to determine the effectiveness of the transcutaneous electrical nerve stimulator (TENS) unit in modulating the pain; and (g) A reevaluation of the client at the end of the trial period which indicates:

(i) How often the client used the transcutaneous electrical nerve stimulator (TENS) unit; (ii) Typical duration of use each time; and (iii) Results.

004.02(GGG)(ii)(1) ADDITIONAL DOCUMENTATION REQUIREMENTS. Authorized durable medical equipment, prosthetics, orthotics, and medical supplies (DMEPOS) provider approval is required for use of four leads with the transcutaneous electrical nerve stimulator (TENS) unit. The documentation must include why two leads are insufficient to meet the client’s needs. Authorized durable medical equipment, prosthetics, orthotics, and medical supplies (DMEPOS) provider approval is required for a conductive garment for use with a transcutaneous electrical nerve stimulator (TENS) unit.

004.02(HHH) TRANSFER EQUIPMENT. Transfer equipment is covered for clients who require assistance with transfer.

004.02(III) TRAPEZE EQUIPMENT. Trapeze equipment is covered for clients to:

(i) Sit up due to a respiratory condition; (ii) Change body position for other medical reasons; or (iii) To get in or out of bed.

004.02(JJJ) ULTRAVIOLET CABINETS. Ultraviolet cabinets are covered for clients with generalized, intractable psoriasis.

004.02(JJJ)(i) DOCUMENTATION REQUIREMENTS. Documentation must justify treatment at home rather than alternative site.

004.02(KKK) UTERINE MONITORS, HOME. Home uterine monitors are covered on a rental basis for clients that meet the following criteria:

(1) Comprehensive client assessment and evaluation by the authorized durable medical equipment, prosthetics, orthotics, and medical supplies (DMEPOS) provider has occurred; (2) The client has successfully completed training on the use of the equipment; (3) The client is at high risk for preterm labor and delivery and must be a candidate for tocolytic therapy. Others at high risk for preterm labor and delivery may be covered upon approval by Medicaid through written communication from the client’s authorized durable medical equipment, prosthetics, orthotics, and medical supplies (DMEPOS) provider; (4) The pregnancy must be greater than 20 weeks gestation; and (5) The client must have one of the following medical conditions:

(a) Recent preterm labor with hospitalization and discharge on tocolytic therapy; (b) Multiple gestations; (c) History of preterm delivery; (d) Anomalies of the uterus; (e) Incompetent cervix; (f) Previous cone biopsy; (g) Polyhydramnios; or (h) Diethylstilbestrol exposure.

004.02(KKK)(i) DOCUMENTATION REQUIREMENTS. Documentation must show the treatment meets both medical necessity and the criteria outlined in this chapter.

004.02(LLL) VAPORIZERS. Vaporizers are covered for clients with a respiratory illness. Coverage includes cool mist and warm mist vaporizers.

004.02(MMM) VENTILATORS. Ventilators are covered for treatment of:

(i) Neuromuscular diseases; (ii) Thoracic restrictive diseases; (iii) Chronic respiratory failure consequent to chronic obstructive pulmonary disease; and (iv) Respiratory paralysis.

004.02(NNN) WALKERS. Walkers are covered for clients with conditions which impair ambulation and there is a need for greater stability and security than provided by a cane or crutches. A heavy duty, multiple braking system, variable wheel resistance walker is covered for clients who are unable to use a standard walker due to one of the following:

(i) Obesity; (ii) Severe neurologic disorders; or (iii) Restricted use of one hand.

004.02(OOO) WHEELCHAIRS, MANUAL AND POWER. Manual and power wheelchairs are covered for clients who have a diagnosed medical condition which impairs their ability to walk. A powered wheelchair may be approved in the event the client has significant limitation of limb function which prohibits the client from being able to propel a manual wheelchair.

004.02(OOO)(i) DOCUMENTATION REQUIREMENTS. Documentation must follow the criteria outlined in this chapter.

004.02(OOO)(ii) PRIOR AUTHORIZATION. All wheelchair and wheelchair accessories require prior authorization before items are provided to the client.

004.02(PPP) WHEELCHAIR SEATING SYSTEM. Wheelchair seating systems are covered for clients who have a diagnosis which impairs their ability to sit. The wheelchair seating system may be covered for the following purposes:

(1) Supporting the client in a position which minimizes the development or progression of musculoskeletal impairment; (2) Relieving pressure; or (3) Providing support in a position which improves the client's ability to perform functional activities.

004.02(PPP)(i) DOCUMENTATION REQUIREMENTS. Documentation must follow the criteria outlined in this chapter.

004.02(QQQ) WHEELCHAIR-RECLINING BACK OR TILT-IN-SPACE WHEELCHAIR FRAME. Tilt-in-space and reclining back wheelchairs are covered for clients with a diagnosis which impairs their ability to tolerate the fully upright sitting position for significant amounts of time. Combination power recline and tilt-in-space wheelchair frames, if unavailable in manually operated forms, are covered for clients who require both recline and tilt-in-space features.

004.02(QQQ)(i) DOCUMENTATION REQUIREMENTS. Documentation must show:

(1) The client needs to remain in a wheelchair for purposes of mobility or other interaction with their environment; (2) The client requires frequent, significant adjustment of their position in the wheelchair, either to change hip angle or their sitting position relative to the ground; and (3) For power operation of elevating leg rests, the client has the cognitive and motor ability to operate the power required control switches and is routinely in situation where caregivers are not available to manually recline or tile them as needed.

004.02(RRR) BUILT-IN TYPE WHIRLPOOL BATH EQUIPMENT STANDARD. Covered for clients who have a condition for which the whirlpool bath is expected to provide substantial therapeutic benefit.

004.02(SSS) WOUND THERAPY NEGATIVE PRESSURE. Covered for clients with stage IV decubiti, which does not respond to usual wound dressing. This is a rental in which the provider is responsible for training the client, caregivers or facility staff and monitoring the use of the equipment.

004.02(TTT) NOT OTHERWISE CLASSIFIED (NOC) CODES. Coverage of items for which no specific procedure code exists will be determined by Medicaid on a case by case basis.

004.02(TTT)(i) DOCUMENTATION REQUIREMENTS. Manufacturer’s invoice and authorized durable medical equipment, prosthetics, orthotics, and medical supplies (DMEPOS) provider approval must be submitted as a part of the Medicaid staff review.

004.03 NON-COVERED SERVICES.

004.03(A) GENERAL COVERAGE RESTRICTIONS. Medicaid does not cover durable medical equipment, prosthetics, orthotics, and medical supplies (DMEPOS) items for the following uses:

(i) Personal comfort; (ii) Convenience; (iii) Education; (iv) Hygiene; (v) Safety; (iv) Cosmetic; (vii) New equipment of unproven value; or (viii) Equipment of questionable current usefulness or therapeutic value.

004.03(B) EQUIPMENT NOT PRIMARILY MEDICAL IN NATURE. Medicaid does not cover the following items because they are not primarily medical in nature:

(i) Air cleaners and purifiers; (ii) Air conditioners; (iii) Bed baths; (iv) Bed lifters; (v) Beds or lounge; (vi) Beds oscillating; (vii) Bed tables; (viii) Bed boards; (ix) Braille teaching texts; (x) Carafes; (xi) Cradles; (xii) Dehumidifiers, room, or central heating type; (xiii) Elevators; (xiv) Emesis basins; (xv) Enuresis alarms; (xvi) Environmental control equipment; (xvii) Exercise equipment; (xviii) Heating and cooling plants or equipment; (xix) Humidifiers, room, or central heating type; (xx) Hypodermic jet pressure injectors for insulin; (xxi) Lifts or wheelchair equipment; (xxii) Massage devices; (xxiii) Mattress and pillow covers; (xxiv) Medical identification items; (xxv) Pillows; (xxvi) Restraints; (xxvii) Sauna baths; (xxviii) Sheets, disposable or reusable; (xxix) Shower attachments, handheld; (xxx) Speech teaching machines; (xxxi) Stairway elevators; (xxxii) Telephone arms; or (xxxiii) Whirlpool pumps, portable.

004.03(C) DIATHERMY MACHINES, STANDARD AND PULSED WAVE TYPES. Medicaid does not cover diathermy machines as part of the durable medical equipment, prosthetics, orthotics, and medical supplies (DMEPOS) benefit.

004.03(D) ESOPHAGEAL DILATORS. Medicaid does not cover esophageal dilators as part of the durable medical equipment, prosthetics, orthotics, and medical supplies (DMEPOS) benefit.

004.03(E) OXYGEN THERAPY. Respiratory therapist services are not covered. The durable medical equipment, prosthetics, orthotics, and medical supplies (DMEPOS) benefit provides for coverage of oxygen and oxygen equipment but does not include a professional component in the delivery of such services. Oxygen therapy is not covered for:

(i) Angina pectoris in the absence of hypoxemia; (ii) Dyspnea without cor pulmonale or evidence of hypoxemia; (iii) Severe peripheral vascular disease resulting in clinically evident desaturation in one or more extremities; (iv) Terminal illness that does not affect the lungs; and (v) Items that are considered precautionary and not therapeutic nature including:

(1) Spare tanks of oxygen; (2) Emergency oxygen inhalators; and (3) Preset portable oxygen delivery unit where flow rate is not adjustable.

004.03(F) PARALLEL BARS. Medicaid does not cover parallel bars as part of the durable medical equipment, prosthetics, orthotics, and medical supplies (DMEPOS) benefit. Parallel bars are primarily intended for institutional use, not in a home setting.

004.03(G) PRESSURE REDUCING SUPPORT SERVICES. Medicaid does not cover powered mattress pads or overlays and mattress replacements, except alternating pressure pads, as part of the durable medical equipment, prosthetics, orthotics, and medical supplies (DMEPOS) benefit.

004.03(H) PULSE TACHOMETERS. Medicaid does not cover pulse tachometers as part of the durable medical equipment, prosthetics, orthotics, and medical supplies (DMEPOS) benefit when they are not reasonable or necessary for monitoring pulse of client with or without a cardiac pacemaker.

004.03(I) SEAT LIFTS. Excluded from coverage is the type of lift which operates by a spring release mechanism with a sudden, catapult like motion, and jolts the client from a seated to standing position.

004.03(J) TELEPHONE ALERT SYSTEMS. Medicaid does not cover emergency communication systems that do not serve a diagnostic or therapeutic purpose.

004.02(K) TOOTHBRUSHES. Medicaid does not cover personal hygiene items including toothbrushes.

005. BILLING AND PAYMENT FOR DURABLE MEDICAL EQUIPMENT, PROSTHETICS, ORTHOTICS, AND MEDICAL SUPPLIES (DMEPOS)

005.01 BILLING.

005.01(A) GENERAL BILLING REQUIREMENTS. Providers must comply with all applicable billing requirements codified in 471 NAC 3. In the event that individual billing requirements in 471 NAC 3 conflict with billing requirements outlined in this chapter, the individual billing requirements in this chapter will govern.

005.01(B) SPECIFIC BILLING REQUIREMENTS. Providers must bill the Department on the appropriate claim form or electronic format. Any item billed to Medicaid must actually be dispensed or directly supplied by the provider that bills for the item. This does not preclude a provider from contracting with billing agents. Providers may not bill for durable medical equipment, prosthetics, orthotics, and medical supplies (DMEPOS) dispensed in advance.

005.01(B)(i) PROCEDURE CODES AND MODIFIERS. The provider will bill the Department using the Healthcare Common Procedure Coding System (HCPCS) and Current Procedural Terminology (CPT) procedure codes and modifiers.

005.01(B)(ii) RENTAL BILLING PROCEDURES. Providers must use the following rental billing procedures:

(1) Bill for rental only while the item continues to be medically necessary and appropriately used by the client; (2) Rental items not used by the client for more than a one month period, during inpatient hospitalization, may not be billed to Medicaid. The provider is responsible for determining whether the item continues to be used by the client; (3) Bill rental on a monthly basis unless the item is used for less than a one month period. When billing for monthly rental, the unit of service "1" indicates a one month rental period. The provider will use the appropriate procedure code modifier when billing for monthly rental. The beginning rental date for each month will be the day of the month on which the item was initially provided. A monthly rental period is not necessarily a calendar month or a standard number of days. The monthly billing period begins the day of rental and extends to the day prior to the corresponding numerical day the following month. When rental equipment is needed at any time by the client for less than a one month rental period, the rental is paid on a daily pro rated basis. The provider will use the appropriate procedure code modifier when billing for daily rental. The unit of service must reflect the number of days the item was actually used; and (4) When billing for rental items, indicate both from and to dates of service and the initial rental date.

005.01(B)(iii) USED ITEMS. When billing for used durable medical equipment, prosthetics, orthotics, and medical supplies (DMEPOS) items, the provider must use the used equipment (UE) procedure code modifier.

005.01(B)(iv) APNEA MONITOR SUPPLIES. Apnea monitor supplies are covered for use with rented and client owned apnea monitors. For rented apnea monitors, the apnea monitor supplies must be billed on the same claim as the apnea monitor rental.

005.01(B)(v) HOME PHOTOTHERAPY. The provider must bill for home phototherapy daily rental on a single claim and indicate the total number of rental days as the units of service.

005.01(B)(vi) UTERINE MONITORS, HOME. The provider must indicate on the claim the condition which necessitates use of the monitor and, when billing for the final rental period, the date of discontinuation of the monitor.

005.01(B)(vii) OXYGEN THERAPY. When billing for oxygen therapy, the durable medical equipment, prosthetics, orthotics, and medical supplies (DMEPOS) provider must use the appropriate unit of service as described in the procedure code. Units of service should be rounded to the nearest unit of the procedure code description.

005.02 PAYMENT.

005.02(A) GENERAL PAYMENT REQUIREMENTS. Medicaid will reimburse the provider for services rendered in accordance with the applicable payment regulations codified in 471 NAC 3. In the event that individual payment regulations in 471 NAC 3 conflict with payment regulations outlined in this chapter, the individual payment regulations in this chapter will govern.

005.02(B) SPECIFIC PAYMENT REQUIREMENTS. Medicaid pays for covered durable medical equipment, prosthetics, orthotics, and medical supplies (DMEPOS) at the lower of:

(1) The provider's submitted charge; or (2)The allowable amount for that procedure code in the Nebraska Medicaid Practitioner Fee Schedule in effect for that date of service.

005.02(B)(i) MEDICARE AND MEDICAID CROSSOVER CLAIMS. Information on payment of Medicare and Medicaid crossover claims is found in 471 NAC 3.

005.02(B)(ii) ORTHOSES AND PROSTHESES. Medicaid payment for orthoses and prostheses includes:

(1) Evaluations only when no device, orthosis, prosthesis, part, repair, or adjustment is provided; (2) Fitting; (3) Cost of parts and labor; (4) Repairs due to normal wear and tear for a minimum of 90 days from the date dispensed; and (5) Adjustments made when fitting and for a minimum of 90 days from the date dispensed when the adjustments are not necessitated by changes in the client's medical condition or the client's functional abilities.

005.02(B)(iii) RENTAL PAYMENT. Payment for rental includes:

(1) All necessary repair and replacement parts; and (2) All accessories and supplies necessary for the effective use of the equipment, unless specifically allowed as outlined in the coverage criteria for the item.

005.02(B)(iv) AIR FLUIDIZED AND LOW AIR LOSS BED UNITS. Medicaid rental payment includes:

(1) Air fluidized or low air loss bed unit and all accessories and services necessary for proper functioning and effective use of the bed; (2) Weekly on site client evaluation and wound care consultation by a registered nurse employed by the provider, with 24 hour per day availability; and (3) Complete caregiver training on use of equipment, wound care, and prevention.

005.02(B)(v) APNEA MONITORS. Medicaid rental payment includes complete parent or caregiver training on use of the equipment and record keeping. Medicaid does not make separate payment for remote alarms. When provided, payment for a remote alarm is included in the monitor rental payment.

005.02(B)(vi) HOME PHOTOTHERAPY PAYMENT. Medicaid daily rental payment includes:

(1) Phototherapy unit and all supplies, accessories, and services necessary for proper functioning and effective use of the therapy; (2) A minimum of one daily visit to the home by a licensed or certified health care professional is required. The daily visits must include:

(a) A brief home assessment; and (b) Collection and delivery of blood specimens for bilirubin testing when ordered by the authorized durable medical equipment, prosthetics, orthotics, and medical supplies (DMEPOS) provider to be collected in the home. The authorized durable medical equipment, prosthetics, orthotics, and medical supplies (DMEPOS) provider must be informed by the provider that this service is available. An outside agency or laboratory with whom the provider contracts for collection and delivery of blood specimens may not bill Medicaid directly since payment is included in the daily rental payment. Daily home visits must occur for home assessment even if the blood collection is done outside the home; and

(3) Complete caregiver training on use of equipment and completion of necessary records.

005.02(B)(vii) RATE NOT ESTABLISHED CODES. For rate not established (RNE) codes on the Nebraska Medicaid Practitioner Fee Schedule, payment will be determined based on manufacturer’s invoice cost.

005.02(B)(viii) SEAT LIFTS. Payment for seat lift chairs which incorporates a recliner feature along with the seat lift is limited to the amount payable for a seat lift without this feature.

005.02(B)(ix) UTERINE MONITORS, HOME. Medicaid rental payment includes all equipment, supplies, and services necessary for the effective use of the monitor. This does not include medications or authorized durable medical equipment, prosthetics, orthotics, and medical supplies (DMEPOS) provider’s professional services.

005.02(B)(x) DIALYSIS EQUIPMENT AND SUPPLIES. Medicaid reimburses for dialysis systems, related supplies, and equipment only to approved renal dialysis facilities under the Medicare Method I composite rate payment methodology. Payment cannot be made to suppliers, pharmacies, or home health agencies for dialysis systems, related supplies, and equipment.

History

• Effective 2024-02-20

Chapter 8 Hearing Aids

Neb. Admin. Code tit. 471, ch. 8 Hearing Aids {#sec-471-nac-8 omnilex-key=us-ne-regs-official--title-471--471 NAC 8}

001. SCOPE AND AUTHORITY . These regulations govern services provided under the Medical Assistance Act, Nebraska Revised Statute (Neb. Rev. Stat.) §§ 68-901 et seq.

002. DEFINITIONS . The following definitions apply:

002.01 ASSISTIVE LISTENING DEVICE. Any instrument or device that helps overcome hearing loss.

002.02 BEHIND THE EAR (BTE). All parts of the hearing aid are behind the ear (BTE) except for the ear piece that is connected by tubing to the behind the ear (BTE) parts.

002.03 COMPLETELY IN THE CANAL (CIC). The hearing aid is completely in the ear (ITE) canal.

002.04 HEARING AID. Any wearable instrument or device, including any parts, attachments, or accessories, but excluding batteries or cords, that is designed for or offered for the purpose of aiding or compensating for impaired human hearing and that is programmed to a specific individual’s hearing loss. Over-the-counter amplification devices with generic settings are excluded.

002.05 IN THE CANAL (ITC). The hearing aid is mostly in the ear (ITE) canal.

002.06 IN THE EAR (ITE). The entire hearing aid fits in the area just outside of the ear canal known as the concha bowl.

002.07 OTOLARYNGOLOGY SPECIALIST. A physician who specializes with disorders and conditions of the ear, nose, and throat region and related areas of the head and neck.

002.08 RECEIVER IN THE CANAL (RIC). Hearing aid with most parts behind the ear (BTE) except the receiver that is in the ear (ITE) and connected by a wire to the behind the ear (BTE) parts.

003. PROVIDER REQUIREMENTS .

003.01 GENERAL PROVIDER REQUIREMENTS. Providers of hearing aids must comply with all applicable provider participation requirements codified in 471 Nebraska Administrative Code (NAC) 2 and 3. In the event that provider participation requirements in 471 NAC 2 or 3 conflict with requirements outlined in this chapter, the individual provider participation requirements in this chapter will govern.

003.02 STANDARDS OF PARTICIPATION. To participate in Medicaid, hearing aid dispensers must complete and sign Form MC-19, Service Provider Agreement, and submit the completed form to the Department for approval. Hearing aid dispensers must be licensed by the Department as a:

(1) Hearing instrument specialist and audiologist;

(2) Audiologist; or

(3) Hearing instrument specialist.

003.02(A) OUT OF STATE PROVIDERS. If the services are provided outside Nebraska, the dispenser must be:

(i) Licensed by the appropriate agency of the state in which they practice; and

(ii) Enrolled with Medicaid as a hearing aid service provider.

003.02(B) HEARING AID BATTERIES. Pharmacies and durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) providers may dispense hearing aid batteries if enrolled as a Medicaid provider.

004. SERVICE REQUIREMENTS .

004.01 GENERAL REQUIREMENTS.

004.01(A) MEDICAL NECESSITY. Medicaid incorporates the definition of medical necessity from 471 NAC 1 as if fully rewritten herein. Services and supplies that do not meet the 471 NAC 1 definition of medical necessity are not covered.

004.01(B) PRIOR AUTHORIZATION. Medicaid requires prior authorization for certain items and services, as outlined on the Nebraska Medicaid Hearing Aid Fee Schedule.

004.01(B)(i) PRIOR AUTHORIZATION PROCEDURE FOR HEARING AIDS, ASSISTIVE LISTENING DEVICES, AND ACCESSORIES. Medicaid requires that the following information be submitted when requesting prior authorization for all hearing aids and assistive listening devices billed at $500.01 or greater per unit, and accessories of $150 or greater per line item:

(a) A complete audiogram;

(b) The name of the examiner or dispenser performing the audiogram;

(c) The type of hearing aid or assistive listening device being recommended and any accessories;

(d) The estimated cost of the hearing aid or assistive listening device;

(e) The estimated cost of each item being provided;

(f) The hearing aid dispenser's provider number; and

(g) The hearing aid dispenser's name, address and phone number.

004.01(B)(i)(1) PRIOR AUTHORIZATION FORM. Form DM-5H, Physician's Report on Hearing Loss, must be used when submitting a request for prior authorization. All requests for prior authorization, and supporting documentation, must be submitted to the Department or the utilization management organization under contract with the Department.

004.01(B)(ii) PRIOR AUTHORIZATION PROCEDURE FOR REPAIRS. All requests for prior authorization, and supporting documentation, must be submitted to the Department or the utilization management organization under contract with the Department. Medicaid requires that the following information be submitted when requesting prior authorization for all repairs of $150 or greater per line item:

(1) The estimated cost of the repair;

(2) The estimated cost of each item being provided;

(3) The hearing aid dispenser's provider number; and

(4) The hearing aid dispenser's name, address and phone number.

004.01(C) EAR, NOSE, AND THROAT (ENT) EVALUATIONS. Medicaid requires that a client be evaluated by a licensed otolaryngology specialist who is an approved Medicaid provider when the following criteria is met:

(i) The client has a conductive hearing loss;

(ii) The client has a unilateral hearing loss;

(iii) The client has asymmetric hearing loss;

(iv) The client reports dizziness; or

(v) The client is age 16 or younger.

004.01(D) SERVICES PROVIDED FOR CLIENTS ENROLLED IN NEBRASKA MEDICAID MANAGED CARE. See 471 NAC 1.

004.01(E) HEALTH CHECK SERVICES. See 471 NAC 33.

004.02 COVERED SERVICES. Medicaid provides hearing aids and supplies to Nebraska Medicaid eligible clients. These services include hearing aids, hearing aid repairs, assistive listening devices, and other hearing aid services when the services are medically necessary and are prescribed by a physician. Medicaid covers in-the-ear (ITE), behind the ear (BTE), in the canal (ITC), completely in the canal (CIC), or receiver in the canal (RIC) hearing aids. Bone conduction aids will be approved with ear, nose, and throat (ENT) physician approval.

004.02(A) NUMBER OF HEARING AIDS. Medicaid covers:

(i) For clients age 20 and younger, the number of hearing aids is dependent on medical necessity; and

(ii) For clients age 21 and older, hearing aids are limited to not more than one aid per ear every four years and then only when medically necessary. Medical necessity is determined using the prior authorization procedure in this chapter.

004.02(B) REPLACEMENT OF HEARING AIDS AND ASSISTIVE LISTENING DEVICES. The provider must obtain prior authorization from Medicaid for all replacements of lost or stolen hearing aids or assistive listening devices.

004.03 NON-COVERED SERVICES. Medicaid does not cover:

(A) Hearing aid batteries for residents of a nursing facility except with the initial fitting;

(B) Accessories which are for convenience; or

(C) Items that are deemed to be not medically necessary.

005. BILLING AND PAYMENT FOR HEARING AIDS .

005.01 BILLING.

005.01(A) GENERAL BILLING REQUIREMENTS. Providers must comply with all applicable billing requirements codified in 471 NAC 3. In the event that individual billing requirements in 471 NAC 3 conflict with billing requirements outlined in this chapter, the individual billing requirements in this chapter will govern.

005.01(B) SPECIFIC BILLING REQUIREMENTS. Providers must submit claims to the Department on the appropriate claim form or electronic format. The provider or the provider's authorized agent must submit the provider's usual and customary charge for each procedure code listed on the claim.

005.01(B)(i) PROCEDURE CODES. Healthcare Common Procedure Coding System (HCPCS) and Current Procedural Terminology (CPT) procedure codes used by Medicaid are listed in the Nebraska Medicaid Practitioner Fee Schedule.

005.02 PAYMENT.

005.02(A) GENERAL PAYMENT REQUIREMENTS. Medicaid will reimburse the provider for services rendered in accordance with the applicable payment regulations codified in 471 NAC 3. In the event that individual payment regulations in 471 NAC 3 conflict with payment regulations outlined in this chapter, the individual payment regulations in this chapter will govern.

005.02(B) SPECIFIC PAYMENT REQUIREMENTS. Medicaid pays for covered hearing aid services at the lower of:

(i) The provider's submitted charge; or

(ii) The allowable amount for that procedure code in the Nebraska Medicaid Practitioner Fee Schedule for that date of service.

History

• Effective 2021-10-09

Chapter 9 Home Health Agencies and Skilled Nursing Services

Neb. Admin. Code tit. 471, ch. 9 Home Health Agencies and Skilled Nursing Services {#sec-471-nac-9 omnilex-key=us-ne-regs-official--title-471--471 NAC 9}

001. SCOPE AND AUTHORITY. These regulations govern services provided under the Medical Assistance Act, Nebraska Revised Statute (Neb. Rev. Stat.) §§ 68-901 et seq.

002. DEFINITIONS. The following definitions apply:

002.01 ADVANCED DIRECTIVE. A legal document, including, but not limited to, a living will, signed by a competent person, to provide guidance for medical and health-care decisions in the event the client becomes incapable to make such decisions.

002.02 HOME HEALTH AGENCY. A person or any legal entity which provides skilled nursing or minimum of one other therapeutic service as defined by the Department on a full-time, part-time, or intermittent basis to person in a place of temporary or permanent residence used as the person’s home.

002.03 HOME HEALTH SERVICES. Services provided to a client in the client's place of residence. The residence does not include a hospital, skilled nursing facility, or nursing facility. A nurse practitioner, physician assistant, or clinical nurse specialist are able to order home health services.

002.04 SKILLED NURSING SERVICE. Skilled nursing services are those services provided by a private duty nurse (PDN) or a nurse employed by a home health agency in a client’s home or current living arrangement. Skilled nursing services do not include services provided in a hospital, skilled nursing facility, or nursing facility.

003. PROVIDER REQUIREMENTS.

003.01 GENERAL PROVIDER REQUIREMENTS. Providers of home health services must comply with all applicable provider participation requirements codified in 471 Nebraska Administrative Code (NAC) 2 and 3. In the event that participation requirements in 471 NAC 2 or 3 conflict with requirements outlined in this chapter, the participation requirements in this chapter will govern.

003.02 SPECIFIC PROVIDER REQUIREMENTS.

003.02(A) PLAN OF CARE AND TREATMENT RECORD. The home health agency must maintain a clinical record that includes the plan of care signed by the attending physician, nurse practitioner, physician assistant, or clinical nurse specialist responsible for the client's care. The attending physician, nurse practitioner, physician assistant, or clinical nurse specialist and home health agency personnel must review the total plan of care and treatment record at least every 60 days. The home health agency must maintain these records on all Medicaid clients and make them readily available upon the Department's request.

003.02(B) COST REPORTS. The home health agency must provide a cost report upon a request made by the Department.

003.02(C) LICENSING. Providers of nursing services must be licensed by the Department of Health and Human Services Division of Public Health or by the appropriate licensing agency of the state in which they practice, as an individual registered nurse (RN) or licensed practical nurse (LPN).

003.02(D) PROVIDER DOCUMENTATION. The nurse must maintain records to document services provided and the time worked for which payment is claimed. These records must be available to the Department upon request. Records must be retained for no fewer than six years for audit purposes. Records must include:

(i) Current, signed physician, nurse practitioner, physician assistant, or clinical nurse specialist orders for the care provided; (ii) Assessment of the client’s health status; (iii) Plan of care; (iv) Nurse’s notes documenting the care provided; and (v) Time sheets documenting the date and times that care was provided.

003.03 SPECIFIC PROVIDER REQUIREMENTS FOR PRIVATE-DUTY NURSE.

003.03(A) CLIENT RECORDS. The private-duty nurse must maintain a medical record in the client’s home or current living arrangement which includes the Form MS-81: Certification and Plan of Care For Private-Duty Nursing.

003.03(B) MULTIPLE REGISTERED NURSE (RN) AND LICENSED PRACTICAL NURSE (LPN) PROVIDERS. When more than one registered nurse (RN) or licensed practical nurse (LPN) is providing skilled nursing services for a client, the providers and client must determine which registered nurse (RN) or licensed practical nurse (LPN) will be the coordinator of services. The coordinator must complete the Form MS-81: Certification and Plan of Care For Private-Duty Nursing, obtaining physician, nurse practitioner, physician assistant, or clinical nurse specialist orders, obtaining authorization for providing services, and making copies available to the other providers.

003.03(D) PROVIDER REQUIREMENTS. To participate in the Medicaid program, the provider must:

(i) Be a participant in the home health and nursing services program; (ii) Be licensed to provide home health care by the Department of Health and Human Services Division of Public Health; (iii) Assume full responsibility of the professional management of the client’s home health care; (iv) Maintain certification; (v) Develop the plan of care as identified by client; (vi) Follow all applicable regulations put in place by the Department; (vii) Comply with the requirements of 471 NAC 1; and (viii) Be a participant in the Medicare home health program.

004. SERVICES REQUIREMENTS.

004.01 GENERAL SERVICE REQUIREMENTS.

004.01(A) MEDICAL NECESSITY. The Department incorporates the medical necessity requirements outlined in 471 NAC 1 as if fully rewritten herein. Services and supplies that do not meet the requirements in 471 NAC 1 are not covered. Durable medical equipment, prosthetics, orthotics, and medical supplies (DMEPOS) must meet the guidelines outlined in 471 NAC 7. In addition to the medical necessity criteria outlined in 471 NAC 1, all home health services and skilled nursing services must be:

(i) Necessary to a continuing medical treatment plan; (ii) Prescribed by a licensed physician, nurse practitioner, physician assistant, or clinical nurse specialist; and (iii) Recertified by the licensed physician, nurse practitioner, physician assistant, or clinical nurse specialist at least every 60 days.

004.01(B) PRIOR AUTHORIZATION FOR HOME HEALTH SERVICES AND SKILLED NURSING SERVICES. Durable medical equipment, prosthetics, orthotics, and medical supplies (DMEPOS) must meet the requirements and procedures for prior authorization outlined in 471 NAC 7. All home health agency services must be authorized and the eligibility of the client must be verified by the home health agency. The Department or its designee may grant authorization of home health agency services. To request authorization, the home health agency must submit Form MS-72, Nebraska Home Health Prior Authorization, and submit a copy of the physician, nurse practitioner, physician assistant, or clinical nurse specialist order and the home health agency's plan of care. Skilled nursing services and home health agencies must be authorized under the same criteria however, providers must send requests for authorization electronically using the standard Health Care Services Review – Request for Review and Response transaction (ASC X 12N 278) or by submitting Form MS-81: Certification and Plan of Care For Private-Duty Nursing to the Medicaid designee. The plan of care must include:

(i) The client's name, address, Medicaid identification number, and date of birth; (ii) The dates of the period covered, not exceeding 60 days; (iii) The diagnosis; (iv) The type and frequency of services; (v) The equipment and supplies needed; (vi) A brief, specific description of the client's needs and services provided; (vii) Any other pertinent documentation that justifies the medical necessity of the services; and (viii) The plan of care must include a signature or verbal authorization from the physician, nurse practitioner, physician assistant, or clinical nurse specialist at prior authorization submittal. Verbal authorizations must be signed within 30 days.

004.01(C) ELIGIBILITY AND ADVANCE PRACTICE REGISTURED NURSE OR PHYSICIAN CERTIFICATION. To be eligible for home health services and skilled nursing services, the attending physician, nurse practitioner, physician assistant, or clinical nurse specialist must certify that based on the client’s medical condition, home health services and skilled nursing services are medically necessary and appropriate services to be provided in the home.

004.01(D) FACE-TO-FACE VISIT. The physician, nurse practitioner, physician assistant, or clinical nurse specialist must document a face-to-face encounter that is related to the primary reason the beneficiary requires home health services and occurred no more than 90 days before or 30 days after the start of services.

004.01(E) SECOND VISIT ON SAME DAY. The medical necessity of a second visit on the same date of service must be documented. Substantiating documentation for skilled nursing services must be submitted with MC-82N, or the request for prior authorization with the standard Health Care Claim: Professional Transaction (ASC X12N 837).

004.01(F) SERVICES PROVIDED FOR CLIENTS ENROLLED IN NEBRASKA MEDICAID MANAGED CARE. See 471 NAC 1.

004.01(G) HEALTH CHECK SERVICES. See 471 NAC 33.

004.01(H) ADVANCE DIRECTIVES. Medicaid-participating home health agencies must comply with applicable state and federal requirements.

004.02 COVERED SERVICES. Medicaid covers the following home health agency services and private duty nursing services:

(i) Skilled nursing services by:

(1) A registered nurse (RN); (2) A licensed practical nurse (LPN); (3) A certified nurse midwife; (4) A nurse practitioner; (5) A physician assistant; or (6) A clinical nurse specialist;

(ii) Home health aide services by:

(1) A nurse aide; or

(iii) Physical therapy provided by a licensed physical therapist; (iv) Speech therapy provided by a licensed speech pathologist; (v) Occupational therapy provided by a licensed occupational therapist; and (vi) Durable medical equipment and medical supplies.

004.02(A) USE OF AUTHORIZED HOURS. A client who requires and is authorized to receive home health nursing services in the home setting may use their approved hours outside of the home during those hours when their normal life activities take them out of the home. The Department will not authorize any additional hours of nursing service beyond what would normally be authorized. If a client requests to receive nursing services to attend school or other activities outside the home, but does not need nursing services in the home, nursing services cannot be authorized.

004.02(B) HOME HEALTH AIDES. A home health aide may provide services to a client in the client's home to meet personal care needs resulting from the client's illness or disability. Skilled nursing visits are not a prerequisite for the provision of home health aide services. The services must be:

(1) Necessary because the care is not available to the client without payment by Medicaid; (2) Necessary to continuing a plan of care; (3) Prescribed by a licensed physician, nurse practitioner, physician assistant, or clinical nurse specialist; (4) Recertified by the licensed physician, nurse practitioner, physician assistant, or clinical nurse specialist at least every 60 days; and (5) Supervised by a registered nurse.

004.02(B)(i) LIMITATION. For extended-hour aide services in home health and nursing services, the Department limits aide services to 56 hours a week with a maximum of 12 hours in a 24 hour period. Department approval must be obtained for services in excess of 56 hours a week.

004.02(C) MEDICATIONS. Medicaid covers intravenous or intramuscular injections and intravenous feeding. Oral medications are covered only where the complexity of the medical condition (physical or psychological) and the number of drugs require a licensed nurse to monitor, detect, and evaluate side effects. The complexity of the medical condition must be documented and submitted with the plan of care.

004.02(C)(i) PREFILLING INSULIN SYRINGES. The Department reimburses home health agencies and private duty nurses for prefilling insulin syringes for blind or disabled diabetic clients who are unable to perform this task themselves and where there is no one else available to fill the insulin syringe on the client’s behalf. The Department considers this a professional nursing service that must be provided only through a professional nurse visit.

004.02(C)(ii) VITAMIN B-12 INJECTIONS. Vitamin B-12 injections are covered initially once a week for a maximum of six weeks, and then once a month when maintenance is established for the treatment of pernicious anemia and other macrocytic anemias, and neuropathies associated with pernicious anemia.

004.02(D) ADDITIONAL SERVICES FOR DIABETIC CLIENTS. Medicaid covers blood sugar testing and foot care for blind or disabled diabetic clients who are unable to perform this task themselves and where there is no one else available to perform the tasks on the client’s behalf.

004.02(E) DECUBITUS AND SKIN DISORDERS. Covered when specific physician, nurse practitioner, physician assistant, or clinical nurse specialist orders indicate that skilled care is necessary, or that skilled nursing care is necessary, requiring prescribed medications and treatment.

004.02(F) DRESSINGS. Medicaid covers application of dressings when aseptic technique and prescription medications are used.

004.02(G) COLOSTOMY, ILEOSTOMY, AND GASTROSTOMY. These services are covered during immediate postoperative time when maintenance care and control by the patient or family is being established. This includes the initial teaching. General maintenance care is not covered.

004.02(H) ENTEROSTOMAL THERAPY. Medicaid recognizes enterostomal therapy visits as a skilled nursing service.

004.02(I) ENEMAS AND REMOVAL OF IMPACTIONS. Medicaid covers enemas and removal of impactions when the complexity of the patient’s condition establishes that the skills of a nurse are required.

004.02(J) BOWEL AND BLADDER TRAINING. Teaching skills and facts necessary to adhere to a specific formal regimen. General routine maintenance program or treating is not covered.

004.02(K) URETHRAL CATHETERS AND STERILE IRRIGATIONS. The Department covers insertions and changes when active urological problems are present or when client is unable to do physician-ordered irrigations. Routine catheter maintenance care is not covered.

004.02(L) CASTS. Casts are covered if the physician’s order evidences more complexity than routine or general supportive care.

004.02(M) DRAW OR COLLECTION OF LABORATORY SPECIMENS. Medicaid covers the collection of specimens only if based on the client’s medical condition home health services are medically necessary and appropriate services to be provided in the home.

004.02(N) OBSERVATION AND EVALUATION. Medicaid covers observation and evaluation requiring the furnishing of a skilled service for an unstable condition. An unstable condition is evidenced by the presence of one of the following conditions:

(i) An episode in the previous 60 days; (ii) A recent acute episode; (iii) A well-documented history of noncompliance without nursing intervention; or (iv) A significant probability that complications would arise without the skilled supervision of the treatment program on an intermittent basis.

004.02(O) TEACHING AND TRAINING ACTIVITIES. Medicaid limits postpartum visits for teaching and training to two visits. The Department covers up to two visits of skilled nursing services for teaching or training purposes. The necessity of further visits must be justified by additional documentation evidencing extenuating circumstances that create the need beyond two visits. Medicaid covers skilled nursing visits for teaching or training that require the skills or knowledge of a nurse. The client must have a medical condition that has been diagnosed and treated by a physician, nurse practitioner, or clinical nurse specialist, and there must be a physician, nurse practitioner, physician assistant, or clinical nurse specialist order for the specific teaching and training. Visits are covered on an individual basis. The provider must maintain specific documentation of both the need for the teaching or training, and the teaching or training provided. Documentation must be submitted along with the plan of care. Teaching or training can occur in the following areas:

(i) Injections; (ii) Irrigating of a catheter; (iii) Care of ostomy; (iv) Administration of medical gases; (v) Respiratory treatment; (vi) Preparation and following a therapeutic diet; (vii) Application of dressing to wounds involving prescription medications and aseptic techniques; (viii) Bladder training; (ix) Bowel training; (x) Use of adaptive devices and special techniques when loss of function has occurred; (xi) Postpartum visits; (xii) Care of a bed-bound patient; and (xiii) Performance of body transfer activities.

004.02(P) OCCUPATIONAL THERAPY, PHYSICAL THERAPY, AND SPEECH, HEARING, AND LANGUAGE THERAPY. Medicaid covers occupational therapy, physical therapy, and speech, hearing, and language therapy as a home health agency service only when the services meet the requirements in accordance with 471 NAC 14 and 23.

004.02(Q) DURABLE MEDICAL EQUIPMENT, PROSTHETICS, ORTHOTICS, AND MEDICAL SUPPLIES (DMEPOS). Durable medical equipment, prosthetics, orthotics, and medical supplies provided by a home health agency or any skilled nursing services must meet all requirements outlined in 471 NAC 7. The Department covers medically necessary durable medical equipment, prosthetics, orthotics, and medical supplies (DMEPOS) which meets program guidelines when ordered by a physician, nurse practitioner, physician assistant, or clinical nurse specialist.

004.02(R) EXTENDED-HOUR NURSING SERVICES. Provision of extended-hour nursing services must be authorized by the Department or its designee. Extended-hour nursing services are authorized only when the client's care needs must be provided by skilled nursing personnel in the absence of the caregiver or parents. Clients are authorized 56 hours a week for a maximum of 12 hours a day in a 24 hour period.

004.02(R)(i) EXTENDED-HOUR NURSING SERVICES FOR ADULTS. Clients are authorized 56 hours a week for a maximum of 12 hours a day in a 24-hour period. Clients are only authorized 56 hours a week. Changes in the client's condition or schedule of the caregiver may require a reevaluation of the approved nursing hours. The Department will authorize the following service:

(1) Patients that are chronically ventilator dependent, 24 hours per day in which interruption from life sustaining ventilation cannot be tolerated may qualify for additional hours based on medical necessity as deemed appropriate by the Department.

004.02(R)(ii) EXTENDED-HOUR NURSING SERVICES FOR CHILDREN. Children must have documented medical needs, which cannot be met by a traditional child care provider system. When providing extended-hour nursing care, the Department will authorize coverage for a maximum of 56 hours a week, depending upon the complexity of a client's care or as approved by The Department. Children who seek Early and Periodic Screening, Diagnosis & Treatment (EPSDT) services and are deemed to have a medical necessity are not limited to certain hours as outlined in 471 NAC 33. A maximum of 12 hours may be approved in a 24-hour period. Changes in the client's condition or schedule of the caregiver or parents may require a reevaluation of the approved nursing hours. If a parent works from home, they can request home health services for a child with disabilities during their working hours.

004.02(R)(iii) NURSING COVERAGE AT NIGHT. Caregivers or families may be eligible for night hours if the client requires procedures on an ongoing basis throughout the night hours. As used in this chapter, night hours refer to the period after the client has gone to bed for the day. Day and evening hours refer to the period of time before the client goes to bed for the day. Night hours will be authorized only if the monitoring and treatments cannot be accomplished during day and evening hours. The medical necessity for monitoring and treatments during the night hours must be reflected in the physician nurse practitioner, physician assistant, or clinical nurse specialist orders and nursing notes. If a scheduled night shift is cancelled by the agency, the caregiver or family may reschedule those hours with the home health agency within the next 24 hours. When that is not possible, they may reschedule the hours within the 48 hours following the missed shift.

004.03 NON-COVERED SERVICES.

004.03(A) MEDICATIONS. Medicaid does not cover injections that can be self-administered, drugs not considered an effective treatment for a condition given; and when a medical reason does not exist for providing the drug by injection rather than by mouth.

004.03(B) DECUBITUS AND SKIN DISORDERS. Medicaid does not cover preventative and palliative measures for minor decubiti, usually Stage I or Stage II.

004.03(C) TEACHING AND TRAINING ACTIVITIES. Medicaid does not cover visits made solely to remind or emphasize the need to follow instructions or when services are duplicated.

004.03(D) DRESSINGS. Medicaid does not cover visits made to dress non-infected closed postoperative wounds or chronic controlled conditions.

004.03(E) STUDENT NURSES. Medicaid does not cover skilled nursing visits by student nurses who are enrolled in a school of nursing and not employed by the home health agency, unless accompanied by a registered nurse who is an employee of the home health agency.

004.03(F) SUPERVISORY VISITS. Skilled nursing visits required for the supervision of licensed practical nurse (LPN) or aide services may not be billed as a skilled nursing visit. The cost of supervision is included in the payment for the licensed practical nurse (LPN) or aide service.

005. BILLING AND PAYMENT FOR HOME HEALTH AGENCIES.

005.01 BILLING.

005.01(A) GENERAL BILLING REQUIREMENTS. Providers must comply with all applicable billing requirements codified in 471 NAC 2 and 471 NAC 3. In the event the individual billing requirements in 471 NAC 2 and 471 NAC 3 conflict with billing requirements outlined in this chapter, the individual billing requirements in this chapter will govern.

005.01(B) SPECIFIC BILLING REQUIREMENTS.

005.01(B)(i) BILLING INSTRUCTIONS. The provider must bill Medicaid, using the appropriate claim form or electronic format, in accordance with the billing instructions. The signed plan of care must be submitted with the claim. Healthcare Common Procedure Coding System (HCPCS) and Current Procedural Terminology (CPT) procedure codes used by Medicaid are listed in the Nebraska Medicaid Practitioner Fee Schedule. Durable medical equipment and medical supplies are billed under the home health agency provider number.

005.01(B)(ii) PRIVATE DUTY NURSING. Registered nurse (RN) and licensed practical nurse (LPN) providers must submit electronically using the standard Health Care Claim Professional transaction (ASC X12N 837) or use Form MC-82-N: Private Duty Nurse Claim Form. The signed plan of care must be submitted with the claim.

005.02 PAYMENT.

005.02(A) GENERAL PAYMENT REQUIREMENTS. Medicaid will reimburse the provider for services rendered in accordance with the applicable payment regulations codified in 471 NAC 2 and 471 NAC 3. Providers must comply with all applicable billing requirements codified in 471 NAC 2 and 471 NAC 3. In the event the individual payment regulations in 471 NAC 3 conflict with payment regulations outlined in this chapter, the individual payment regulations in this chapter will govern.

005.02(B) SPECIFIC PAYMENT REQUIREMENTS. Medicaid pays for medically prescribed and Department-approved home health agency services provided by Medicare-certified home health agencies.

005.02(B)(i) REIMBURSEMENT. Durable medical equipment and medical supplies are reimbursed according to the payment methodology outlined in 471 NAC 7. Medicaid pays for covered home health agency services and nursing services at the lower of:

(1) The provider's submitted charge; (2) The allowable amount for each respective procedure in the Nebraska Medicaid Home Health Agency Fee Schedule in effect for that date of service; or (3) The maximum allowable fee as established by the Department in the Nebraska Medicaid Nursing Services Fee Schedule in effect for that date of service.

005.02(B)(ii) MEDICARE COVERAGE. Medicare coverage is considered to be the primary source of payment for home health agency services for eligible individuals age 65 and older and for certain disabled beneficiaries. Medicaid does not make payment for services denied by Medicare for lack of medical necessity. Medicaid may cover services denied by Medicare for other reasons if the services are within the scope of Medicaid. Claims submitted to the Department for services provided to Medicare-eligible clients must be accompanied by documentation, which verifies the services are not covered by Medicare. To be covered by Medicaid, these services must be provided in accordance with all requirements in limitations outlined in this chapter.

005.02(B)(iii) MEDICAL SUPPLIES. Payment for supplies normally carried in the nursing bag and incidental to the nursing visit is included in the per visit rate. This includes but is not limited to disposable needles and syringes, disposable gloves, applicators, tongue blades, cotton swabs, 4 x 4's, gauze, bandages. Medical supplies not normally carried in the nursing bag may be provided by pharmacies, medical suppliers, or the home health agency under requirements outlined in 471 NAC 7.

005.02(B)(iv) NURSING SERVICES, REGISTERED NURSE (RN) AND LICENSED PRACTICAL NURSE (LPN), FOR ADULTS AGE 21 AND OLDER. In addition to the requirements and limitations outlined in this chapter, Medicaid applies the following limitations to skilled nursing services, for adults age 21 and older:

(1) Per diem reimbursement for skilled nursing services for the care of ventilator-dependent clients must not exceed the average ventilator per diem of all Nebraska nursing facilities, which are providing that service. This average will be computed using nursing facility's ventilator interim rates that are effective January 1 of each year, and are applicable for that calendar year period; and (2) Per diem reimbursement for all other in-home skilled nursing service will not be changed by the Department for purposes of the Nebraska Medicaid Case Mix System. A record modification may replace an existing record in the Centers for Medicare and Medicaid Services (CMS) Minimum Data Set (MDS) data base, but the Department will not replace the existing record in the Nebraska Medicaid Case Mix system. The record modification will be processed by the Department as an original record. This means that the Department will process the record in the usual manner if the record is not already in the Case Mix system. The Department will reject the record as a duplicate if the record has already been accepted into the Case Mix system. The Department will inactivate a discharge or re-entry tracking record but not an assessment. If determined by the Department to be medically necessary, the per diem reimbursement may exceed this maximum for a short period of time. However, in these cases, the 30-day average of the in-home nursing per diems will not exceed the maximum above. The 30 days are defined to include the days which are paid in excess of the maximum plus those days immediately following, totaling 30.

005.02(B)(v) EXTENDED HOME HEALTH HIGH-TECH RATES. High-tech hourly rates are approved when clients require:

(1) Ventilator care; (2) Tracheostomy care that involves frequent suctioning and monitoring; or (3) Care and observation of unstable, complex medical conditions requiring advanced nursing knowledge and skills.

History

• Effective 2024-05-05

Chapter 10 Hospital Services

Neb. Admin. Code tit. 471, ch. 10 Hospital Services {#sec-471-nac-10 omnilex-key=us-ne-regs-official--title-471--471 NAC 10}

TITLE 471 NEBRASKA MEDICAL ASSISTANCE PROGRAM SERVICES

CHAPTER 10 HOSPITAL SERVICES

001. SCOPE AND AUTHORITY. These regulations govern the services provided under Nebraska’s Medicaid program as defined by the Medical Assistance Act, Nebraska Revised Statute (Neb. Rev. Stat.) §§ 68‑901 et seq.

002. DEFINITIONS. The following definitions apply:

002.01 ALLOWABLE COSTS. Those costs as provided in the Medicare statutes and regulations for routine service costs, inpatient ancillary costs, capital-related costs, medical education costs, and malpractice insurance costs.

002.02 ALL-PATIENT REFINED DIAGNOSIS-RELATED GROUP (APR DRG). The All-Patient Refined Diagnosis-Related Group (APR DRG) software application that assigns patients into categories based on severity of illness and risk of mortality.

002.03 AMBULATORY ROOM AND BOARD.Accommodations for families and beneficiaries undergoing acute, long-term inpatient or outpatient hospital treatment. To qualify for this service, the location of the hospital where the beneficiary is receiving care must be 90 miles or greater from the beneficiary’s or family’s home.

002.04 ANCILLARY SERVICES. Ancillary services are supportive or diagnostic measures that supplement and support a primary physician, nurse, or other healthcare provider in treating a patient.

002.05 BASE YEAR. The period covered by the most recent settled Medicare cost report, which will be used for purposes of calculating prospective rates.

002.06 CAPITAL-RELATED COSTS. Those costs, excluding tax-related costs, as provided in the Medicare regulations and statutes in effect for each facility's base year.

002.07 CASE-MIX INDEX. An arithmetical index measuring the relative average resource use of discharges treated in a hospital compared to the statewide average.

002.08 Clinical Trials. For services not subject to Food and Drug Administration (FDA) approval, clinical trials fall into one of three phases.

002.08(A) PHASE I CLINICAL TRIALS. Initial introduction of an investigational service into humans.

002.08(B) PHASE II CLINICAL TRIALS. Controlled clinical studies conducted to evaluate the effectiveness of the service for a particular indication or medical condition of the patient; these studies are also designed to determine the short-term side effects and risks associated with the new service.

002.08(C) PHASE III CLINICAL TRIALS. Clinical studies to further evaluate the effectiveness and safety of a service that is needed to evaluate the overall risk or benefit and to provide an adequate basis for determining patient selection criteria for the service as the recommended standard of care. These studies usually compare the new service to the current recommended standard of care.

002.09 COMORBIDITY. The simultaneous presence of two chronic diseases, or conditions, in a patient.

002.10 COORDINATION PLAN. An overall program outline for the delivery of a specific service; it is not an individual patient care plan.

002.11 COST OUTLIER. Cases which have an extraordinarily high cost as established in this title as eligible for additional payments above and beyond the initial diagnosis-related group (DRG) payment.

002.12 CRITICAL ACCESS HOSPITAL (CAH). A hospital licensed as a critical access hospital (CAH) by the Department of Health and Human Services, Division of Public Health, and certified for participation by Medicare as a critical access hospital (CAH).

002.13 DIAGNOSIS-RELATED GROUP (DRG). A group of similar diagnoses combined based on patient age, birth weight, procedure coding, comorbidity, and complications.

002.14 DIAGNOSIS-RELATED GROUP (DRG) WEIGHT. A number that reflects relative resource consumption as measured by the relative costs by hospitals for discharges associated with each diagnosis-related group (DRG) and severity of illness .

002.15 DIAGNOSTIC SERVICE. An examination or procedure performed either on the patient, or materials obtained from the patient, to provide information for the diagnosis or treatment of a disease or to assess a medical condition. This may include radiological and pathological services.

002.16 DIALYSIS. A process by which waste products are removed from the body by diffusion from one fluid compartment to another across a semi-permeable membrane.

002.17 DIRECT MEDICAL EDUCATION (DME) COST PAYMENT. An add-on to the operating cost payment amount to compensate for direct medical education (DME) costs associated with approved intern and resident programs.

002.18 DISTINCT PART UNIT. A Medicare-certified hospital-based substance use disorder, psychiatric, or physical rehabilitation unit that is certified as a distinct part unit for Medicare.

002.19 DURABLE MEDICAL EQUIPMENT. Equipment which withstands repeated use is primarily and customarily used to serve a medical purpose, generally is not useful to a person in the absence of an illness or injury, and is appropriate for use in the beneficiary’s home.

002.20 EMERGENCY MEDICAL CONDITION. A medical or behavioral condition, the onset of which is sudden, manifesting itself by symptoms of sufficient severity such that the absence of immediate medical attention could result in:

(A) Placing the health of the beneficiary or with respect to a pregnant woman, the health of the woman or her unborn child in serious jeopardy;

(B) Serious impairment to such person's bodily functions;

(C) Serious dysfunction of any bodily organ or part; or

(D) With respect to a pregnant woman who is having contractions:

(i) Inadequate time to effect a safe transfer to another hospital before delivery; or

(ii) That transfer may pose a threat to the health or safety of the woman or the unborn child.

002.21 EXTENDED STAY. An inpatient hospital stay during which a beneficiary no longer requires acute in-patient care, and more than five days for discharge planning have passed.

002.22 HEALTH CARE-ACQUIRED CONDITIONS (HAC). A health care-acquired condition (HAC) means a condition occurring in any inpatient hospital setting, identified as a hospital-acquired condition (HAC) by Medicare that is reasonably preventable and was not present or identifiable at hospital admission but is either present at discharge or documented after admission .

002.23 HOSPITAL EMERGENCY SERVICES. Services that are necessary to prevent the death of the beneficiary or serious impairment of the beneficiary’s health and, because of the threat to the life or health of the beneficiary , necessitate the use of the most accessible hospital equipped to provide the necessary services.

002.24 HOSPITAL INPATIENT SERVICES. Services that:

(A) Are ordinarily furnished in a hospital for the care and treatment of inpatients;

(B) Are furnished under the direction of a physician or dentist;

(C) Are furnished in an institution that:

(i) Is maintained primarily for the care and treatment of patients with disorders other than mental diseases;

(ii) Is licensed or formally approved as a hospital by an officially designated authority for state standard-setting;

(iii) Is enrolled with and certified by Medicare for participation as a hospital; and

(iv) Has in effect a utilization review (UR) plan, applicable to all Nebraska Medicaid beneficiaries, that meets the requirements of federal regulations , unless a waiver has been granted by the Secretary of the United States Department of Health and Human Services; and

(D) Do not include special needs facilities and independent clinical laboratory services furnished by a hospital with a swing-bed approval.

002.25 HOSPITAL MERGERS. Hospitals that have combined into a single entity, and have applied for and received a single inpatient Medicare provider number and a single inpatient Nebraska Medicaid provider number.

002.26 HOSPITAL OUTPATIENT OBSERVATION SERVICES. Outpatient observation services are those services furnished by a hospital on the hospital premises, including use of a bed and periodic monitoring by a hospital’s nursing staff or other staff, which are reasonable and necessary to determine the need for a possible admission to the hospital as an inpatient. Some beneficiaries may require a second day of outpatient observation services. A maximum of 48 hours of outpatient observation may be reimbursed. When a beneficiary receives hospital outpatient observation services and is thereafter admitted as an inpatient of the same hospital, the hospital observation services are included in the hospital's payment for the inpatient services.

002.27 HOSPITAL OUTPATIENT SERVICES. Preventive, diagnostic, therapeutic, rehabilitative, or palliative services that are provided to outpatients under the direction of a physician, optometrist, ophthalmologist, audiologist, or dentist in an institution that meets provider requirements.

002.28 HOSPITAL-AFFILIATED AMBULATORY SURGICAL CENTER (HAASC). An ambulatory surgical center (ASC) operated by a hospital. A hospital-affiliated ambulatory surgical center (HAASC) may be covered under Medicare, and therefore under Nebraska Medicaid, as an ambulatory surgical center (ASC) or a hospital-affiliated ambulatory surgical center (HAASC).

002.29 HOSPITAL-SPECIFIC BASE YEAR OPERATING COST. Hospital-specific operating allowable cost associated with treating Nebraska Medicaid beneficiaries. Operating costs include the major moveable equipment portion of capital-related costs but exclude the building and fixtures portion of capital-related costs, direct medical education (DME) costs, indirect medical education (IME) costs, and graduate medical education costs.

002.30 HOSPITAL-SPECIFIC COST-TO-CHARGE RATIO (CCR). Hospital-specific cost-to-charge ratio (CCR) is based on total hospital aggregate costs divided by total hospital aggregate charges. Hospital-specific cost-to-charge ratios (CCR) used for outlier cost payments and transplant diagnosis-related group (DRG) cost-to-charge ratio (CCR) payments are derived from the outlier cost-to-charge ratios (CCR) in the Medicare inpatient prospective payment system.

002.31 INDEPENDENT CLINICAL LABORATORY . A laboratory which is operated by or under the supervision of a hospital or the organized medical staff of the hospital which does not meet the definition of a hospital is considered to be an independent laboratory. However, a laboratory serving hospital inpatients and outpatients and operated on the premises of a hospital which meets the definition of a hospital is presumed to be subject to the supervision of the hospital or its organized medical staff and is not classified as an independent clinical laboratory. The hospital's certification covers the services performed in this laboratory.

002.32 INDIRECT MEDICAL EDUCATION (IME) COST PAYMENT. Payment for costs that are associated with maintaining an approved medical education program, but that are not reimbursed as part of direct medical education cost payments.

002.33 INFANT OR INFANCY. The time period from an individual’s birth through completion of one year of age.

002.34 INPATIENT. A beneficiary who has been admitted to a medical institution as an inpatient on the recommendation of a physician or dentist and who:

(A) Receives room, board, and professional services in the institution for a 24-hour period or longer; or

(B) Is expected by the institution to receive room, board, and professional services in the institution for a 24-hour period or longer even though it later develops that the beneficiary dies, is discharged, or is transferred to another facility and does not actually stay in the institution for 24 hours.

002.35 INPATIENT DAYS. The number of days of care covered for inpatient hospital services is always in units of full days. A day begins at midnight and ends 24 hours later. The midnight-to-midnight method is to be used in counting days of care for Nebraska Medicaid reporting purposes, even if the hospital uses a different definition of a day for statistical or other purposes. The day of admission is counted as a full day.

002.35(A) PART OF DAY. Except for the day of admission, a part of a day, including the day of discharge, death, or a day on which a beneficiary begins a leave of absence, is not counted as a day. Charges for ancillary services on the day of discharge or death, or the day on which a beneficiary begins a leave of absence are covered. If inpatient admission and discharge or death occur on the same day, the day is considered a day of admission and counted as one inpatient day.

002.35(B) ANCILLARY AREAS. When a registered inpatient is occupying any other ancillary area, such as surgery or radiology, at the census-taking hour before occupying an inpatient bed, the beneficiary must be included in the inpatient census of the routine care area, not the ancillary area.

002.35(C) MEDICARE METHODOLOGY. The methodology that Medicare requires to be used to account for inpatient accommodations on the Medicare cost report.

002.36 LONG-TERM ACUTE CARE HOSPITAL (LTACH). A hospital that is licensed as a general acute care hospital that focuses on treating patients requiring extended hospital-level care, typically following initial treatment at a general acute care hospital. Patients treated in a long-term acute care hospital (LTACH) are not generally appropriate for lower level of care (LOC) settings but are expected to improve to lower level of care (LOC) status.

002.37 NEBRASKA MEDICAID ALLOWABLE INPATIENT CHARGES. Nebraska Medicaid allowable inpatient charges equal the total claim submitted charges less the non-allowable amount.

002.38 NEBRASKA MEDICAID ALLOWABLE INPATIENT DAYS. Nebraska Medicaid allowable inpatient days are the total number of covered Nebraska Medicaid inpatient days.

002.39 NEBRASKA MEDICAID RATE PERIOD. The period of July 1 through the following June 30.

002.40 MEDICAL NECESSITY. Health care services and supplies which are medically appropriate and:

(A) Necessary to meet the basic health needs of the beneficiary ;

(B) Rendered in the most cost-efficient manner and type of setting appropriate for the delivery of the covered service;

(C) Consistent in type, frequency, and duration of treatment with scientifically based guidelines of national medical, research, or health care coverage organizations or governmental agencies;

(D) Consistent with the diagnosis of the condition;

(E) Required for means other than convenience of the beneficiary or his or her physician;

(F) No more intrusive or restrictive than necessary to provide a proper balance of safety, effectiveness, and efficiency;

(G) Of demonstrated value; and

(H) No more intense level of service than can be safely provided.

002.41 MEDICAL REVIEW. Review of Nebraska Medicaid claims, including validation of hospital diagnosis and procedure coding information; continuation of stay; completeness; adequacy; quality of care; appropriateness of admission; discharge and transfer; and appropriateness of prospective payment outlier cases.

002.42 MEDICAL SOCIAL SERVICES. Medical social services are those social services which contribute meaningfully to the treatment of a beneficiary’s condition.

002.43 MEDICAL SUPPLIES. Expendable or specified reusable supplies required for care of a medical condition and used in the beneficiary’s home must be prescribed by a physician or other licensed practitioner within the scope of their licensure. This includes dressings, colostomy supplies, catheters, and other similar items.

002.44 MEDICARE COST REPORT. The report filed by each facility with its Medicare intermediary. A hospital that does not participate in the Medicare program will complete the Medicare cost report in compliance with Medicare principles and supporting rules, regulations, and statutes. The hospital will file the completed form with Nebraska Medicaid within five months after the end of the hospital's reporting period. A 30-day extension of the filing period may be granted if requested in writing before the end of the five-month period. Completed Medicare cost reports are subject to audit by Nebraska Medicaid or its designees. If a nursing facility is affiliated with the hospital, the nursing facility cost report must be filed as outlined in these regulations.

002.45 NEONATAL INTENSIVE CARE. Intensive care services provided to an infant in an intensive care unit specially equipped to care for infants.

002.46 NEW OPERATIONAL FACILITY. A new operational facility is created neither by virtue of a change in ownership nor by the construction of additional beds to an existing facility. A new operating facility provides inpatient hospital care that meets one of the following criteria:

(A) A licensed newly constructed facility, which either totally replaces an existing facility, or which is built at a site where hospital inpatient services have not previously been provided;

(B) A licensed facility which begins providing hospital inpatient services in a building at a site where those services have not previously been provided; or

(C) A licensed facility which is reopened at the same location where hospital inpatient care has previously been provided but not within the previous 12 months.

002.47 NON-PATIENT. A beneficiary receiving services who is neither an inpatient nor an outpatient. When a sample or specimen is obtained by personnel not employed by the hospital and is sent to the hospital for tests, the tests are non-patient services because the beneficiary is not registered as an inpatient or an outpatient of the hospital. If the sample is obtained by hospital personnel, the tests are outpatient services.

002.48 NURSERY CARE. Services for a newborn child from time of birth to time of discharge of the mother from the facility.

002.49 OPERATING COST PAYMENT AMOUNT. The calculated payment that compensates hospitals for operating cost, including the major moveable equipment portion of capital-related costs, but excluding the building and fixtures portion of capital-related costs, direct medical education (DME) costs, and graduate medical education costs.

002.50 OTHER PROVIDER-PREVENTABLE CONDITIONS (OPPC). A wrong surgical or other invasive procedure performed on a patient; surgical or other invasive procedure performed on the wrong body part; surgical or other invasive procedure performed on the wrong patient.

002.51 ORTHOTICS. Rigid or semi-rigid devices to prevent or correct physical deformity or malfunction, to support a weak or deformed part of the body, or to eliminate motion in a diseased or injured part of the body.

002.52 OUTPATIENT. A person who has not been admitted as an inpatient but is registered on the hospital records as an outpatient and receives services.

002.53 PASS OR LEAVE OF ABSENCE. A patient is absent from the hospital but has not been discharged from the facility. A hospital may place a patient on a leave of absence when readmission is expected, and the patient does not require a hospital level of care during the interim period.

002.54 PATHOLOGICAL SERVICES. Microbiological, serological, chemical, hematological, radiobioassay, cytological, immunohematological, or other pathological examinations or procedures performed on materials obtained from the patient to provide information for the diagnosis or treatment of a disease or an assessment of the medical condition of the patient.

002.55 Present on Admission (POA) Indicator. A status code the hospital uses on an inpatient claim that indicates if a condition was present or incubating at the time the order for inpatient admission occurs.

002.56 Prosthetic. A device which replaces a missing part of the body.

002.57 Provider-Preventable Conditions (PPC). An umbrella term which is defined as two distinct categories: health care-acquired conditions (HCAC) and other provider-preventable conditions (OPPC).

002.58 Radiological Services. Services in which x-rays or rays from radioactive substances are used for diagnostic or therapeutic purposes and associated medical services necessary for the diagnosis and treatment of the patient.

002.59 Reporting Period. Same reporting period as that used for its Medicare cost report.

002.60 Resource Intensity. The relative volume and types of diagnostic, therapeutic, and bed services used in the management of a particular disease.

002.61 Risk of Mortality (ROM). The likelihood of dying.

002.62 RURAL EMERGENCY HOSPITAL. A hospital licensed as a rural emergency hospital by the Department of Health and Human Services, Division of Public Health, and certified for participation by Medicare as a rural emergency hospital. A rural emergency hospital solely provides outpatient services, including emergency department services, observation care, and additional outpatient medical and health services that do not exceed an annual per patient length of stay of 24 hours on average.

002.63 Severe Obesity. Body Mass Index greater than 35.

002.64 Severity of Illness Level . The extent of physiologic decompensation or organ system loss of function.

002.65 SWING BED. Post-hospital 24-hour skilled nursing care services that must be provided by or under the direct supervision of professional or technical personnel and requires skilled knowledge, judgment observation, and assessment.

002.66 SWING BED FACILITY. A rural acute hospital which is certified to provide skilled nursing facility (SNF) level of care.

002.67 Tax-Related Costs. Any real or personal property tax, sales tax, excise tax, tax enacted pursuant to federal public laws or any amendments thereto, franchise fee, license fee, or hospital specific tax, fee or assessment imposed by the local, state, or federal government, but not including income taxes.

002.68 Therapeutic Services. Services and supplies which are not diagnostic services, are furnished incident to the services of physicians and practitioners, and which aid physicians and practitioners in the treatment of patients.

002.69 TRANSPLANT DIAGNOSIS-RELATED GROUPS (DRG). Transplant diagnosis- related groups (DRG) are identified in the All-Patient Refined Diagnosis-Related Group (APR DRG). Nebraska Medicaid does not recognize bone marrow transplant diagnosis-related groups in its classification with all other transplant diagnosis-related groups categorized by the All-Patient Refined Diagnosis-Related Group (APR DRG). Bone marrow transplant diagnosis-related groups do not receive a transplant cost-to-charge ratio or transplant direct medical education (DME) payment. The bone marrow transplant diagnosis-related groups per discharge payment is the sum of the operating cost payment amount, the capital-related cost payment, and when applicable a direct medical education (DME) cost payment, indirect medical education (IME) cost payment, and a cost outlier payment.

002.70 Uncompensated Care. Uncompensated care includes the difference between costs incurred and payments received in providing services to Nebraska Medicaid beneficiary and uninsured.

002.71 Ward. Either:

(A) A large room in the hospital for the accommodation of several patients; or

(B) A division within a hospital for the care of numerous patients having the same condition.

003. PROVIDER REQUIREMENTS.

003.01 General Provider Requirements. To participate in Nebraska Medicaid, hospital providers must comply with all the applicable participation requirements.

003.02 Specific Provider Requirements. To participate in Nebraska Medicaid, a hospital that provides hospital inpatient, outpatient, or emergency room services must:

(i) Be maintained primarily for the care and treatment of patients with disorders other than mental disease;

(ii) Be licensed as a hospital by the Department of Health and Human Services, Division of Public Health or the officially designated authority for state standard-setting in the state where the hospital is located;

(iii) Have licensed and certified hospital beds; and

(iv) Be enrolled with Medicare as a hospital .

003.02(A) Provider Agreement. To participate in Nebraska Medicaid, a hospital must complete the appropriate Nebraska Medicaid approved provider agreement form and submit the completed form to the Department. A copy of the appropriate Nebraska Medicaid approved certification form , must be submitted as part of the enrollment process.

003.02(B) Independent Clinical Laboratory. An independent clinical laboratory must be independent both of an attending or consulting physician's office, and of a hospital. A clinical laboratory must meet the following criteria:

(i) When state or applicable local law provides for licensing of independent clinical laboratories, the laboratory must be licensed under the law; and

(ii) The laboratory must also meet the health and safety requirements prescribed by the United States Secretary of Health and Human Services.

003.02(C) Providers of Portable X-Ray Services. To be approved as a Nebraska Medicaid provider, providers of portable x-ray services must be certified by the Centers for Medicare & Medicaid Services (CMS) . Each provider must submit a copy of the appropriate Nebraska Medicaid approved certification form , and remain in compliance with federal regulations . An out-of-state portable x-ray provider must provide Nebraska Medicaid with verification of certification from the Centers for Medicare & Medicaid Services (CMS) . Nebraska Medicaid approves or denies enrollment as a Nebraska Medicaid provider based on the certification information received from the Centers for Medicare & Medicaid Services (CMS) .

003.02(C)(i) Applicability of Health and Safety Standards. Health and safety standards outlined in Nebraska regulations will apply to all providers of portable x-ray services, except physicians who provide immediate personal supervision during the administration of diagnostic x-ray services. Payment is made only for services of approved providers who have been found to meet the standards.

003.02(D)( Approval as an Ambulatory Room and Board Provider. Only hospitals are approved as ambulatory room and board providers. To be eligible to receive Nebraska Medicaid payment for ambulatory room and board services, each hospital providing those services must be enrolled with Nebraska Medicaid as a provider for hospital services and must submit the appropriate Nebraska Medicaid approved room and board agreement form. Additional information may be requested from the hospital to approve ambulatory room and board services.

003.02(D)((i) Provider Re-Approval. Each hospital approved by Nebraska Medicaid to provide ambulatory room and board services must seek re-approval of its ambulatory room and board services from Nebraska Medicaid when any of the following occur:

(1) The charge to Nebraska Medicaid for ambulatory room and board services changes;

(2) There is a change in the physical location of the ambulatory room and board facility or the distance from the hospital building;

(3) There is a change in the services the hospital is able to provide to beneficiaries in the ambulatory room and board facility; or

(4) Other substantial changes are made to the hospital's ambulatory room and board services.

004. SERVICE REQUIREMENTS.

004.01 General Requirements.

004.01(A) Medical Necessity. Services and supplies that do not meet the definition of medical necessity are not covered. The fact that the physician has performed or prescribed a procedure or treatment or the fact that it may be the only treatment for a particular injury, sickness, or mental illness does not mean that it is covered by Nebraska Medicaid. Services and supplies which do not meet the definition of medical necessity set out above are not covered. Approval by the Food and Drug Administration (FDA) or similar approval does not guarantee coverage by Nebraska Medicaid. Licensure or certification of a particular provider type does not guarantee Nebraska Medicaid coverage.

004.01(B) Prior Authorization. Physicians must request prior authorization from Nebraska Medicaid before providing:

(1) Medical transplants;

(2) Abortions;

(3) Cosmetic and reconstructive surgery;

(4) Bariatric surgery for obesity;

(5) Out-of-state services, except emergency services provided out-of-state ;

(6) Established procedures of questionable current usefulness;

(7) Procedures which tend to be redundant when performed in combination with other procedures;

(8) New procedures of unproven value;

(9) Certain drug products;

(10) All attended sleep studies; and

(11) Ventricular assist devices.

004.01(B)(i) Prior Authorization Procedures. The physician must request prior authorization for the services in the section above in writing.

004.01(B)(i)(1) Request for Additional Evaluations. Additional evaluations may be requested and must be provided when Nebraska Medicaid determines that the medical history for the request is questionable or when there is not sufficient information to support the requirements for authorization.

004.01(B)(i)(2) Notification Process. Upon determination of approval or denial, a written response is provided to the following, as applicable, and depending on the source of the request:

(a) Physician(s) submitting or contributing to the request;

(b) Caseworker or case manager; and

(c) Medical review organization when appropriate.

004.01(B)(ii) Verbal Authorization Procedures. A verbal authorization may be issued when circumstances are of an emergency nature, or urgent to the extent that a delay would place the beneficiary at risk of not receiving medical care. When a verbal authorization is granted, a written request must be submitted within 14 days of the verbal authorization.

004.01(B)(iii) Billing and Payment Requirements. Claims submitted to Nebraska Medicaid for services requiring prior authorization will not be paid without written or electronic approval. A copy of the approval letter or notification of authorization issued by Nebraska Medicaid must be submitted with all claims related to the procedure or service authorized.

004.02 SPECIFIC REQUIREMENTS.

004.02(A) Services Provided for BENEFICIARIES Enrolled in Nebraska Medicaid. Certain Nebraska Medicaid beneficiaries are required to participate in the Nebraska Medicaid Managed Care Program . Services provided to beneficiaries enrolled in a managed care plan are not billed to Nebraska Medicaid . The provider must provide services only under arrangement with the managed care organization (MCO). The prior authorization requirements, payment limitations, and billing instructions outlined in this chapter do not apply to services provided to beneficiaries enrolled in a managed care plan with the following exceptions:

(i) Transplants continue to require prior authorization by Nebraska Medicaid and are reimbursed on a fee-for-service basis, outside the managed care organization’s (MCO) capitation payment;

(ii) Abortions require prior authorization by Nebraska Medicaid and are included in the capitation fee for the managed care organization (MCO); and

(iii) The beneficiary must be able to obtain family planning services upon request and from any appropriate provider who is enrolled in Nebraska Medicaid. Family planning services are reimbursed by the managed care organization (MCO), regardless of whether the service is provided by a primary care provider (PCP) enrolled with the managed care organization (MCO) or a family planning provider outside the managed care organization (MCO).

004.02(B) Prior Authorization for Transplant Services. Transplant services are reimbursed on a fee-for-service basis. Prior authorization is required for all transplant services. Physicians must request prior authorization before performing any transplant service or related donor service.

004.02(B)(i) PRIOR AUTHORIZATION REQUIREMENTS. Prior authorization requests must include at a minimum:

(1) The patient's name, Nebraska Medicaid identification number , and date of birth;

(2) Diagnosis, pertinent past medical history and treatment, prognosis with and without the transplant, and the procedure(s) for which the authorization is requested;

(3) Name of the hospital, city, and state where the service(s) will be performed, including the National Provider Identification number of the provider. All providers must be enrolled with Nebraska Medicaid before services are performed. ;

(4) Name of the physician(s) who will perform the surgery if other than the physician requesting authorization; and

(5) In addition to the above information, a physician specializing in the specific transplantation must also supply the following:

(a) The screening criteria used in determining that a beneficiary is an appropriate candidate for the requested transplant;

(b) The results of that screening for this beneficiary ; and

(c) A written statement by the physician:

(i) Recommending the transplant;

(ii) Certifying and explaining why the transplant is medically necessary as the only clinical, practical, and viable alternative to prolong the beneficiary’s life in a meaningful, qualitative way and at a reasonable level of functioning; and

(iii) Psycho-social evaluation for solid organ transplants, except for heart and liver transplants. A second physician specializing in the specific transplant must also supply a second written statement meeting the above criteria.

004.02(C) Prior Authorization for BARIATRIC Surgery. Prior authorization requests must include documentation of all of the following:

(i) Medical diagnoses;

(ii) Body mass index 35 or greater with one of the following co-morbidities:

(1) Type 2 Diabetes Mellitus including recent lab results and current medications;

(2) Medically refrectory hypertension including current medications, antihypertensive, and blood pressure readings;

(3) Hyperlipidema including recent lab results and current medications;

(4) Cardiovascular disease;

(5) Coronary Artery Disease;

(6) Obstructive sleep apnea including sleep study results and treatment;

(7) Obesity-hypoventilation syndromes;

(8) Gastroesophageal Reflux Disease including test results and current medications ;

(9)Osteoarthritis including information about the beneficiary’s ability to ambulate, assistive devices used, and any medications ; or

(10)Idiopathic intracranial hypertension pseudo tumor cerebri ; and

(iii) Preoperative evaluation within six months of the scheduled surgery must include:

(1) Nutritional consultation that includes:

(a) Diet and physical activity history and patterns of previous weight loss and regain;

(b) Counseling on steps to modify current problem eating behaviors;

(c) Counseling on postoperative dietary modifications; and

(d) Determination of the beneficiary’s motivation to comply with dietary modifications to reduce the risk of postoperative complications;

(2) Psychiatry or psychology consultation that includes:

(a) Evaluation of the beneficiary to determine readiness for surgery and lifestyle change;

(b) Assessment for major mental health disorders, psychosocial functioning, alcohol and substance use disorder, and maladaptive eating behaviors; and

(c) Adequate treatment as needed, to maximize successful postoperative outcomes; and

(3) Medical clearance that includes:

(a) Evaluation of cardiac and pulmonary risk;

(b) Nutritional, hormonal, and other lab parameters as indicated;

(c) No history of tobacco use, or tobacco cessation has been attempted prior to surgery; and

(d) Beneficiary’s understanding of surgical risk, postoperative compliance, and follow-up.

004.03 Covered Inpatient Services.

004.03(A) Bed and Board. The same amount is paid for inpatient services whether the beneficiary has a private room, a semiprivate room, or ward accommodations.

004.03(B) Nursing Services. Nursing and other related services and use of hospital facilities for the care and treatment of inpatients are included in the hospital's payment for inpatient services.

004.03(C) Services of Interns and Residents-In-Training. The reasonable cost of the services of interns or residents-in-training are covered under a teaching program approved by the Council on Medical Education of the American Medical Association or, in the case of an osteopathic hospital, approved by the Committee on Hospitals of the Bureau of Professional Education of the American Osteopathic Association.

004.03(C)(i) Approved Programs for Podiatric Interns and Residents-In-Training. The services of interns and residents-in-training in the field of podiatry under a teaching program approved by the Council on Podiatry Education of the American Podiatry Association are covered under Nebraska Medicaid on the same basis as the services of other interns and residents-in-training in approved teaching programs.

004.03(C)(ii) Dental Interns and Residents-In-Training. For services of interns or residents-in-training in the field of dentistry in a hospital or osteopathic hospital, the teaching program must be approved by the Council of Dental Education of the American Dental Association.

004.03(D) Outpatient OR Emergency Services. When a beneficiary receives hospital outpatient or emergency room services and is thereafter admitted as an inpatient of the same hospital before midnight of the same day, the hospital outpatient or emergency room services are covered by Nebraska Medicaid as inpatient services. Hospital outpatient services furnished in the outpatient or emergency room to a beneficiary classified as dead on arrival are covered through pronouncement of death, providing the hospital considers these beneficiaries as outpatients for recordkeeping purposes and follows its usual outpatient billing practices for services to all patients. This coverage does not apply if the beneficiary was pronounced dead before arrival at the hospital.

004.03(E) Ancillary Services. Payment for the ancillary services described in this section is included in the payment for inpatient services. Outpatient services must be claimed using the appropriate national standard code sets.

004.03(F) Blood Administration. For beneficiaries who are receiving both Medicare and Nebraska Medicaid benefits, Nebraska Medicaid covers the first three pints of blood. Autologous blood donation processing costs are not covered for reimbursement by Nebraska Medicaid. Nebraska Medicaid covers any blood administration not covered by Medicare or other third-party insurance if it is medically necessary. Hospitals must distinguish between blood and blood processing costs under the following rules:

(i) A hospital's blood costs will consist of amounts it spends to procure blood, including:

(1) The cost of activities as soliciting and paying donors and drawing blood for its own blood bank; and

(2) When a hospital purchases blood from an outside blood source an amount equal to the amount of credit which the outside blood source customarily gives the hospital if the blood is replaced.

(ii) A hospital's blood processing costs consist of amounts spent to process and administer blood after it has been procured, including:

(1) The cost of such activities as storing, typing, cross-matching, and transfusing blood;

(2) The cost of spoiled or defective blood. This cost does not include blood that is spoiled or defective as a result of general storage expiration; and

(3) The portion of the outside blood source's blood fee which remains after credit is given for replacement.

004.03(G) Personal Care Items. Personal care items are covered when they are necessary for the care of a beneficiary during inpatient or outpatient services.

004.03(H) LONG-TERM ACUTE CARE HOSPITAL (LTACH) SERVICES. Long-term acute care hospital (LTACH) admission may be considered when continued daily monitoring and complex medical intervention is required for the complex medical condition(s). Prior authorization is required for long-term acute care level of care (LOC) as follows:

004.04 Drugs.

004.04(A) Inpatient Drugs. Drugs for use in the hospital which are ordinarily provided by the hospital for the care and treatment of inpatients are covered. Payment for inpatient drugs is included in the hospital's payment for inpatient services.

004.04(B) Hospital Outpatient or Emergency Room Drugs. Drugs utilized in the actual treatment as part of the outpatient or emergency room service are covered. The hospital must bill drugs used in the outpatient or emergency room service by National Drug Code (NDC) on the appropriate Nebraska Medicaid approved health care claim form Providers must also report the quantity and unit of measure of the National Drug Code (NDC). Include the correct National Drug Code (NDC) information on all claims, including Medicare and other third-party claims.

004.05 Medical Supplies and Equipment.

004.05(A) Inpatient Supplies and Equipment. Supplies and equipment provided to inpatients for use during the inpatient stay are covered. These are included in the hospital's payment for inpatient services. Certain items used during the beneficiary’s inpatient stay are included in the hospital's payment for inpatient services even though they leave the hospital with the beneficiary . This includes items used in the actual treatment of the beneficiary which are permanently or temporarily inserted in or attached to the beneficiary’s body.

004.05(B) Hospital Outpatient and Emergency Room Supplies and Equipment. Medically necessary supplies and equipment used for outpatient and emergency room services are covered. This includes items used in the actual treatment of the beneficiary as well as items necessary to facilitate the beneficiary's discharge.

004.05(C) Take-Home Supplies and Equipment. The following supplies and equipment are covered:

(1) Up to a ten-day supply of take-home supplies following an inpatient or outpatient service. Durable medical equipment must be billed by a recognized durable medical equipment provider with the exception of rental apnea monitors and home phototherapy units.

004.05(C)(i) Infant Apnea Monitors. Rental of home infant apnea monitors is covered for infants with medical conditions that require monitoring due to a specific medical diagnosis only if prescribed by and used under the supervision of a physician. Proper infant evaluation by the physician and parent or caregiver training must occur before placement of infant apnea monitor. Payment for hospital apnea monitoring services provided to an inpatient is included in the hospital payment for inpatient services.

004.05(C)(ii) PHOTOTHERAPY SERVICES. Phototherapy equipment is covered on a rental basis for infants that meet the following criteria:

(a) Neonatal hyperbilirubinemia is the infant's sole clinical problem;

(b) The infant is greater than or equal to 37 weeks gestational age and birth weight greater than 2,270 gm or five lbs.;

(c) The infant is greater than 48 hours of age;

(d) Bilirubin level at initiation of phototherapy greater than 48 hours of age is 14-18 mgs per deciliter. Home phototherapy is not covered if the bilirubin level is less than 12 mgs at 72 hours of age or older; and

(e) Direct bilirubin level is less than two mgs per deciliter.

004.06 Laboratory and Pathology.

004.06(A) PROFESSIONAL COMPONENT. The professional component of laboratory services provided by a physician is covered to an individual patient in accordance with this title . The professional component must be billed on the appropriate Nebraska Medicaid approved health care claim form .

004.06(B) CLINICAL LAB SERVICES. Clinical laboratory services are considered technical components and must be billed as such. The technical component of clinical laboratory services provided to hospital inpatients, outpatients, and non-patients performed by non-physicians manually or using automated laboratory equipment is covered. Payment is made to the hospital as follows:

(1) The hospital may include inpatient service costs on its cost report to be considered in calculating the hospital's payment rate.

(2) Outpatient clinical laboratory services must be itemized on the appropriate claim form or electronic format using the appropriate Healthcare Common Procedure Coding System (HCPCS) procedure codes. Payment is made pursuant to the fee schedule determined by Centers for Medicare & Medicaid Services (CMS).

(3) Payment is made pursuant to the fee schedule determined by Centers for Medicare & Medicaid Services (CMS) for non-patient services.

004.06(B)(i) LEASED DEPARTMENTS. Leased department status has no bearing on billing or payment for clinical lab services. The hospital must claim all clinical lab services, whether performed in a leased or non-leased department. Payment for the total service, which includes the professional and technical component, is made to the hospital. Separate payment is not made for the professional component for clinical lab services.

004.06(C) ANATOMICAL PATHOLOGY SERVICES. Anatomical pathology services require a physician's interpretation. If these services are provided to hospital inpatients or outpatients, the professional and technical components must be separately identified for billing and payment. There is no separate payment made to the pathologist for routine clinical lab services. To be paid, the pathologist must negotiate with the hospital to arrange a salary or compensation agreement.

004.06(C)(i) BILLING AND PAYMENT FOR HOSPITAL INPATIENT ANATOMICAL PATHOLOGY SERVICES. Payment for the technical component of anatomical pathology is included in the hospital's payment for inpatient services which is claimed on the appropriate claim form or electronic format as an ancillary service. The hospital may include these costs on its cost report to be considered in calculating the hospital's payment rate. The pathologist must claim the professional component of anatomical pathology on the appropriate Nebraska Medicaid approved health care claim form using the appropriate Healthcare Common Procedure System Procedure Code (HCPCS) and modifier .

004.06(C)(i)(1) EXCEPTION. If an anatomical pathology specimen is obtained from a hospital inpatient but is referred to an independent laboratory or the pathologist of a second hospital's laboratory, the independent lab or the pathologist of the second hospital's laboratory to which the specimen has been referred may claim payment for the total service on the appropriate Nebraska Medicaid approved health care claim form .

004.06(C)(ii) BILLING AND PAYMENT FOR HOSPITAL OUTPATIENT ANATOMICAL PATHOLOGY SERVICES. The hospital must bill the technical component of outpatient anatomical pathology services in a summary bill format using the appropriate revenue code on the appropriate claim form or electronic format. The pathologist must claim the professional component on the appropriate Nebraska Medicaid approved health care claim form using the appropriate Healthcare Common Procedure System Procedure Code (HCPCS) and modifier .

004.06(C)(ii)(1) EXCEPTION. If an anatomical pathology specimen is obtained from a hospital outpatient and is referred to an independent lab or the pathologist of a second hospital's laboratory, the independent lab or the pathologist of a second hospital's laboratory to which the specimen was referred may claim payment for the total service on the appropriate Nebraska Medicaid approved health care claim form .

004.06(C)(iii) BILLING AND PAYMENT FOR NON-PATIENT ANATOMICAL PATHOLOGY SERVICES. For specimens from non-patients referred to the hospital, the hospital must bill the total service on the appropriate claim form or electronic format using the appropriate revenue code.

004.06(C)(iv) LEASED DEPARTMENTS. If the pathology department is leased and an anatomical pathology service is provided to a hospital non-patient, the pathologist must claim the total service, which includes the professional and technical components, on the appropriate Nebraska Medicaid approved health care claim form . Leased department status has no bearing on billing for or payment for hospital inpatient or outpatient anatomical pathology services.

004.06(D) ADJUSTMENT BASED ON LEGISLATIVE APPROPRIATIONS. The starting point for the payment amounts must be adjusted by a percentage. This percentage will be determined by Nebraska Medicaid as required by the available funds appropriated by the Nebraska Legislature.

004.07 HOSPITAL DIAGNOSTIC AND THERAPEUTIC SERVICES. Hospital diagnostic and therapeutic services are procedures performed to determine the nature and severity of an illness or injury, or procedures used to treat disease or disorders. Hospital diagnostic and therapeutic services include both hospital inpatient and outpatient services. Hospital diagnostic and therapeutic services are comprised of two distinct elements: the professional component and the technical component.

004.07(A) TECHNICAL COMPONENT. The technical component of hospital diagnostic and therapeutic services is comprised of two distinct elements:

(1) Physicians' professional services not directly related to the medical care of the individual beneficiary; and

(2) Hospital services.

004.07(A)(i) INPATIENT TECHNICAL COMPONENT. Payment for the technical component of inpatient services is included in the hospital's payment for inpatient services whether provided directly or under arrangement with an outside provider. The hospital is responsible for payment of all services provided to an inpatient under arrangement by an outside provider, except ambulance services, to the outside provider for inpatient services, if the service is provided under arrangement.

004.07(A)(ii) OUTPATIENT AND NON-PATIENT TECHNICAL COMPONENT. The technical component of outpatient and non-patient services must be claimed by the provider actually providing the service. Nebraska Medicaid’s payment for the technical component includes payment for all non-physician services required to provide the procedure.

004.07(B) NON-PHYSICIAN SERVICES AND ITEMS. All non-physician services, drugs, medical supplies, and items, provided to hospital inpatients or outpatients must be provided directly by the hospital or under arrangements. If the services or items are provided under arrangements, the hospital is responsible for payment to the non-physician provider or supplier. The unbundling of costs by hospitals for non-physician services or supplies provided to hospital patients is prohibited, including ancillary services provided by another hospital.

004.08 RADIOLOGY. Medically necessary radiological services provided to inpatients and outpatients are covered. Only those services which are directly related to the beneficiary's diagnosis are covered and the provider must indicate the diagnosis which reflects the condition for which the service is performed on the claim from, and if necessary, include a notation on the claim which documents the need. A radiological laboratory is not considered an independent laboratory under Nebraska Medicaid. All radiology services have a technical component and a professional component, including physician interpretation. The professional and technical component of hospital services must be separately identified for billing and payment.

004.08(A) PROFESSIONAL COMPONENT. The professional component of radiology services provided by a physician to an individual beneficiary is covered in accordance with this chapter .

004.08(B) TECHNICAL COMPONENT. The technical component of hospital radiology services is covered.

004.08(C) MAMMOGRAMS. Diagnostic and screening mammograms are covered. Mammography services are covered only for providers who have met Medicare certification criteria for mammography services.

004.08(C)(i) SCREENING MAMMOGRAPHY. One screening mammogram is covered annually according to the periodicity schedule and guidelines of the American Cancer Society.

004.08(C)(ii) DIAGNOSTIC MAMMOGRAPHY. Diagnostic mammograms are covered based on the medical necessity of the service.

004.08(D) PORTABLE X-RAY SERVICES. Diagnostic x-ray services provided by a certified portable x-ray provider are covered when provided in a place of residence used as the beneficiary's home and in nonparticipating institutions. These services must be performed under the general supervision of a physician and certain conditions relating to health and safety must be met.

004.08(D)(i) COVERED PORTABLE X-RAY SERVICES. The following portable x-ray services are covered:

(1) Skeletal films involving arms and legs, pelvis, vertebral column, and skull;

(2) Chest films which do not involve the use of contrast media; and

(3) Abdominal films which do not involve the use of contrast media.

004.08(D)(ii) SPECIAL NEEDS FACILITIES. Diagnostic portable x-ray services are covered when provided in participating special need facilities, under circumstances in which they cannot be covered as special need facilities services. If portable x-ray services are provided in a participating hospital under arrangement, the hospital must bill Nebraska Medicaid for the service.

004.08(D)(iii) ELECTROCARDIOGRAMS. The taking of an electrocardiogram tracing by an approved supplier of portable x-ray services can be covered as an other diagnostic test. The health and safety standards in this chapter must be met.

004.08(D)(iv) CERTIFIED PROVIDERS. Providers of portable x-ray services must be certified by the Centers for Medicare & Medicaid Services (CMS) .

004.08(D)(iv)(1) NEBRASKA PORTABLE X-RAY PROVIDER. The provider must submit the appropriate Nebraska Medicaid approved certification form .

004.08(D)(iv)(2) OUT-OF-STATE PORTABLE X-RAY PROVIDER. Nebraska Medicaid approves or denies enrollment based on verification of certification information received from the Centers for Medicare & Medicaid Services (CMS) .

004.08(D)(v) APPLICABILITY OF HEALTH AND SAFETY STANDARDS. Health and safety standards apply to all providers of portable x-ray services, except physicians who provide immediate personal supervision during the administration of diagnostic x-ray services. Payment is made only for services of approved providers who have been found to meet the standards.

004.08(D)(v)(1) CONDITIONS OF COVERAGE NOTIFICATION. When the services of a provider of portable x-ray services no longer meet the conditions of coverage, physicians responsible for supervising the portable x-ray services and having an interest in the x-ray provider's certification status must be notified. The notification action regarding suppliers of portable x-ray equipment is the same as required for decertification of independent laboratories, and the same procedures are followed.

004.08(E) RADIOLOGY FOR ANNUAL PHYSICAL EXAMS FOR BENEFICIARIES RESIDING IN NURSING FACILITIES AND INTERMEDIATE CARE FACILITIES FOR INDIVIDUALS WITH DEVELOPMENTAL DISABILITIES (ICF/DD). All long-term care facility (LTC) residents are required to have an annual physical examination. The physician, based on their authority to prescribe continued treatment, determines the extent of the examination for Nebraska Medicaid beneficiaries based on medical necessity.

004.08(F) BILLING AND PAYMENT FOR RADIOLOGY SERVICES.

004.08(F)(i) BILLING AND PAYMENT FOR HOSPITAL INPATIENT RADIOLOGY SERVICES. Payment for the technical component of inpatient radiology services is included in the hospital's payment for inpatient services. These costs may be included on the hospital's cost report to be considered in calculating the hospital's payment rate. Physicians must claim the professional component of inpatient radiology services on the appropriate Nebraska Medicaid approved health care claim form using the appropriate healthcare procedure code and modifier .

004.08(F)(ii) BILLING AND PAYMENT FOR HOSPITAL OUTPATIENT RADIOLOGY SERVICES. The hospital must claim the technical component of outpatient radiology services on the appropriate claim form or electronic format. Payment is made according to this chapter . The physician must claim the professional component on the appropriate Nebraska Medicaid approved health care claim form using the appropriate Healthcare Common Procedure Coding System (HCPCS) procedure code and modifier .

004.08(F)(iii) BILLING AND PAYMENT FOR NON-PATIENT RADIOLOGY SERVICES. If a radiology procedure is performed for a non-patient, the hospital must claim the total component on the appropriate claim form or electronic format.

004.08(F)(iv) LEASED DEPARTMENTS. If the radiology department is leased and the service is provided to a non-patient, the radiologist must claim the total service - both technical and professional components, on the appropriate Nebraska Medicaid approved health care claim form .

004.09 OUTPATIENT DIAGNOSTIC SERVICES PROVIDED BY ARRANGEMENT. Medically necessary diagnostic services provided to an outpatient by arrangement.

004.09(A) Specimen Collection Fees. Separate charges made by laboratories for drawing or collecting specimens are allowable whether or not the specimens are referred to another hospital or laboratory for testing. This fee will be paid to the provider who extracted the specimen from the beneficiary. Only one collection fee is allowed for each type of specimen for each beneficiary encounter, regardless of the number of specimens drawn. When a series of specimens is required to complete a single test, the series is treated as a single encounter. A specimen collection fee is allowed for activities such as drawing a blood sample through venipuncture or collecting a urine sample by catheterization.

004.09(A)(i) SPECIMENS COLLECTED OUTSIDE OF THE HOSPITAL. A specimen collection fee is allowed when it is medically necessary for a laboratory technician to draw a specimen from a beneficiary who resides in a nursing facility or who is homebound. The technician must personally draw the specimen. A specimen collection fee is not allowed for a visiting technician when a beneficiary in a facility is not confined to the facility or when the facility has personnel on duty qualified to perform the specimen collection.

004.09(A)(ii) TRAVEL EXPENSES. The fees allowed for a visiting technician cover the travel expenses of the technician, as well as the specimen drawing service, and the material and supplies used. Exceptions to this rule may be made when it is clear that the payment is inequitable in light of the distances the technician must travel to perform the test for nursing home or homebound beneficiaries in rural areas.

004.09(A)(iii) NON-COVERED SERVICES. A specimen collection fee is not allowed for samples where the cost of collecting the specimen is minimal.

004.10 AMBULANCE SERVICES. A hospital-based ambulance service is an ambulance service owned and operated by a hospital. Providers of ambulance services must meet the licensure and certification requirements of the Department of Health and Human Services, Division of Public Health. Providers of hospital-based ambulance services must comply with all applicable requirements in this title.

004.10(A) BILLING FOR HOSPITAL-BASED AMBULANCE SERVICES. Hospital-based ambulance services provided to an inpatient or an outpatient must be claimed on the appropriate claim format or electronic format as a hospital outpatient service by the hospital-based ambulance provider. Hospital-based ambulance services are reimbursed as a hospital outpatient service. Hospital-based ambulance costs are not included in the calculations for hospital inpatient rates.

004.10(B) GROUND AMBULANCE SERVICES. Nebraska Medicaid covers basic life support and advanced life support ambulance services. Ground ambulance base rates include all services, equipment, and other costs.

004.10(B)(i) BASIC LIFE SUPPORT (BLS) AMBULANCE. A basic life support (BLS) ambulance provides transportation plus the equipment and staff needed for basic services .

004.10(B)(ii) ADVANCED LIFE SUPPORT (ALS) SERVICES. An advanced life support (ALS) ambulance provides transportation and has complex specialized life-sustaining equipment and equipment for radio-telephone contact with a physician or hospital.

.

004.10(C) MILEAGE. Miles traveled while the beneficiary is present in the ambulance vehicle is covered for out-of-town ambulance transports. Out-of-town transports are defined as trips in which the final destination of the beneficiary is outside the limits of the town in which the trip originated. Mileage traveled while the beneficiary is not present in the ambulance vehicle is included in the payment for the base rate.

004.10(D) THIRD ATTENDANT. A third attendant is covered only if the circumstances of the transport requires three attendants. The circumstances which required the third attendant must be documented on or with the claim when billing Nebraska Medicaid. Payment for a third attendant cannot be made when the third attendant is:

(i) Needed because a crew member is not qualified to provide a service; or

(ii) Staff provided by the hospital to accompany a beneficiary during transport.

004.10(E) WAITING OR STANDBY TIME. Waiting or standby time is separately reimbursed only when unusual circumstances exist. The unusual circumstances including why the ambulance waited and where the wait took place must be documented on or with the claim when billing Nebraska Medicaid. When waiting time is covered, the first one-half hour is not reimbursed. Payment for waiting time under normal circumstances is included in the payment for the base rate.

004.10(F) AIR AMBULANCE. Medically necessary air ambulance services are covered only when transportation by ground ambulance is contraindicated and:

(1) Great distances or other obstacles are involved in getting the beneficiary to the destination;

(2) Immediate and rapid admission is essential; or

(3) The point of pickup is inaccessible by land vehicle.

004.10(F)(i) BILLING. When billing Nebraska Medicaid, the provider must bill air ambulance services as a single charge which includes base rate and mileage. The number of miles traveled while the beneficiary is present must be included on the claim. If a determination is made that ambulance transport is medically necessary, but ground ambulance would have been appropriate, payment for the air ambulance service is limited to the amount allowable for ground transport.

004.10(G) LIMITATIONS AND REQUIREMENTS FOR CERTAIN AMBULANCE SERVICES.

004.10(G)(i) EMERGENCY AND NON-EMERGENCY TRANSPORTS. Emergency transports are defined as services provided after the sudden onset of a medical condition manifesting itself by acute symptoms of sufficient severity that the absence of immediate medical attention could reasonably be expected to result in:

(a) Placing the beneficiary’s health in serious jeopardy;

(b) Serious impairment to bodily functions; or

(c) Serious dysfunction of any bodily organ or part.

004.10(G)(i)(1) NON-EMERGENT TRANSPORT. Any ambulance transport that does not meet the definition of an emergency transport must be billed as a non-emergency transport. This includes all scheduled runs regardless of origin and destination and transports to nursing facilities or to the beneficiary’s home.

004.10(G)(ii) TRANSPORTS TO THE FACILITY WHICH MEETS THE NEEDS OF THE BENEFICIARY . Ambulance services are covered to enable the beneficiary to obtain medical care in a facility or from a physician or practitioner that most appropriately meets the needs of the beneficiary , including:

(1) Support from the beneficiary’s community or family; or

(2) Care from the beneficiary’s own physician, practitioner, or a qualified physician or practitioner or specialist.

004.10(G)(iii) TRANSPORTS TO A PRACTITIONER'S OFFICE, CLINIC, OR THERAPY CENTER. Emergency ambulance transports to a physician or practitioner's office, clinic, or therapy center are covered. Non-emergency ambulance transports to a physician or practitioner's office, clinic, or therapy center are covered when:

(1) The beneficiary is bed confined before, during, and after transport; and

(2) The services cannot reasonably be expected to be provided at the beneficiary’s home including a nursing facility or intermediate care facilities for individuals with developmental disabilities (ICF/DD).

004.10(G)(iv) ROUND TRIP TRANSPORTS FOR HOSPITAL INPATIENTS. Ambulance services provided to a beneficiary receiving hospital inpatient services, where the beneficiary is transported to another facility for services and the beneficiary is returned to the originating hospital for continuation of inpatient care, are not included in the payment to the hospital for inpatient services and must be billed by the hospital-based ambulance provider.

004.10(G)(v) COMBINED ADVANCED LIFE SUPPORT (ALS) AND BASIC LIFE SUPPORT (BLS) TRANSPORTS. When a beneficiary is transferred from a basic life support (BLS) ambulance to an advanced life support (ALS) ambulance, the advanced life support (ALS) service may be billed, however only one ambulance provider may submit the claim for the service.

004.10(G)(v)(1) ADVANCED LIFE SUPPORTS (ALS) BILLING. When the placement of advanced life support (ALS) personnel and equipment on board a basic life support (BLS) ambulance qualifies the basic life support (BLS) ambulance as an advanced life support (ALS) ambulance, the advanced life support (ALS) service may be billed.

004.10(G)(vi) TRANSPORT OF MORE THAN ONE BENEFICIARY . When more than one beneficiary is transported during a single trip, a base rate is covered for each beneficiary transported. The number of miles and mileage charges must be prorated among the number of beneficiaries being billed. A notation that the mileage is prorated and why must be on or with the claim when billing Nebraska Medicaid.

004.10(G)(vii) TRANSPORT OF MEDICAL TEAMS. Transport of a medical team or other medical professionals to meet a beneficiary is not separately reimbursed. If the transport of the medical team results in an ambulance transport of the beneficiary , the services are included in the base rate of the beneficiary’s transport.

004.10(G)(viii) TRANSPORT OF DECEASED BENEFICIARIES . Ambulance services are covered if the beneficiary is pronounced dead while in route to or upon arrival at the hospital. Ambulance services are not covered if a beneficiary is pronounced dead before the beneficiary is transported.

004.11 PRE-ADMISSION TESTING. Pre-admission testing and diagnostic services rendered up to three days before the day of admission are covered, as an ancillary service.

004.11(A) NON-COVERED TESTING. Pre-admission testing is not covered when performed in a physician's office or as an outpatient which is performed solely to meet hospital pre-admission requirements.

004.12 HOSPITAL ADMISSION DIAGNOSTIC PROCEDURES. In addition to meeting medical necessity requirements, the major factors which are considered to determine that a diagnostic procedure performed as part of the admitting procedure to a hospital is reasonable and medically necessary are:

(A) The test is specifically ordered by the attending physician, or a hospital staff physician responsible for the beneficiary when there is no admitting physician ;

(B) The test is medically necessary for the diagnosis or treatment of the individual beneficiary's condition; and

(C) The test does not unnecessarily duplicate:

(i) The same test performed on an outpatient basis before admission; or

(ii) The same test performed in connection with a separate, but recent, hospital admission.

004.13 THERAPEUTIC SERVICES. Therapeutic services, that a hospital provides to an inpatient or outpatient are those services which are incidental to the services of the physicians in the treatment of beneficiaries. Covered therapeutic services to hospital inpatients or outpatients include the services of therapists and equipment necessary for therapeutic services.

004.13(A) COVERED SERVICES – PHYSICAL THERAPY (PT), OCCUPATIONAL THERAPY (OT), AND SPEECH-LANGUAGE PATHOLOGY SERVICES. Physical therapy (PT), occupational therapy (OT), speech-language pathology, and audiology services are covered in accordance with this title.

004.13(B) RESPIRATORY THERAPY. Respiratory therapy is covered when provided by a respiratory therapist or technician in accordance with the conditions and criteria outlined in this title .

004.14 ANESTHESIOLOGY.

004.14(A) PROFESSIONAL COMPONENT. The professional component of anesthesiology services provided by a physician to an individual beneficiary is covered in accordance with this title . Rural hospitals that have been exempted by their Medicare fiscal intermediary for certified registered nurse anesthetist (CRNA) billing must follow the Medicare billing requirements.

004.14(A)(i) MEDICAL DIRECTION OF FOUR OR FEWER CONCURRENT PROCEDURES. The professional component for the physician's personal medical direction of concurrent anesthesiology services provided by qualified anesthetists is covered, such as certified registered nurse anesthetists (CRNA), in accordance with this chapter . The professional component of personal services up to and including induction is covered as a physician's service and must be billed on the appropriate Nebraska Medicaid approved health care claim form .

004.14(B) TECHNICAL COMPONENT. If the physician leaves the immediate area of the operating suite for longer than short durations, devotes extensive time to an emergency case, or is otherwise not available to respond to the immediate needs of surgical , beneficiaries the physician's services to the surgical beneficiary are supervisory in nature and are considered a technical component.

004.14(B)(i) MEDICAL DIRECTION OF MORE THAN FOUR CONCURRENT PROCEDURES. If the physician is involved in providing direction for more than four concurrent procedures or is performing other services while directing the concurrent procedures, the concurrent anesthesia services are covered as the technical component of the hospital services. The physician must ensure that a qualified individual performs any procedure in which the physician does not personally participate.

004.14(C) STANDBY ANESTHESIA SERVICES. A physician's standby anesthesia services are covered when the physician is physically present in the operating suite, monitoring the beneficiary’s condition, making medical judgments regarding the beneficiary's anesthesia needs and ready to furnish anesthesia services to a specific beneficiary who is known to be in potential need of services. The professional component must be billed on the appropriate Nebraska Medicaid approved health care claim form .

004.14(D) CERTIFIED REGISTERED NURSE ANESTHETIST (CRNA). The hospital may engage the services of a certified registered nurse anesthetist (CRNA), either on a salary or fee-for-service basis, under arrangements which provide for billing to be made by the hospital. Reimbursement for the service when provided to an inpatient or outpatient is included in the payment rate under Nebraska Medicaid.

004.15 OUTPATIENT SURGICAL PROCEDURE. When a beneficiary with a known diagnosis enters a hospital for a specific surgical procedure or other treatment that is expected to keep the beneficiary in the hospital for less than 24 hours, and this expectation is realized, the beneficiary will be considered an outpatient regardless of the hour of admission; whether or not the beneficiary used a bed; and whether or not the beneficiary remained in the hospital past midnight. If the beneficiary receives 24 or more hours of care, the beneficiary is considered an inpatient regardless of the hour of admission or whether the beneficiary remained in the hospital past midnight or the census-taking hour.

004.16 OUTPATIENT OBSERVATION SERVICES. A maximum of 48 hours of outpatient observation is covered. After 48 hours, the beneficiary must either be admitted as an inpatient, by written order, or discharged.

004.17 HOSPITAL DENTAL SERVICES. Dental care and oral surgery are effectively provided in an office setting. Dental services may be provided in a hospital or ambulatory surgical center (ASC) when the beneficiary has medical or behavioral conditions that warrant these settings to maintain beneficiary safety. These services must be provided, billed, and reimbursed in accordance with the provisions of this title .

004.18 OTHER ANCILLARY SERVICES.

004.18(A) EMERGENCY ROOM PHYSICIANS' SERVICES. The hospital must bill Nebraska Medicaid for emergency room physicians' services on the appropriate Nebraska Medicaid approved health care claim form using the physician's provider number.

004.18(B) DIALYSIS SERVICES. Both hemodialysis and peritoneal dialysis are covered as acceptable modes for treatment of end stage renal disease.

004.18(B)(i) INPATIENT DIALYSIS SERVICES. Dialysis services provided to a beneficiary who is an inpatient are considered to be inpatient services.

004.18(B)(ii) OUTPATIENT DIALYSIS SERVICES. Outpatient dialysis services are those dialysis services provided to a beneficiary who is an outpatient. Outpatient dialysis services must be provided by a Medicare certified renal dialysis facility.

004.18(B)(iii) PAYMENT FOR OUTPATIENT DIALYSIS SERVICES. Outpatient dialysis services are reimbursed at the provider's current Medicare composite rate for the services provided. Payment excludes the cost of physician services.

005. NON-COVERED SERVICES. Non-covered services will not be covered by Nebraska Medicaid. Services will be reviewed on a case-by-case basis to determine if they are covered or not.

005.01 SERVICES REQUIRED TO TREAT COMPLICATIONS OR CONDITIONS RESULTING FROM NON-COVERED SERVICES. Payment for medically necessary services that are required to treat complications or conditions resulting from non-covered services may be made.

005.02 EXPERIMENTAL AND INVESTIGATIONAL SERVICES. Medical services which are considered investigational or experimental or which are not generally employed by the medical profession are not covered. While the circumstances leading to participation in an experimental or investigational program may meet the definition of medical necessity, payment is prohibited for these services.

005.02(A) RELATED SERVICES. Associated or adjunctive services that are directly related to non-covered experimental or investigational services are not covered. All medically necessary expenses incurred which are not directly related to the non-covered experimental or investigative services will be paid. Complications of non-covered services may be covered once the non-covered service is completed.

005.02(B) COVERAGE REQUESTS FOR NEW SERVICES. Requests for Nebraska Medicaid coverage for new services or those which may be considered experimental or investigational must be submitted to Nebraska Medicaid before providing the services, or in the case of true medical emergencies, before submitting a claim. The request for coverage must include sufficient information to document that the new service is not considered investigational or experimental for Nebraska Medicaid payment purposes. Reliable evidence must be submitted identifying the status with regard to the criteria below, cost-benefit data, short and long-term outcome data, patient selection criteria that is both disease or condition specific and age specific, information outlining under what circumstances the service is considered the accepted standard of care, and any other information that would be helpful to Nebraska Medicaid in deciding coverage issues. Additional information may be requested by Nebraska Medicaid.

005.02(C) INVESTIGATIONAL OR EXPERIMENTAL CRITERIA. Services are deemed investigational or experimental by Nebraska Medicaid , who may convene ad hoc advisory groups of experts to review requests for coverage. A service is deemed investigational or experimental if it meets any one of the following criteria:

(i) There is no Food and Drug Administration (FDA) or other governmental or regulatory approval given, when appropriate, for general marketing to the public for the proposed use;

(ii) Reliable evidence does not permit a conclusion based on consensus that the service is a generally accepted standard of care employed by the medical profession as a safe and effective service for treating or diagnosing the condition or illness for which its use is proposed. Reliable evidence includes peer reviewed literature with statistically significant data regarding the service for the specific disease, proposed use, and age group. Also, facility specific data, including short and long-term outcomes, must be submitted to the Nebraska Medicaid;

(iii) The service is available only through an institutional review board (IRB) research protocol for the proposed use or subject to such an institutional review board (IRB) process; or

(iv) The service is the subject of an ongoing clinical trial(s) that meets the definition of a phase I, phase II, or phase III clinical trial, regardless of whether the trial is actually subject to Food and Drug Administration (FDA) oversight and regardless of whether an institutional review board (IRB) process or protocol is required at any one particular institution.

005.03 CUSTODIAL OR RESPITE CARE. Hospital services that are custodial or respite care are not covered.

005.04 PRIVATE-DUTY NURSING. The services of a private-duty nurse or other private-duty attendant are not covered as a hospital service.

005.05 PROSTHETICS. External powered prosthetic devices are not covered.

005.06 FACILITY BASED PHYSICIAN CLINICS. Physician clinic services provided in a hospital, or a facility under the hospital’s licensure, are considered to be a physician's service and are reimbursed accordingly.

005.07 TOBACCO CESSATION SERVICES. Tobacco cessation services are not covered as a hospital service.

005.08 HOSPITAL ACQUIRED CONDITIONS (HAC). No payment will be made for treatment of conditions that are a result of avoidable inpatient hospital complications and medical errors that are identifiable, preventable, and serious in their consequences to beneficiaries . Any diagnosis code(s) which are flagged as hospital acquired will be excluded from the final claim All Patient Refined Diagnosis-Related Group (APR DRG) determination.

005.09 NON-COVERED PORTABLE X-RAY SERVICES. The following portable x-ray services are not covered:

(A) Procedures involving fluoroscopy;

(B) Procedures involving the use of contrast media;

(C) Procedures requiring the administration of a substance to the beneficiary, injection of a substance into the beneficiary, or special manipulation of the beneficiary ;

(D) Procedures which require special medical skill or knowledge possessed by a doctor of medicine or doctor of osteopathy or which require that medical judgment be exercised;

(E) Procedures requiring special technical competency or special equipment or materials;

(F) Routine screening procedures; and

(G) Procedures which are not of a diagnostic nature.

006. LIMITATIONS AND REQUIREMENTS FOR CERTAIN SERVICES.

006.01 PRIOR AUTHORIZATION PROCEDURES. The physician must request prior authorization in writing or through the appropriate electronic request prior to providing the service described in this chapter.

006.02 HIV TESTING FOR ACQUIRED IMMUNE DEFICIENCY SYNDROME. Payment for HIV testing is limited to medical necessity.

006.02(A) NON-COVERED HIV TESTING. HIV testing is not covered when there is no history of risk as defined in this chapter . This includes the following:

(i) Routine prenatal screening;

(ii) Routine pre-operative testing;

(iii) Educational or employment requirements;

(iv) Entrance requirements for the armed services; and

(v) Insurance applications.

006.03 MINOR SURGICAL PROCEDURES. Reimbursement for excision of lesions of the skin or subcutaneous tissues includes all services and supplies necessary to provide the service. Nebraska Medicaid does not make additional reimbursement for suture removal to the physician who performed the initial service or to a hospital. If the sutures are removed by a non-hospital-based physician who is not the physician who provided the initial service, Nebraska Medicaid may approve separate payment for the suture removal.

006.04 TREATMENT FOR OBESITY. Services provided when the sole diagnosis is obesity will not be covered. While obesity is not itself considered an illness, there are conditions which can be caused by or aggravated by obesity. Treatment for obesity can be covered when the services are an integral and necessary part of a course or treatment.

006.04(A) INTESTINAL BY-PASS SURGERY. This procedure is not considered to be reasonable and necessary and it is not covered .

006.04(B) BARIATRIC SURGERY FOR OBESITY. Bariatric surgery for beneficiaries with extreme obesity can be covered when the surgery is:

(1)Medically appropriate for the beneficiary; and

(2)Performed to correct an illness which caused the obesity or was aggravated by the obesity.

006.04(B)(i) COVERAGE CONDITIONS. This procedure must be performed at a facility that is accredited by the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) or a children’s hospital that has a comprehensive multidisciplinary bariatric surgery program and provides access to an experienced surgeon who employs a team that is capable of long-term follow-up of the metabolic and psychosocial needs of the beneficiary and family. Proof of accreditation must be submitted with each prior approval request.

006.05 COSMETIC AND RECONSTRUCTIVE SURGERY. Cosmetic and reconstructive surgical procedures and medical services are covered when medically necessary for the purpose of correcting the following conditions:

(i) Limitations in movement of a body part caused by trauma or congenital conditions;

(ii) Disfiguring or painful scars in areas that are visible;

(iii) Congenital birth anomalies that result in functional impairment or are severely disfiguring;

(iv) Post-mastectomy breast reconstruction; and

(v) Other procedures determined to be restorative or necessary to correct a medical condition.

006.05(A) EXCEPTIONS. To determine the medical necessity of the condition, prior authorization for cosmetic and reconstructive surgical procedures is required except for the following conditions:.

(i) Cleft lip and cleft palate;

(ii) Post-mastectomy breast reconstruction;

(iii) Congenital hemangioma's of the face; and

(iv) Nevus removals.

006.06 STERILIZATIONS.

006.06(A) COVERAGE RESTRICTIONS. Payment for sterilization of beneficiaries is prohibited when the beneficiary is :

(i) Under the age of 21 on the date the beneficiaries is prohibited when the beneficiary is signs the appropriate Nebraska Medicaid approved consent form ; or

(ii) Legally incapable of consenting to sterilization.

006.06(B) COVERAGE CONDITIONS. Sterilizations are only covered when:

(i) The sterilization is performed because the beneficiary receiving the service made a voluntary request for services;

(ii) The beneficiary is advised at the outset and before the request or receipt of their consent to the sterilization that benefits provided by programs or projects will not be withdrawn or withheld because of a decision not to be sterilized;

(iii) Beneficiaries whose primary language is other than English must be provided with the required elements for informed consent in their primary language; and

(iv) Suitable arrangements must be made to communicate the required elements of informed consent to a beneficiary who is blind, deaf or hard of hearing, or otherwise disabled.

006.06(C) PROCEDURE FOR OBTAINING SERVICES. Non-therapeutic sterilizations are covered by Nebraska Medicaid only when:

(1) Legally effective informed consent is obtained on the appropriate Nebraska Medicaid approved consent form from the beneficiary on whom the sterilization is to be performed. The surgeon must submit a properly completed and legible appropriate Nebraska Medicaid approved consent form to Nebraska Medicaid before payment of claims can be considered; and

(2) The sterilization is performed at least 30 days following the date informed consent was given. To calculate this time period, day one is the first day following the date on which the form is signed by the beneficiary . Day 31 in this period is the first day on which the procedure could be covered by Nebraska Medicaid. The consent is effective for 180 days from the date the appropriate Nebraska Medicaid approved consent form is signed.

006.06(C)(i) EXCEPTION. A beneficiary may consent to be sterilized at the time of a premature delivery or emergency abdominal surgery, if at least 72 hours have passed since the beneficiary signed the informed consent for the sterilization. For a premature delivery, the beneficiary must have signed the informed consent at least 72 hours before the surgery is performed and at least 30 days before the expected date of delivery; the expected delivery date must be entered on the appropriate Nebraska Medicaid approved consent form .

006.06(C)(ii) INFORMED CONSENT. Informed consent means the voluntary, knowing assent of the beneficiary who is to be sterilized after the beneficiary has been given the following information:

(a) A clear explanation of the procedures to be followed;

(b) A description of the attendant discomforts and risks that may follow the procedure, including an explanation of the type and possible effects of an anesthetic to be used;

(c) A description of the benefits to be expected;

(d) Counseling concerning appropriate alternative methods, and the effect and impact of the proposed sterilization including the fact that it must be considered an irreversible procedure;

(e) An offer to answer any questions concerning the procedures;

(f) An instruction that the beneficiary is free to withhold or withdraw their consent to the sterilization at any time before the sterilization without prejudicing future care and without loss of other project or program benefits to which the beneficiary might otherwise be entitled;

(g) Advice that the sterilization will not be performed for at least 30 days, except under circumstances previously specified ; and

(h) The beneficiary to be sterilized must be permitted to have a witness of her or his choice present when informed consent was obtained.

006.06(C)(ii)(1) BENEFICIARY RESPONSIBILITY. The required informed consent information is shown on the appropriate Nebraska Medicaid approved consent form , which must be completed by the beneficiary .

006.07 HYSTERECTOMIES. For payment of claims for hysterectomies, the surgeon must submit to Nebraska Medicaid the appropriate Nebraska Medicaid approved consent form , properly signed and dated by the woman in which the woman states that they were informed before the surgery was performed that this surgical procedure results in permanent sterility before claims associated with the hysterectomy can be considered. The completed appropriate Nebraska Medicaid approved consent form must be submitted to Nebraska Medicaid, by the surgeon before claims for the hysterectomy can be considered for payment. A medically necessary hysterectomy will be covered if the following conditions have been met:

(i) The provider who secured authorization to perform the hysterectomy has informed the woman and her representative, if any, orally and in writing, that the hysterectomy will make the woman permanently incapable of reproducing; and

(ii) The woman or her representative, if any, has signed the appropriate Nebraska Medicaid approved consent form acknowledging receipt of that information.

006.07(A) EXCEPTION. Informed consent is not required if:

(1) The woman was already sterile before the hysterectomy and the physician who performs the hysterectomy certifies in writing that the woman was already sterile before the hysterectomy and states the cause of the sterility;

(2) In the case of a post-menopausal woman, Nebraska Medicaid considers the woman to be sterile. All claims related to the procedure must indicate that the woman is post-menopausal; or

(3) The woman requires a hysterectomy because of a life-threatening emergency situation in which the physician determines that informed consent is not possible, and the physician who performs the hysterectomy certifies in writing that the hysterectomy was performed under a life-threatening emergency situation in which the physician determined informed consent was not possible. The physician must also include certification of the emergency.

006.07(A)(i) EXCEPTION CERTIFICATION. A copy of the physician's certification regarding the above exceptions must be submitted to Nebraska Medicaid before consideration for payment for claims associated with the hysterectomy can be submitted.

006.07(B) NON-COVERED HYSTERECTOMIES. A hysterectomy will not be covered if:

(i) It was performed solely to make the woman sterile; or

(ii) If there was more than one purpose for the procedure, it would not have been performed except to make the woman sterile.

006.08 ABORTIONS. Abortions are covered when the life of the mother would be endangered if the fetus were carried to term for which federal financial participation is currently available under federal regulations and the Nebraska Medicaid State Plan. A physician must certify the diagnosis by medical reports which include the name and address of the mother . The treating physician must request and receive prior authorization from Nebraska Medicaid before providing the service . If approved, a letter of authorization will be sent to the provider . In cases of documented emergencies, authorization may be requested after the service has been provided. All other requirements of this subsection must be met.

006.09 INFERTILITY. Coverage for infertility is covered to diagnosis and treat medical conditions when infertility is a symptom of a suspected medical problem. Reimbursement or coverage is not available when the sole purpose of the service is achieving a pregnancy.

006.10 LABOR AND DELIVERY. Reasonable and necessary services associated with pregnancy are covered. Medical care for pregnancy is reimbursable, beginning with diagnosis of the condition, continuing through delivery, and ending after the necessary postnatal care, or termination of pregnancy. Postpartum services are covered through the applicable postpartum period as defined in this chapter for women who were eligible for, applied for, and received medical assistance on the day the pregnancy ends. After the infant is delivered, the infant is treated as a separate patient for reimbursement purposes.

006.10(A) PHYSICIANS’ SERVICES. Routine prenatal care, delivery, post-partum care, and routine urinalysis are covered as a package service for physicians in accordance with this title . Hospitals will not be reimbursed for any physicians' services included in the package service.

006.10(B) EXCEPTIONS. Exceptions may be made to cover hospital outpatient or emergency room services which meet the coverage criteria for medically necessary services which are not included in the physicians' package service.

006.10(C) INPATIENT. If the beneficiary is admitted as an inpatient, and not released the same day, the services are considered inpatient services. If the beneficiary is not admitted as an inpatient, the services are considered outpatient services.

006.11 ALCOHOL AND CHEMICAL DETOXIFICATION. Payment for alcohol and chemical detoxification is limited to medically necessary treatment, subject to Nebraska Medicaid’s utilization review (UR). This coverage period includes up to five days as the beneficiary's condition dictates. A detoxification program for a particular beneficiary may exceed five days and be covered if determined medically necessary by Nebraska Medicaid. Services when the detoxification needs of a beneficiary no longer require an inpatient hospital setting are not covered.

006.12 OSTEOGENIC STIMULATION. Electrical stimulation to augment bone repair can be performed either invasively or non-invasively.

006.12(A) INVASIVE OSTEOGENIC STIMULATION. Use of the invasive device is covered only for non-union of long bone fractures. Non-union is considered to exist only after six months or more have elapsed without the fracture healing.

006.12(B) NON-INVASIVE OSTEOGENIC STIMULATION. Use of the non-invasive device is covered only for:

(i) Non-union of long bone fractures;

(ii) Failed fusion; and

(iii) Congenital pseudarthrosis.

006.13 BIOFEEDBACK THERAPY. Biofeedback therapy is covered only when it is reasonable and necessary for the individual beneficiary for muscle re-education of specific muscle groups or for treating pathological muscle abnormalities of spasticity, incapacitating muscle spasm, or weakness, and more conventional treatments have not been successful. This therapy is not covered for treatment of ordinary muscle tension states, for psychosomatic conditions, or for psychiatric conditions.

006.14 DIAGNOSTIC SERVICES. All reasonable and necessary diagnostic tests given for narcolepsy and sleep apnea are covered when the following criteria are met:

(i) The clinic is affiliated with a hospital;

(ii) Beneficiaries are referred to the sleep disorder clinic by a physician. The clinic must maintain a record of the attending physician's orders with signatures; and

(iii) The need for diagnostic testing is confirmed by medical evidence.

006.14(A) DUPLICATE TESTING. Diagnostic testing that is duplicative of previous testing done by the attending physician to the extent the results are still pertinent is not covered. Most beneficiaries who undergo the diagnostic testing are not considered inpatients, although they may come to the facility in the evening for testing and then leave after their tests are over. The overnight stay is considered an integral part of these tests.

006.15 THERAPEUTIC SERVICES. Therapeutic services may be covered provided they are standard and accepted services, and are reasonable and medically necessary for the beneficiary. Sleep disorder clinics must provide therapeutic services in the hospital outpatient setting. Therapeutic services will be provided for:

(A) Insomnia that is not associated with psychiatric disorders;

(B) Nocturnal myoclonus;

(C) Sleep apnea;

(D) Drug dependency;

(E) Shift work and schedule disturbances;

(F) Restless leg syndrome;

(G) Hypersomnia;

(H) Somnambulism;

(I) Night terrors or dream anxiety attacks;

(J) Enuresis; and

(K) Bruxism.

006.16 CARDIAC STRESS TESTING AND HOSPITAL OUTPATIENT CARDIAC REHABILITATION PROGRAMS. Stress testing is a covered diagnostic procedure for evaluating chest pain and as a component in the development of rehabilitation exercise prescriptions for the treatment of beneficiaries with known cardiac disease provided that during the testing:

(i) A physician is present;

(ii) Emergency equipment is available; and

(iii) A standard emergency procedure plan is in effect.

006.16(A) STRESS TESTING. The use of stress testing in the absence of any specific diagnostic or therapeutic purpose is not covered as reasonable and necessary to the treatment of the beneficiary's condition.

006.16(B) OUTPATIENT. Outpatient cardiac rehabilitation programs consist of individually prescribed physical exercise or conditioning and concurrent telemetric monitoring. When a program is provided by a hospital to its outpatients, the service is covered as an outpatient service.

006.16(B)(i) CARDIAC REHABILITATION EXERCISE PROGRAM. Hospital outpatient services in connection with a cardiac rehabilitation exercise program are considered reasonable and necessary only during that period of time when the beneficiary's condition is such that the exercises can only be carried out safely under the direct, continuing supervision of a physician, and in a hospital environment. The monitoring required in these programs must be carried out by a hospital-employed nurse trained in cardiac rehabilitation with a physician overseeing the monitoring. Although on occasion physical therapists (PT) or occupational therapists (OT) are involved in these programs, they generally act only as exercise leaders. These services do not constitute covered physical therapy (PT) or occupational therapy (OT). Since the type of cardiac rehabilitation exercise program which can be covered requires a hospital setting, this program is not covered in a skilled nursing facility (SNF).

006.16(B)(ii) COVERAGE LIMIT. Coverage is limited to 12 weeks or 36 sessions of a monitored exercise program. For coverage beyond a maximum duration of 12 weeks

or 36 sessions, the provider must submit documentation supporting the beneficiary's need for additional services. Documentation must include:

(1) Progress report and exercise sessions;

(2) Diagnosis;

(3) Cardiac history;

(4) Risk factors;

(5) Other medical problems;

(6) Medications;

(7) Allergies;

(8) Personal habits;

(9) Sources of stress, and support system; and

(10) Treatment plan.

006.17 MEDICAL TRANSPLANTS. Transplants including donor services that are medically necessary and defined as non-experimental by Medicare are covered. If no Medicare policy exists for a specific type of transplant, it will be determined whether the transplant is medically necessary or non-experimental. Transplantation services are covered when performed in a facility approved by Centers for Medicare & Medicaid Services (CMS) as meeting coverage criteria.

006.17(A) PRIOR AUTHORIZATION. Prior authorization of all transplant services or related donor service is required before the services are provided. An exception may be made for emergency situations, in which case verbal approval is obtained and the notification of authorization is sent later. This request for authorization must be submitted in writing or using the standard electronic request form The physician must submit the request for authorization to Nebraska Medicaid in writing or using the standard electronic request form. The Prior Authorization request must include at a minimum:

(i) The beneficiary's name, age, diagnosis, pertinent past medical history and treatment to this point, prognosis with and without the transplant, and the procedure(s) for which the authorization is requested;

(ii) The beneficiary's Nebraska Medicaid number;

(iii) Name of hospital, city, and state where the service(s) will be performed; and

(iv) Name of physician(s) who will perform the surgery, if other than physician requesting authorization:

(1) If authorization is requested for a liver or heart transplant, in addition to the above information, two physicians must also submit a statement recommending the transplant; and

(2) Certifying and explaining why a transplant is medically necessary as the only clinical, practical, and viable alternative to prolong the beneficiary’s life in a meaningful, qualitative way and at a reasonable level of functioning.

006.17(B) SERVICES FOR A NEBRASKA MEDICAID-ELIGIBLE DONOR. Medically necessary services, including laboratory tests directly related to the transplant are covered, for the Nebraska Medicaid-eligible donor to a Nebraska Medicaid-eligible beneficiary . The services must be directly related to the transplant.

006.17(C) SERVICES FOR A NEBRASKA MEDICAID-INELIGIBLE DONOR. Medically necessary services, including laboratory tests directly related to the transplant, for the Nebraska Medicaid-ineligible donor to a Nebraska Medicaid-eligible beneficiary are covered . The services must be directly related to the transplant and must directly benefit the Nebraska Medicaid transplant beneficiary . Coverage of treatment for complications related to the donor is limited to those that are reasonably medically foreseeable. Claims must be submitted under the Nebraska Medicaid-eligible beneficiary’s case number.

006.17(D) ADDITIONAL RECORDS REQUEST. Nebraska Medicaid reserves the right to request any medical documentation from the beneficiary’s record to support and substantiate claims submitted for payment.

006.17(E) PAYOR OF LAST RESORT. Nebraska Medicaid is the payor of last resort.

006.17(F) HOSPITAL INPATIENT SERVICES. Procurement costs include removal of organ, transportation, and associated costs. These costs must be billed by the transplanting hospital on the appropriate claim form or electronic format and separately identified on the Medicare cost report. The hospital must submit copies of the actual invoices for procurement costs, including transportation costs, on the appropriate claim form or electronic format.

006.17(G) Ambulatory Room and Board. Ambulatory room and board services may be covered for transplant patients and an attendant if necessary.

006.18 PHYSICIAN SERVICES. Surgeon(s) services will be paid according to the Nebraska Medicaid Practitioner Fee Schedule. This fee will include two weeks' routine post-operative care by the designated primary surgeon. Payment for routine post-operative care will not be made to other members of the surgical team. Physician services must be billed on the appropriate Nebraska Medicaid approved claim form

006.19 ITINERANT PHYSICIAN VISITS. Non-emergency physician visits provided in a hospital outpatient setting are covered if the services are:

(i) Provided by an out-of-town specialist who has a contractual agreement with the hospital. General practitioners or family practitioners are not considered to be specialists; and

(ii) Determined to have been provided in the most appropriate place of service.

006.19(A) BILLING TECHNICAL COMPONENT. The hospital room charge is considered the technical component of the visit and must be billed on the appropriate Nebraska Medicaid approved claim form .

006.20 INFANT APNEA MONITORS. Rental of home infant apnea monitors for infants with medical conditions that require monitoring due to a specific medical diagnosis is covered only if prescribed by and used under the supervision of a physician. Proper infant evaluation by the physician and parent or caregiver training must occur before placement of infant apnea monitor. Parent or caregiver training is not reimbursed as a service separate from infant apnea monitor rental.

006.20(A) MEDICAL GUIDELINES FOR THE PLACEMENT OF HOME INFANT APNEA MONITORS. Home infant apnea monitoring services for infants, defined as birth through completion of one year of age, who meet one of the following criteria are covered according to criteria under this title.

;

006.20(B) APPROVAL OF HOME INFANT APNEA MONITOR SERVICE PROVIDERS. Rental of home infant apnea monitors and related supplies provided only by approved providers is covered. To ensure all home apnea monitoring needs of infants are met, the development of a home infant apnea monitor coordination plan is required. The coordination plan is not an individual patient plan; it is an overall program outline for the delivery of home apnea monitoring services.

006.20(C) DOCUMENTATION REQUIRED AFTER INITIAL RENTAL PERIOD. Monitor rental exceeding the first two-month prescription period requires that an updated physician's narrative report of the beneficiary progress and a statement of continued need accompany the claim. A new progress report is required every two months. The report must include:

(i) The number of apnea episodes during the previous prescription period;

(ii) The results of any tests performed during the previous prescription period;

(iii) Additional length of time needed; and

(iv) Any additional information the physician may wish to provide.

006.20(D) REMOVING THE INFANT FROM THE MONITOR. Criteria for removing infants from home infant apnea monitoring must be based on the infant's clinical condition. A monitor may be discontinued when apparent life-threatening event (ALTE) infants have had two periods, each of three months duration, free of significant alarms or apnea where vigorous stimulation or resuscitation was not needed. The provider must state the date of removal of the infant monitor on or in the final claim.

006.20(E) COVERED AND NON-COVERED COMPONENTS. Monitors that do not use rechargeable batteries are not covered. Separate payment for remote alarms will not be made. If provided, payment for a remote alarm is included in the monitor rental. Apnea monitor belts, lead wires, and reusable electrodes are covered for rented apnea monitors.

006.20(F) PNEUMOCARDIOGRAMS. Pneumocardiograms are covered for diagnostic or evaluation purposes and when required to determine when the infant may be removed from the monitor. Payment does not include analysis and interpretation.

006.20(G) BILLING. The hospital must bill for the technical component of infant apnea monitor services on the appropriate claim form or electronic format. The provider of the apnea monitor must state the date of removal of the infant monitor on the claim. Physicians' services must be billed as professional services on the appropriate Nebraska Medicaid approved claim form or the standard electronic claim.

006.21 HOME PHOTOTHERAPY. Rental of home phototherapy equipment for infants that require phototherapy is covered when neonatal hyperbilirubinemia is the infant's sole clinical problem when prescribed by and used under the supervision of a physician. To ensure that home phototherapy needs of infants are met, development of a coordination plan is required. The coordination plan is not an individual patient plan; it is an overall program outline for the delivery of home phototherapy services.

006.21(A) APPROVAL OF HOME PHOTOTHERAPY PROVIDERS. Rental of home phototherapy equipment provided by approved providers is covered. Physicians will not be approved as home phototherapy providers.

006.21(A)(i) HOME PHOTOTHERAPY REQUIREMENTS. The following conditions must be met prior to initiation of home phototherapy:

(1) History and physical assessment by the infant's attending physician has occurred. If home phototherapy begins immediately upon discharge from the hospital, the newborn discharge exam will suffice;

(2) Required laboratory studies have been performed, including, complete blood count (CBC), blood type on mother and infant, direct Coombs test, direct and indirect bilirubin;

(3) The physician certifies that the parent or caregiver is capable of administering home phototherapy;

(4) Parent or caregiver have successfully completed training on use of the equipment; and

(5) Equipment must be delivered and set up within four hours of discharge from the hospital or notification of provider, whichever is more appropriate. There must be a 24-hour per day repair or replacement service available.

006.21(A)(ii) BILIRUBIN LEVEL. At a minimum, one bilirubin level must be obtained daily while the infant is receiving home phototherapy.

006.21(B) DISCONTINUING HOME PHOTOTHERAPY. Home phototherapy services will not be covered if the bilirubin level is less than 12 mgs at 72 hours of age or older.

006.21(C) DOCUMENTATION. A physician's narrative report outlining the beneficiary’s progress and the circumstances necessitating extended therapy must be submitted with the claim when billing for home phototherapy exceeding three days.

006.21(D) PAYMENT. Payment for home phototherapy services does not include physician's professional services or laboratory and radiology services related to home phototherapy. These services must be billed by the physician or laboratory performing the service. The daily rental payment includes:

(i) Phototherapy unit and all supplies, accessories, and services necessary for proper functioning and effective use of the therapy;

(ii) A minimum of one daily visit to the home by a licensed or certified health care professional is required. The daily visits must include:

(1) A brief home assessment; and

(2) Collection and delivery of blood specimens for bilirubin testing when ordered by the physician to be collected in the home. The physician must be informed by the provider that this service is available. An outside agency or laboratory with whom the provider contracts for collection and delivery of blood specimens may not bill Nebraska Medicaid directly since payment is included in the daily rental payment. Daily home visits must occur for home assessment even if the blood collection is done outside the home; and

(iii) Complete caregiver training on use of equipment and completion of necessary records.

006.21(E) BILLING REQUIREMENTS. The provider must bill for home phototherapy daily rental services on a single claim and indicate the total number of rental days as the units of service using the appropriate claim form or electronic format as outpatient services.

006.22 COORDINATION PLAN REQUIREMENTS FOR CERTAIN SERVICES. Providers of apnea monitoring services and phototherapy services must maintain, as a part of the provider’s records, a coordination plan, which must include:

(1) An overview of the services provided, including the provider's charge for the services;

(2) Descriptions and literature on the equipment and all supplies and accessories provided;

(3) Copies of all forms, instructions, and record sheets for beneficiary use;

(4) An outline of the training format used to train the beneficiary on use of equipment and other training requirements;

(5) The type and frequency of beneficiary contact and identification and qualifications of personnel conducting beneficiary contacts; and

(6) A statement of the provider's policy on equipment set-up, servicing, and availability for consultation on equipment problems.

006.22(A) CHANGES TO COORDINATION PLAN. The provider must notify Nebraska Medicaid of any changes in the coordination plan. After review of the coordination plan, the provider may be required to amend the coordination plan.

006.22(B) APPROPRIATE HOSPITAL SERVICES. Appropriate home infant apnea monitor services provided by a hospital with an approved infant apnea monitor coordination plan includes rental of the apnea monitor; trend event recorder; and ECG or respirator recorder; purchase of related supplies; and CO2 hypoxia studies.

006.23 AMBULATORY ROOM AND BOARD. Ambulatory room and board is covered as a related transportation and as follows:

006.23(A) APPROVAL AS AN AMBULATORY ROOM AND BOARD PROVIDER. Only hospitals are approved as ambulatory room and board providers. To receive payment, each hospital providing ambulatory room and board services must be enrolled with Nebraska Medicaid as a provider for hospital services.

006.23(A)(i) PROVIDER RE-APPROVAL. Each hospital approved by Nebraska Medicaid to provide ambulatory room and board services must seek re-approval of its ambulatory room and board services from Nebraska Medicaid when any of the following occur:

(1) The charge to Nebraska Medicaid for ambulatory room and board services changes;

(2) There is a change in the physical location of the ambulatory room and board facility or the distance from the hospital building;

(3) There is a change in the services the hospital is able to provide to beneficiaries in the ambulatory room and board facility; or

(4) Other substantial changes are made to the hospital's ambulatory room and board services.

006.23(B) GUIDELINES. Ambulatory room and board services are covered when travel is necessary to seek medical care. Coverage of ambulatory room and board must meet the following guidelines :

(1) The services must be necessary to secure Nebraska Medicaid coverable services, including medical examinations or treatment;

(2) Meals are covered when receipt of Nebraska Medicaid coverable services requires the beneficiary to be away from their home for 12 hours or longer;

(3) An out-of-town overnight stay is necessary while receiving Nebraska Medicaid coverable services or if coverage of ambulatory room and board services will prevent a hospital inpatient stay;

(4) Meals and lodging for up to one day before or after receiving services if extensive travel is necessary; and

(5) Up to one person who accompanies the beneficiary when the beneficiary is physically or mental unable to travel or wait alone.

006.23(B)(i) ADDITIONAL REQUIREMENT. Payment for ambulatory room and board services outside these requirements must be approved Nebraska Medicaid .

006.23(C) DOCUMENTATION. The hospital must include a statement that documents the necessity for ambulatory room and board services for a beneficiary or for a beneficiary and an attendant on the hospital claim.

006.23(D) BILLING AND PAYMENT. The hospital must bill for ambulatory room and board services provided by a Nebraska Medicaid enrolled hospital as an outpatient service on the appropriate claim form or electronic format and the appropriate Healthcare Common Procedure Coding System (HCPCS) procedure codes. Payment will be made using a hospital-specific rate. Payment to the hospital must not exceed its charge for services provided to the general public.

007. BILLING AND PAYMENT FOR HOSPITAL SERVICES.

007.01 PAYMENT.

007.01(A) GENERAL PAYMENT REQUIREMENTS. Services rendered by the provider in accordance with the applicable payment regulations codified in this chapter will be reimbursed .

007.01(B) SPECIFIC PAYMENT REQUIREMENTS.

007.01(B)(i) OUTPATIENT SERVICES. Reimbursement for hospital outpatient services provided to Nebraska Medicaid eligible beneficiaries will be provided on a prospective basis in accordance with the rate methodology for outpatient hospital and emergency room services. Reimbursement for the following services is included in the prospective rate payment for hospital inpatient services:

(1)Technical component of hospital outpatient radiology services;

(2)Non-patient radiology services;

(3)Anesthesiology:

(a)Technical component of medical direction of four or fewer concurrent procedures for hospital outpatient;

(b)Technical component of outpatient anesthesiology services provided by anesthetists who are not employees of a physician;

(4)Medical transplants, hospital charges for ambulatory stays; and

(5) Services which are customarily reimbursed as a part of the prospective payment for outpatient services.

007.01(B)(ii) INPATIENT SERVICES. Reimbursement for hospital inpatient services provided to Nebraska Medicaid eligible beneficiaries will be provided on a prospective basis. Each facility, with the exception of critical access hospitals (CAH), must receive a prospective rate in accordance with Nebraska Medicaid’s outlined rate methodology for hospital inpatient services. Reimbursement for the following services is included in the prospective rate payment for hospital inpatient services:

(1)Hospital observation services when the beneficiary is thereafter admitted as an inpatient of the same hospital;

(2)Hospital outpatient or emergency room services when the beneficiary is thereafter admitted as an inpatient of the same hospital before midnight of the same day;

(3)Non-physician inpatient services and items:

(a)Outpatient and emergency room services provided by the hospital before admission;

(b)Outpatient or inpatient services provided by another hospital or free-standing medical facility to an inpatient of the original admitting facility; and

(c)Payment for durable medical equipment, orthotics, and prosthetics for hospital inpatients ;

(4)Labor and delivery utilizing the current Medicare methodology is utilized in accounting for labor and delivery charges on the Medicare cost report;

(5)Technical component of inpatient clinical laboratory services;

(6)Technical component of inpatient anatomical pathology services;

(7)Technical component of hospital inpatient radiology services;

(8)Anesthesiology:

(a)Technical component of medical direction of four or fewer concurrent procedures for hospital; and

(b)Technical component of inpatient anesthesiology services provided by anesthetists who are not employees of a physician;

(9)Inpatient dialysis;

(10)Pre-Admission Testing;

(11)Medical transplants:

(a)Hospital inpatient services, including procurement costs; and

(b)Technical component of inpatient laboratory and diagnostic and therapeutic radiology;

(12)Infant apnea monitoring services provided to an inpatient;

(13) Services which are included by a hospital in the Medicare cost report; and

(14) Services which are customarily reimbursed as a part of the prospective payment for inpatient services.

007.01(B)(iii) INPATIENT ADMISSION AFTER OUTPATIENT SERVICES. A beneficiary may be admitted to the hospital as an inpatient after receiving hospital outpatient services. Inpatient services, for billing and payment purposes, includes the following:

(1)Non-physician outpatient services rendered on the day of admission or during the inpatient stay;

(2)Diagnostic services rendered up to three days before the day of admission; and

(3)Admission related non-diagnostic services rendered up to three days before the day of admission. The day of the admission as an inpatient is the first day of the inpatient hospitalization.

007.01(B)(iii)(a) READMISSIONS. All Nebraska Medicaid beneficiaries readmitted as an inpatient within 31 days will be reviewed by Nebraska Medicaid or its designee. Payment may be denied if either admissions or discharges are performed without medical justification as determined by medical review.

007.01(B)(iv) NON-PAYMENT FOR HOSPITAL ACQUIRED CONDITIONS. Payment will be made for those claims which are identified as non-payable by the All-Patient Refined Diagnosis-Related Group (APR DRG) as a result of avoidable hospital complications and medical errors that are identifiable, preventable, and serious in their consequences to beneficiaries.

007.01(C) Payments for Psychiatric Services. Tiered rates will be used for all psychiatric services, regardless of the type of hospital providing the service. This includes services provided at a facility enrolled as a provider for psychiatric services which is not a licensed psychiatric hospital or a Medicare-certified distinct part unit. Payment for each discharge equals the applicable per diem rate times the number of approved beneficiary days for each tier. Payment is made for the day of admission, but not the day of discharge. Mental health and substance use services provided to beneficiaries enrolled in managed care for the mental health and substance abuse benefits package will be reimbursed by the managed care organization (MCO).

007.01(C)(i) Payment for Hospital Sponsored Psychiatric Residential Treatment Facilities (PRTF). Nebraska Medicaid reimbursement is capped at the psychiatric residential treatment facilities (prtf) usual and customary daily charges billed for eligible beneficiaries . Public psychiatric residential treatment facilities (prtf) will be cost-settled annually. Payment rates do not include costs of providing educational, pharmacy, and physician services.

007.01(C)(ii) Payment for Psychiatric Adult Inpatient Subacute Hospital Services. Payments for psychiatric adult inpatient subacute hospital services are made on a per diem basis. The subacute inpatient hospital per diem rate is not a tiered rate. Payment will be an all-inclusive per diem, with the exception of physician services.

007.01(C)(iii) Rates for State-Operated institutions for mental disease (IMD). Institutions for mental disease (IMD) operated by the State of Nebraska will be reimbursed for all reasonable and necessary costs of operation. State-operated institutions will receive an interim per diem payment rate, with an adjustment to actual costs following the cost reporting period.

007.01(C)(iv) Free-Standing Psychiatric Hospitals. When a free-standing psychiatric hospital, in Nebraska or out of state, does not have ancillary services on-site, such as pharmacy or laboratory, the provider of the ancillary service must bill Nebraska Medicaid for the ancillary services provided to inpatients.

007.01(D) Payment for Services Furnished by a Critical Access Hospital (CAH). Items and services that a critical access hospital (CAH) provides to its inpatients are covered if they are items and services that would be covered if furnished for hospital-to-hospital inpatients, subject to the 96-hour average on inpatient stays in critical access hospitals. The reasonable cost of providing the services is reimbursed, as determined under applicable Medicare principles of reimbursement., The following Medicare principles of reimbursement do not apply:

(i) The lesser of costs or charges (LCC) rule;

(ii) Ceilings on hospital operating costs; and

(iii) Reasonable compensation equivalent (RCE) limits for physician services to providers.

007.01(E) Access to Records. Hospitals must make all records relating to the care of Nebraska Medicaid beneficiaries and any and all other cost information available to Nebraska Medicaid, its designated representatives or agents, or representatives of the federal Department of Health and Human Services, upon reasonable notice during regular business hours.

007.01(E)(i) ADDITIONAL CONDITIONS. Hospitals must allow authorized representatives of the Department, the federal Department of Health and Human Services, and state and federal fraud and abuse units to review and audit the hospital's data processing procedures and supportive software documentation involved in the production of computer-encoded claims submitted to Nebraska Medicaid. The hospital must allow the authorized representatives access for the purpose of audit and review at any reasonable time during normal working hours upon written notice by the Department at least one working day before the review and audit.

007.01(F) Approval of Payment for Emergency Room Services. At least one of the following conditions must be met before payment for use of an emergency room is approved:

(1) The beneficiary is evaluated or treated for an emergency medical condition;

(2) The beneficiary's evaluation or treatment in the emergency room results in an approved inpatient hospital admission. The emergency room charges must be displayed on the inpatient claim as ancillary charges and included in the inpatient per diem; or

(3) The beneficiary is referred by his or her physician for treatment in an emergency room.

007.01(F)(i) NON-EMERGENT SERVICES. When the facility or Nebraska Medicaid determine services are non-emergent, the room fee for non-emergent services provided in an emergency room will be disallowed to 50 percent of what would otherwise be allowed. All other Nebraska Medicaid allowable charges incurred in this type of visit will be paid according to this chapter .

007.01(G) Limitations on Payment for Hospital Services.

007.01(G)(i) Place of Service. Payment for covered outpatient or emergency room drugs, supplies, or services which could have been provided in a less expensive setting may be reviewed, reduced, or denied.

007.01(G)(ii) Items Not Utilized in the Facility. Drugs, medical supplies, and services prescribed at discharge from the hospital must be obtained from and billed by the appropriate provider. Payment to a hospital for drugs, supplies, and services prescribed at discharge from the hospital for nursing home residents is not provided. Payment for these items is included in the nursing home per diem.

007.01(G)(iii) Outpatient OR Emergency Services on the Same Day as Inpatient Services. When a beneficiary receives outpatient or emergency room hospital services and is thereafter admitted as an inpatient of the same hospital before midnight of the same day, the outpatient or emergency room hospital services are treated as inpatient services for billing purposes.

007.01(G)(iv) Billed Charges. Inpatient hospital services are paid on a prospective rate basis, regardless of billed charges.

007.01(H)(i) Review Activities for Hospital Inpatient Services Reimbursed on a Prospective Per Discharge Basis. All hospital inpatient services reimbursed on a prospective per discharge basis are subject to random retrospective review by Nebraska Medicaid or its designee. Admissions within three calendar days of a hospital outpatient service may be included in the sample. In addition to the random sample, focused reviews of inpatient stays for transplant(s) or neonatal intensive care unit (NICU) stays provided in a subspecialty care facility or cost outliers may be done by Nebraska Medicaid or its designee.

007.01(H)(i)(1) PAYMENT REDUCTION. If Nebraska Medicaid, or its designee, determines that either admissions or discharges are performed without medical justification, payment for inpatient services may be denied. Payment can be reduced if coding inaccuracies are identified by Nebraska Medicaid or its designee. Any cost outlier which is not determined to be medically necessary for hospital inpatient care by Nebraska Medicaid, or its designee may qualify for payment as a lower level of care (LOC) payment.

007.01(H)(ii) Review Activities for Hospital Inpatient Services Reimbursed on a Prospective Per Diem Basis. Hospital inpatient care must be reasonable, medically necessary, and appropriate for the class of care being billed. All hospital inpatient admissions must be certified by Nebraska Medicaid or its designee prior to payment. . Payment for services will be denied if Nebraska Medicaid or its designee determines the service was not medically necessary. Nebraska Medicaid or its designee will conduct these activities through pre-admission, concurrent, and retrospective reviews. If the class of care is not appropriate, the claim may be reduced to the appropriate level of care (LOC) according to this chapter or denied.

007.01(H)(iii) SURVEILLANCE AND UTILIZATION REVIEW (UR) OF HOSPITAL OUTPATIENT SERVICES. Claims for payment for hospital outpatient services are subject to review by Nebraska Medicaid or its designee. Hospital outpatient care must be reasonable and medically necessary, and must be provided in the most appropriate place of service.

007.02 BILLING.

007.02(A) GENERAL BILLING REQUIREMENTS. Providers must comply with all applicable billing requirements codified in this title .

007.02(B) SPECIFIC BILLING REQUIREMENTS. Providers of hospital services must submit claims to Nebraska Medicaid on the appropriate Nebraska Medicaid approved claims form .

007.02(B)(i) MEDICARE COVERAGE. For a Medicare-Medicaid beneficiary , the provider must bill Medicare for appropriate benefits before submitting a claim to Nebraska Medicaid except Medicare non-covered services covered by Nebraska Medicaid.

007.02(B)(i)(1) MEDICARE PART B. If the Medicare-Medicaid beneficiary has exhausted their Medicare Part A benefits, the hospital must bill these services or items to Medicare Part B if the beneficiary is covered by Medicare Part B before billing Nebraska Medicaid. The hospital must enter the amount approved by Medicare as a prior payment on the appropriate Nebraska Medicaid approved claims form or by electronic format.

007.02(B)(ii) DOCUMENTATION. Nebraska Medicaid requires that documentation, when required, be submitted with each claim for hospital services. Documentation must be complete and legible.

007.02(B)(iii) HOSPITAL-ACQUIRED CONDITIONS (HAC). Hospitals are required to report whether each diagnosis on a Nebraska Medicaid claim was present at the time of patient admission, or present on admission (POA). Claims submitted without the required present on admission (POA) indicators will be denied.

007.02(B)(iii)(1) HOSPITAL-ACQUIRED CONDITIONS (HAC) DIAGNOSIS CLAIMS. For claims containing diagnoses that are identified by Medicare as hospital-acquired conditions (HAC) and for which the condition was not present on admission (POA), these diagnoses will not be used for All-Patient Refined Diagnosis-Related Group (APR DRG). The claim will be paid as though any diagnoses included in the list of hospital-acquired conditions (hac) were not present on the claim. Payment for any hospital-acquired conditions (HAC) that results in death or serious disability will be denied. Additional payments are not made for services on inpatient hospital claims that are attributable to hospital-acquired conditions (hac) and are coded with present on admission (POA) indicator codes N or U. Specifically, for hospitals paid under the:

(i) Diagnostic-related group (DRG) payment method, the Department does not make additional payments are not made for complications and comorbidities, (CC) and major complications and comorbidities (MCC).

(ii) Cost-to-charges (CCR) payment method, charges attributable to the hospital-acquired conditions (hac) are not paid.

(iii) Per diem payment method, provider payment reductions are limited to the extent that the identified provider-preventable condition (PPC) would otherwise result in an increase in payment, or if the portion of the payment directly related to the provider-preventable condition (PPC) can be reasonably isolated for nonpayment.

007.02(B)(iv) Other Provider Preventable Condition (OPPC). Inpatient, inpatient crossover, outpatient, and outpatient crossover hospital claims, payment will be denied for the following other provider preventable conditions:

(1) Incorrect surgical or other invasive procedure performed on a beneficiary ;

(2) Incorrect surgical or other invasive procedure performed on the wrong body part; or

(3) Incorrect surgical or other invasive procedure performed on the wrong patient.

007.02(B)(v) NURSERY CARE. Hospitals reimbursed by per diem must bill nursery care unless the newborn:

(1) Is transferred from nursery bassinet care to acute care or intensive care; or

(2) Remains in the hospital after the mother's discharge, if the child is being discharged to the mother's care.

007.02(B)(vi) HOSPITAL UTILIZATION REVIEW (UR). Each hospital must have in effect a utilization review (UR) plan that provides for review of services provided by the hospital and by members of the medical staff to Nebraska Medicaid beneficiaries.

007.02(B)(vi)(1) COMPOSITION OF THE UTILIZATION REVIEW (UR) COMMITTEE. A utilization review (UR) committee consisting of two or more practitioners must carry out the utilization review (UR) function. This committee must be:

(i) A staff committee of the institution; or

(ii) A group outside the institution established by the local medical society and some or all of the hospitals in the locality or established in a manner approved by the Centers for Medicare & Medicaid Services (CMS).

007.02(B)(vi)(1)(a) SMALL INSTITUTION. If, because of the small size of the institution, it is impossible to have a properly functioning staff committee, the utilization review (UR) committee must be established under item (ii) above. The committee's or group's reviews may not be conducted by any individual who has a direct financial interest in that hospital or was professionally involved in the care of the beneficiary whose case is being reviewed. At least two members of the committee must be doctors of medicine or osteopathy. The other members may be:

(i) A doctor of medicine or osteopathy;

(ii) A doctor of dental surgery or dental medicine;

(iii) A doctor of podiatric medicine;

(iv) A doctor of optometry;

(v) An advanced practice registered nurse (APRN); or

(vi) A chiropractor.

007.02(B)(vi)(2) Scope and Frequency of Reviews. The utilization review (UR) plan must provide for review of Nebraska Medicaid beneficiaries with respect to the medical necessity of:

(i) Admissions to the hospital;

(ii) The duration of stays; and

(iii) Professional services provided, including drugs.

007.02(B)(vi)(2)(a) REVIEW OF ADMISSIONS. Review of admissions may be performed before, at, or after hospital admission. Except for extended stay reviews, reviews may be conducted on a sample basis.

007.02(B)(vii) DETERMINATIONS REGARDING DENIAL OF MEDICAL NECESSITY OF ADMISSIONS OR CONTINUED STAYS. The determination that an admission or continued stay is not medically necessary:

(a) May be made by one member of the utilization review (UR) committee if the practitioner(s) responsible for the beneficiary’s care concur with the determination or fail to present their view when given the opportunity; or

(b) Must be made, in all other cases, by at least two members of the utilization review (UR) committee.

007.02(B)(vii)(1) MEDICALLY NECESSARY. Before making a determination that an admission or continued stay is not medically necessary, the utilization review (UR) committee must consult the practitioner(s) responsible for the care of the beneficiary and afford the practitioner(s) the opportunity to present their views. If the committee decides that admission to or continued stay in the hospital is not medically necessary, written notification must be given no later than two days after the determination, to the hospital, the patient, and the practitioner(s) responsible for the care of the beneficiary.

007.02(B)(vii)(2) Billing the BENEFICIARY . The hospital may bill the beneficiary for services provided after the date the beneficiary receives notification if the following criteria are met:

(i) The hospital's utilization review (UR) committee has determined that an admission or an extended stay is or was not medically necessary;

(ii) The hospital has met the beneficiary notification requirements in this chapter ; and

(iii) The Nebraska Medicaid beneficiary chooses to remain in the hospital or be admitted to the hospital.

007.02(B)(vii)(2)(a) PERMISSABLE BILLING. When an individual is admitted to a hospital as a non-Nebraska Medicaid patient and is later determined to be eligible for Nebraska Medicaid, the hospital must not bill the beneficiary for services that are covered by Nebraska Medicaid. If the services are covered by Nebraska Medicaid but have been denied based on medical necessity, the provider must not bill the beneficiary . The hospital may bill the beneficiary for those services that are specifically not covered by Nebraska Medicaid.

007.02(B)(vii)(3) Extended Stay Review. The utilization review (UR) committee must make a periodic review as specified in the utilization review (UR) plan of each current inpatient receiving hospital services during a continuous period of extended duration. The scheduling or the periodic reviews may be the same for all cases or different for different classes of cases.

007.02(B)(vii)(4) Recertification of Continued Stay. A beneficiary’s first recertification is required no later than the 12^th day of continued hospitalization. Subsequent recertifications are required at least every 30 days.

007.02(B)(viii) Review of Professional Services. The utilization review (UR) committee must review professional services provided, to determine medical necessity and to promote the most efficient use of available health facilities and services.

007.02(B)(ix) SWING BEDS. A per diem that includes post-hospital 24-hour skilled nursing care services that must be provided by or under the direct supervision of professional or technical personnel and requires skilled knowledge, judgment, observation, and assessment will be paid. This per diem payment includes all items and services aside from ancillary services and therapies. Prior authorization for admission to a swing bed is required by Nebraska Medicaid.

007.02(B)(x) ANCILLARY SERVICES AND THERAPIES. The hospital must bill for ancillary services for swing-bed beneficiaries who are eligible for Nebraska Medicaid only. If Medicare is covering the swing-bed services, the facility must not bill Nebraska Medicaid for ancillary services. Laboratory, radiology, respiratory therapy, physical therapy (PT), occupational therapy (OT), speech-language pathology, and audiology services must be billed on the outpatient claim form or in electronic format as outpatient services. Payments for therapies must be reported on the Medicare cost report as outpatient revenues.

008. MEDICAL RECORDS. The hospital must have a medical record service that has administrative responsibility for medical records. A medical record must be maintained for every individual evaluated or treated in the hospital. For the purposes of this chapter , the term medical record includes electronic health records (EHR).

008.01 ORGANIZATION AND STAFFING. The organization of the medical record service must be appropriate to the scope and complexity of the services performed. The hospital must employ adequate personnel to ensure prompt completion, filing, and retrieval of records.

008.01(A) MEDICAL RECORDS MAINTENANCE. The hospital must maintain a medical record for each inpatient and outpatient. Medical records must be accurately written, including accurate entry of electronic health records (EHR) into computer systems, promptly completed, properly filed and retained, and accessible. The hospital must use a system of author identification and record maintenance that ensures the integrity of the authentication and protects the security of all record entries.

008.01(B) MEDICAL RECORDS RETENTION. Medical records must be retained in their original or legally reproduced form for a period of five years. The hospital must have a system of coding and indexing medical records. The system must allow for timely retrieval by diagnosis and procedure, in order to support medical care evaluation studies.

008.01(C) CONFIDENTIALITY OF MEDICAL RECORDS. The hospital must have a procedure for ensuring the confidentiality of patient records. Information from or copies of records may be released only to authorized individuals, and the hospital must ensure that unauthorized individuals cannot gain access to or alter patient records. Original medical records must be released by the hospital only in accordance with federal or state laws, court orders, or subpoenas.

008.01(D) BENEFICIARY MEDICAL RECORDS. If a beneficiary is seeking to be considered by a Medicaid program, medical records must be provided to them at no cost.

008.02 CONTENT OF RECORD. The medical record must contain information to justify admission and continued hospitalization, support the diagnosis, and describe the beneficiary's progress and response to medications and services. All entries must be legible and complete and must be signed and dated promptly by the person, identified by name and discipline, who is responsible for ordering, providing, or evaluating the service furnished. All records must document the following, as appropriate:

(i) Evidence of a physical examination, including a health history, performed no more than seven days before admissions or within 48 hours after admission;

(ii) Admitting diagnosis;

(iii) Results of all consultative evaluations of the beneficiary and appropriate findings by clinical and other staff involved in the care of the beneficiary;

(iv) Documentation of complications, hospital acquired infections, and unfavorable reactions to drugs and anesthesia;

(v) Properly executed informed consent forms for procedures and treatments specified by the medical staff, or by federal or state law if applicable, to require written patient consent;

(vi) All practitioners' orders, nursing notes, reports of treatment, medication records, radiology, and laboratory reports, and vital signs, and other information necessary to monitor the beneficiary's condition;

(vii) Discharge summary with outcome of hospitalization, disposition of case, and provisions for follow-up care; and

(viii) Final diagnosis with completion of medical records within 30 days following discharge.

008.02(A) NOTE. All orders must be signed by the ordering physician.

History

• Effective 2026-07-19

Chapter 11 Indian Health Service (ihs) Facilities

Neb. Admin. Code tit. 471, ch. 11 Indian Health Service (ihs) Facilities {#sec-471-nac-11 omnilex-key=us-ne-regs-official--title-471--471 NAC 11}

11-001 Definitions

Encounter: A face-to-face visit, including telehealth services provided in accordance with 471 NAC 1-006, between a health care professional and an individual eligible for the provision of medically necessary Medicaid-defined services in an IHS or Tribal (638) facility within a 24-hour period ending at midnight, as documented in the client’s medical record.

Indian or Indians: An individual who meets any of the definitions in 25 U.S.C. §§1603(3), 1603(13), and 1679, or who has been determined eligible, as an Indian, pursuant to 42 C.F.R. §§136.1 and 136.12 or Title V of the Indian Health Care Improvement Act, to receive health care services from Indian health care providers (IHS, an Indian Tribe, Tribal Organization, or Urban Indian Organization – I/T/U) or through referral under Contract Health Services (25 U.S.C §1603(5)).

Indian Health Service (IHS): An agency within the United State Department of Health and Human Services, which is responsible for providing federal health services to American Indians and Alaska Natives.

IHS Provider: A health care program, including contract health services (25 U.S.C §1603(5)), operated by the Indian Health Service or by an Indian Tribe, Tribal Organization, or Urban Indian Organization as those terms are defined 25 U.S.C. §1603. This includes Hospitals, Hospital Based Facilities, Pharmacies and outpatient clinics.

IHS Supplier: A freestanding (non-hospital based) entity that furnishes durable medical equipment, prosthetics, orthotics, supplies, and parenteral or enteral nutrition.

IHS Physician or Practitioner: Physician and non-physician practitioners billing for services under Medicaid.

11-002 Provider Requirements

11-002.01 General Provider Requirements: To participate in the Nebraska Medical Assistance Program (Medicaid), IHS facilities shall comply with all applicable participation requirements codified in 471 NAC Chapters 2 and 3. In the event that provider participation requirements in 471 NAC Chapters 2 or 3 conflict with requirements outlined in this 471 NAC Chapter 11, the individual provider participation requirements in 471 NAC Chapter 11 shall govern.

11-002.02 Service Specific Provider Requirements: Medicaid accepts IHS facilities as Medicaid providers on the same basis as other qualified providers. The facilities shall meet all applicable standards for licensure by the Nebraska Department of Health and Human Services, Division of Public Health (Licensure Unit), but need not be licensed. The absence of Nebraska licensure of any staff member of an IHS facility may not be regarded as failure to meet the standards for licensure of the facility, so long as that member is licensed in another state. The Department verifies the Indian Health Service facility status by contacting the appropriate Indian Health Service area office.

11-002.02A Provider Agreement: An Indian Health Service facility shall submit to the Department (Medicaid) Form MC-19, "Medical Assistance Provider Agreement," (See 471- 000-91) and Form CMS-1539, "Medicare/Medicaid Certification and Transmittal," (see 471-000-66). Medicaid must approve enrollment before making payment to the IHS facility. A non-hospital-based provider who has met the Nebraska Department of Health and Human Services Regulation and Licensure standards shall submit to the Department Form MC-19, "Medical Assistance Provider Agreement," (see 471-000-90). Medicaid must approve enrollment before making payment to the provider.

11-002.02B Compliance with Provider Requirements: In addition to the limitations and requirements outlined in this 471 NAC Chapter 11, IHS Providers shall comply with all applicable limitations in 471 NAC Chapters 1, 2 and 3, and all requirements outlined in each applicable service specific chapter in Title 471 of the Nebraska Administrative Code. As an example, IHS Providers of Dental Services must comply with both provider and service delivery limitations and requirements outlined in 471 NAC Chapter 6. IHS Providers of Pharmacy Services must comply with both provider and service delivery limitations and requirements in 471 NAC Chapter 16. These requirements apply to all services provided by IHS providers under the provisions of this 471 NAC Chapter 11.

11-003 Service Requirements

11-003.01 General Requirements

11-003.01A Eligibility: Medically necessary services will be made available to any Indian, as that term is defined herein, who is also determined to be eligible for Medicaid in accordance with Title 477 of the Nebraska Administrative Code.

11-003.01B Services Provided for Clients Enrolled in the Nebraska Medicaid Managed Care Program: See 471 NAC 1-002.01.

11-003.01C HEALTH CHECK (EPSDT) Treatment Services: See 471 NAC Chapter 33.

11-003.01D Copayments / Cost Sharing: American Indians or Alaskan Natives who are eligible for, and have received, Medicaid covered services from an IHS or Tribal (638) facility shall be exempt from all copayment and cost sharing obligations.

11-003.02 Covered Services

11-003.02A Scope of an Encounter: An encounter includes:

1. A practitioner visit which may be a:

a. Physician, doctor of osteopathy, physician assistant, nurse practitioner, or certified nurse midwife;

b. Dentist;

c. Optometrist;

d. Podiatrist;

e. Chiropractor;

f. Speech, audiology, physical or occupational therapist;

g. Mental health provider such as a psychologist, psychiatrist, licensed mental health practitioner, certified drug and alcohol counselor, or a certified nurse practitioner providing psychotherapy or substance abuse counseling or other treatment with family and group therapy; or,

h. Pharmacist.

2. Diagnostic services such as:

a. Radiology;

b. Laboratory;

c. Psychological testing; or,

d. Assessment (mental health)

3. Supplies used in conjunction with a visit such as dressings, sutures, etc.;

4. Medications used in conjunction with a visit such as an antibiotic injection; and,

5. Prescribed drugs dispensed as a part of the encounter.

11-003.02B Encounters: Visits with more than one health professional, and multiple visits with the same health professional, that take place during the same day within the IHS or Tribal (638) facility constitute a single encounter.

11-003.02B1 Exceptions:

a. When the patient is seen in the clinic, or by a heath professional, more than once in a 24-hour period for distinctly different diagnosis. Documentation must include unrelated diagnosis codes;

b. When the patient must return to the clinic for an emergency or urgent care situation subsequent to the first encounter that requires additional diagnosis or treatment;

c. When a patient requires a pharmacy encounter in addition to a medical health professional or mental health encounter on the same day. Medicaid covers only one pharmacy encounter per day; or,

d. When the patient is seen in the clinic by a clinical social worker or psychologist for a mental health encounter in addition to a medical health professional encounter on the same day.

11-003.03 Non-Encounter Services: Services rendered outside the office setting, office services that do not meet the criteria for the encounter, non-IHS Facility services, pharmacy services that are not provided by a designated tribal pharmacy or pharmacist, or services provided to non-American Indian or non-Alaskan Native clients. Examples of non-encounter services include, but are not limited to: Inpatient hospital visits, home and nursing facility visits, home health visit, durable medical equipment, ambulance, brief visit with nurse for blood pressure check or telephone consultations.

11-004 Billing and Payment for IHS or Tribal (638) Facility Services

11-004.01 Billing

11-004.01A General Billing Requirements: Providers shall comply with all applicable billing requirements codified in 471 NAC Chapter 3. In the event that individual billing requirements in 471 NAC Chapter 3 conflict with billing requirements outlined in this 471 NAC Chapter 11, the individual billing requirements in 471 NAC Chapter 11 shall govern.

11-004.01B Specific Billing Requirements: The hospital-based facility shall submit all claims for payment for services to Medicaid clients on Form CMS-1450 or the standard electronic Health Care Claim: Institutional transaction (ASC X12N 837). Non-hospital-based providers shall use the appropriate claim form or electronic format (see Claim Submission Table at Appendix 471-000-49). All IHS Providers shall comply with applicable billing instructions in Appendix 471-000-62.

11-004.01B1 Non-Encounter Charges: IHS Providers may provide services outside of those that meet encounter criteria. Services covered by Medicaid, but not considered eligible for encounter reimbursement, are to be billed on Form CMS-1500 using the appropriate HCPCS codes and will be paid according to the Nebraska Practitioner Fee Schedule.

11-004.01B2 Outpatient Encounter Charges: The Indian Health Service shall bill all outpatient encounter charges provided on the same day for the same Medicaid client as one outpatient charge per day.

11-004.01B3 Inpatient Charges: The Inpatient hospital per diem rate for inpatient medical care provided by IHS facilities is published annually in the Federal Register or Federal Register Notices. In order to receive the inpatient hospital per diem rate, the IHS or Tribal 638 facility must:

a. Be enrolled as a provider with Medicaid; and

b. Appear on the IHS maintained listing of IHS-operated facilities and Indian health care facilities operating under a 638 agreement. It is the sole responsibility of the facility to petition IHS for placement on this list

11-004.01B4 Utilization Review: All IHS Provider claims for payment are subject to appropriate claim edits and to surveillance and utilization review upon entry into the claims processing system. The hospital utilization review abstract/summary may be requested by Department staff.

11-004.02 Payment

11-004.02A General Payment Requirements: Nebraska Medicaid will reimburse the Provider for services rendered in accordance with the applicable payment regulations codified in 471 NAC Chapter 3. In the event that individual payment regulations in 471 NAC Chapter 3 conflict with payment regulations outlined in this 471 NAC Chapter 11, the individual payment regulations in 471 NAC Chapter 11 shall govern.

11-004.02B Specific Payment Requirements:

11-004.02B1 Reimbursement: IHS or Tribal (638) facilities will be paid at the most current encounter rate established by the IHS which is published annually in the Federal Register for established services provided in a facility that would ordinarily be covered services through the Nebraska Medicaid Program. Medicaid reimburses IHS facilities for inpatient and outpatient services at the Medicare/Medicaid rates established by the federal Department of Health and Human Services (DHHS).

11-004.02B2 Rate Methodology: Rate changes are effective the first day of the month following the Department’s receipt of the Medicare Interim Rate Notice, and will be applied retroactively to the federal effective date. Because specific Medicare/Medicaid rates are used and there is 100 percent federal match of these costs, Medicaid will not make an end-of-year settlement for Indian Health Service facilities.

History

• Effective 2018-06-05

Chapter 12 Nursing Facility Regulations

Neb. Admin. Code tit. 471, ch. 12 Nursing Facility Regulations {#sec-471-nac-12 omnilex-key=us-ne-regs-official--title-471--471 NAC 12}

001. SCOPE AND AUTHORITY . The regulations govern the services provided under Nebraska’s Medicaid program as defined by Nebraska Revised Statute (Neb. Rev. Stat.) §§ 68-901 et seq. (the Medical Assistance Act).

002. DEFINITIONS . The following definitions apply:

002.01 ACUTE MEDICAL HOSPITAL. An institution which:

(A) Is licensed or formally approved as a hospital by an officially designated authority for State standard-setting;

(B) Meets the requirements for participation in Medicare as a hospital; and

(C) Has in effect a utilization review plan, applicable to all Medicaid patients, that meets the requirements of 42 Code of Federal Regulations (CFR) 482.30.

002.02 ADMISSION. An admission applies to an individual who:

(A) Has never resided in the nursing facility (NF);

(B) Has been formally discharged from one nursing facility (NF) and is being admitted to a different facility; or

(C) Has been formally discharged, return not anticipated from a previous stay, by the admitting facility.

002.03 ADVANCE DIRECTIVE. A written instruction, such as a living will or power of attorney for health care, recognized under State law, or as recognized by the courts of the State, that relates to the provision of medical care if the individual becomes incapacitated.

002.04 ALLOWABLE COST. Those facility costs which are included in the computation of the facility's per diem. The facility's reported costs may be reduced because they are not allowable under Medicaid or Medicare regulation, or because they are limited under this chapter.

002.05 ALTERNATIVE SERVICES. Living arrangements providing less care than nursing facility (NF), intermediate care facility for individuals with developmental disabilities (ICF/DD), institution for mental diseases (IMD), or inpatient psychiatric hospital, and more than independent living, such as adult family home, room and board, or assisted living.

002.06 APPROPRIATE. That which best meets the client's needs in the least restrictive setting.

002.07 ASSISTED LIVING RATES. Standard rates, single occupancy, rural or urban, per day equivalent, paid under the home and community-based waiver services for aged persons or adults or children with disabilities.

002.08 BED HOLDING. Reimbursement made to a facility to hold a bed when a client is hospitalized and return is anticipated or on therapeutic leave.

002.09 BEHAVIORAL HEALTH REGIONS (BHR). Community mental health programs divided geographically into mental health regions to organize and facilitate the delivery of community mental health services.

002.10 BRAIN INJURY. Any level of injury to the brain often caused by an impact with the skull. Mild symptoms include persistent headaches, mood changes, dizziness, and memory difficulties. Severe head injury symptoms are more obvious: loss of consciousness; loss of physical coordination, speech, and many thinking skills; and substantial changes in personality. A brain injury can be acute, meaning that the injury or insult occurred two years or less from the date of admission to the current extended brain injury rehabilitation program. A brain injury can also be chronic, meaning that the insult or injury that occurred more than two years before admission to the current extended brain injury rehabilitation program as described.

(A) Acquired Brain Injury (ABI): An injury to the brain that has occurred after birth and which may result in mild, moderate, or severe impairments in cognition, speech-language communication, memory, attention and concentration, reasoning, abstract thinking, physical functions, psychosocial behavior, or information processing.

(B) Traumatic Brain Injury (TBI): An injury to the brain caused by external physical force and which may produce a diminished or altered state of consciousness resulting in an impairment of cognitive abilities or physical functioning. These impairments may be either temporary or permanent and cause partial or total functional disability or psychological maladjustment.

002.11 CATEGORICAL DETERMINATIONS. Advance group determinations under preadmission screening and resident review (PASRR) that take into account that certain situations, diagnoses, or levels of severity of illness clearly indicate that admission to or residence in a nursing facility (NF) is needed, exempting the client from a Level II evaluation for a specified period of time. These determinations must be based on current documentation, such as hospital or physician report.

002.12 CENTER FOR PERSONS WITH DEVELOPMENTAL DISABILITIES (CDD). A facility where shelter, food, and care, including habilitation, advice, counseling, diagnosis, treatment, or related services are provided for a period of more than twenty-four consecutive hours to four or more persons residing at such facility who have developmental disabilities.

002.13 CERTIFIED FACILITY. A facility which participates in the Medicaid program, whether that entity comprises all or a distinct part of a larger institution.

002.14 CIVIL MONEY PENALTY (CMP). A per day or per instance fine imposed against a nursing facility (NF) as a result of a survey deficiency(ies) identified by the Department of Public Health or Centers for Medicare and Medicaid Services (CMS).

002.15 COMMUNITY-BASED MENTAL HEALTH SERVICES (CBMHS). An array of mental health services, including residential, day rehabilitation, vocational support, and service coordination.

002.16 DEINSTITUTIONALIZATION. The release of institutionalized individuals from institutional care to care in the community.

002.17 DEPARTMENT. The Nebraska Department of Health and Human Services.

002.18 DEVELOPMENTAL DISABILITY (DD). A severe chronic disability of an individual five years of age or older that is:

(A) Attributable to a mental or physical impairment or combination of mental and physical impairments.

(B) Likely to continue indefinitely.

(C) Manifested before the individual attains age 22.

(D) Is likely to continue indefinitely; results in substantial functional limitations in three or more of the following major life activities:

(i) Self-care;

(ii) Receptive and expressive language;

(iii) Learning;

(iv) Mobility;

(v) Self-direction;

(vi) Capacity for independent living; and

(vii) Economic self-sufficiency.

(E) Reflects the individual’s need for a combination and sequence of special, interdisciplinary, or generic services, supports, or other assistance that is lifelong or extended duration and is individually planned and coordinated, except that such term, when applied to infants and young children means individuals from birth to age five, inclusive, who have substantial developmental delay or congenital or acquired conditions with a high probability of resulting in developmental disabilities if services are not provided.

002.19 DISCHARGE PLAN. A plan developed by the interdisciplinary team at the time of admission which identifies:

(A) The rationale for the client's current level of care;

(B) The types of services the client would require in an alternate living environment; and

(C) The steps to be taken for movement to a less restrictive living environment.

002.20 DIVISION. The Division of Medicaid and Long-Term Care.

002.21 DUAL DIAGNOSIS. For preadmission screening and resident review (PASRR) purposes, an individual is considered to have a dual diagnosis of serious mental illness and intellectual disability if they have a primary or secondary diagnosis in each category according to the definitions found in this chapter.

002.22 FAIR MARKET VALUE. The price that the asset would bring by bona fide bargaining between well-informed buyers and sellers at the date of acquisition.

002.23 HOME AND COMMUNITY-BASED WAIVER SERVICES FOR AGED PERSONS OR ADULTS OR CHILDREN WITH DISABILITIES. An array of community-based services available to individuals who are eligible for nursing facility (NF) services under Medicaid but choose to receive services at home. The purpose of the waiver services is to offer options to Medicaid clients who would otherwise require nursing facility (NF) services.

002.24 HOSPICE. Hospice or hospice services shall meet the definition in 471 Nebraska Administrative Code (NAC) 36.

002.25 IHS NURSING FACILITY (NF) PROVIDER. An Indian Health Services Nursing Facility (NF) or a Tribal Nursing Facility (NF) designated as an Indian Health Services (IHS) provider and funded by the Title I or III of the Indian Self-Determination and Education Assistance Act, Public Law 93-638.

002.26 INPATIENT PSYCHIATRIC HOSPITAL. A psychiatric hospital or an inpatient program in a psychiatric facility, either of which is accredited by the Joint Commission on Accreditation of Healthcare Organizations.

002.27 INSTITUTION FOR MENTAL DISEASES (IMD). A hospital, nursing facility (NF), or other institution of more than 16 beds, that is primarily engaged in providing diagnosis, treatment, or care of persons with mental diseases, including medical attention, nursing care, and related services.

002.28 INTELLECTUAL DISABILITY (ID). Significantly sub-average general intellectual functioning existing concurrently with deficits in adaptive behavior and manifested during the developmental period.

002.29 SPECIALIZED ADD-ON SERVICES FOR INDIVIDUALS WITH INTELLECTUAL DISABILITY OR A RELATED CONDITION. A continuous program for each individual, which includes aggressive, consistent implementation of a program of specialized and generic training, treatment, health services, and related services that is directed towards:

(1) The acquisition of the skills necessary for the individual to function with as much self-determination and independence as possible; and

(2) The prevention or deceleration of regression or loss of current optimal functional status.

002.29(A) SPECIALIZED ADD-ON SERVICES. Specialized add-on services do not include services to maintain generally independent clients who are able to function with little supervision or in the absence of a continuous specialized add-on services program. Specialized add-on services may include services provided in an intermediate care facility for individuals with developmental disabilities (ICF/DD) setting or in a community-based developmental disability services (CBDDS) program and are provided for: residents determined to have medical needs which are secondary to developmental or habilitative needs. Specialized add-on service options include:

(i) Assessment or evaluation for alternative communication devices;

(ii) Behavior management program;

(iii) Day program;

(iv) Vocational evaluation;

(v) Psychological or psychiatric evaluation; and

(vi) Stimulation or environmental enhancements or use of assistive devices.

002.30 SPECIALIZED ADD-ON SERVICES FOR INDIVIDUALS WITH SERIOUS MENTAL ILLNESS. Services which result in the continuous and aggressive implementation of an individualized plan of care that:

(A) Is developed and supervised by an interdisciplinary team, which includes a physician, qualified mental health professionals, and, as appropriate, other professionals;

(B) Prescribes specific therapies and activities for the treatment of persons experiencing an acute episode of serious mental illness, which necessitates supervision by trained mental health personnel; and

(C) Is directed toward diagnosing and reducing the resident's behavioral symptoms that necessitated institutionalization, improving their level of independent functioning, and achieving a functioning level that permits reduction in the intensity of mental health services to below the level of specialized add-on services at the earliest possible time.

002.31 INTERDISCIPLINARY TEAM. A group of persons who meet to identify the needs of the client and develop an integrated comprehensive plan of care to accomplish these needs.

002.32 INTERMEDIATE CARE FACILITY FOR INDIVIDUALS WITH DEVELOPMENTAL DISABILITIES (ICF/DD). A facility that:

(A) Meets the standards for licensure as established by the Nebraska Department of Health and Human Services, Division of Public Health (Public Health) and all related requirements for participation as prescribed in federal law and regulations governing medical assistance under Title XIX of the Social Security Act;

(B) Is certified as a Title XIX Intermediate Care Facility for Individuals with Intellectual Disabilities (ICF/IID) under Medicaid; and

(C) Has a current provider agreement.

002.33 INTERMEDIATE SPECIALIZED SERVICES (ISS) FOR INDIVIDUALS WITH SERIOUS MENTAL ILLNESS. Services necessary to prevent avoidable physical and mental deterioration and to assist clients in obtaining or maintaining their highest practicable level of functional and psycho-social well being. Services are characterized by the client’s regular participation, in accordance with his/her comprehensive care plan, in professionally developed and supervised activities, experiences, and therapies and activities, experiences, and therapies that reduce the client’s psychiatric and behavioral symptoms, improve the level of independent functioning, and achieve a functional level that permits reduction in the need for intensive mental health services.

002.34 LEGAL REPRESENTATIVE. Any person who has been vested by law with the power to act on behalf of an individual. The term includes a guardian appointed by a court of competent jurisdiction in the case of an incompetent individual or minor, or a parent in the case of a minor, or a person acting under a valid power of attorney.

002.35 LEVEL OF CARE (LOC) DETERMINATION. Medicaid’s nursing facility (NF) screening for medical necessity.

002.36 LEVEL I SCREEN. The initial preadmission screening and resident review (PASRR) for all admissions to a Medicaid certified nursing facility (NF). A Level I screen must be completed before an individual is admitted to a nursing facility (NF) to determine whether there is an indication or diagnosis of serious mental illness, intellectual disability or a related condition, or a dual diagnosis.

002.37 LEVEL II EVALUATION. The preadmission screening and resident review (PASRR) assessment of any individual who has a diagnosis or indication of serious mental illness, intellectual disability or a related condition, or a dual diagnosis.

002.38 MAINTENANCE THERAPY. Therapy to maintain the client at current level or to prevent loss or deterioration of present abilities.

002.39 MEDICAID AGED AND DISABLED WAIVER. See 480 NAC 5.

002.40 MEDICAID-ELIGIBLE. The status of a client who has been determined to meet established standards to receive benefits of Medicaid.

002.41 MEDICARE. The federal health insurance program for persons who are aged or have disabilities under Title XVIII of the Social Security Act.

002.42 MEDICARE DISTINCT PART FACILITY. Some facilities have a "distinct part" which participates only in the Medicaid program as a nursing facility (NF) and another "distinct part" which participates only in the Medicare program. In such cases the Medicaid distinct part is subject to the preadmission screening and resident review (PASRR) requirements and the Medicare part is not. If the beds are dually certified as both Medicaid and Medicare, preadmission screening and resident review (PASRR) screening processes are required because of the Medicaid participation. Likewise, a nursing facility (NF) participating solely in the Medicare program as a skilled nursing facility (SNF), with no Medicaid certification, is not subject to Level I or Level II screening through preadmission screening and resident review (PASRR).

002.43 MENTAL HEALTH (MH) SERVICES. For purposes of preadmission screening and resident review (PASRR), an array of services that are less intensive than intensive services. Mental health (MH) services may include medication monitoring, counseling and therapy, consultations with a psychiatrist, or mental health interventions. The nursing facility (NF) is responsible for ensuring the provision of mental health services.

002.44 MISAPPROPRIATION OF RESIDENT PROPERTY. The deliberate misplacement, exploitation, or wrongful, temporary or permanent use of a resident’s belongings or money without the resident’s consent.

002.45 NEBRASKA CASEMIX INTERNET SYSTEM (NCIS). A Nebraska Medicaid web-nursing facility (NF) resident assessment and level of care information.

002.46 NEUROLOGICAL EXAMINATION. For purposes of preadmission screening and resident review (PASRR), a neurological examination may consist of the following components:

(A) Mental status exam. A mental status exam usually contains the following components:

(i) Appearance - age, grooming, posture, motor activity, and stature, meaning height and weight;

(ii) General behavior - cooperative, withdrawn, apathetic, suspicious, aggressive, compliant, histrionic, anxious, relaxed, or hostile;

(iii) Affect and mood - appropriate, flat, labile, sad, elated, angry, or inappropriate;

(iv) Thought processes - logical, circumstantial, dissociated, obsessive, phobic, suicidal, flight of ideas, or ideas of reference;

(v) Perception - illusions, hallucinations, or delusions; and

(vi) Cognitive Functions - level of awareness, meaning orientation to time, place, and person, attention and concentration, memory both remote and recent, judgment, and insight;

(B) Client's muscle strength and movements;

(C) Pupillary reaction in terms of time and uniformity;

(D) Coordination and balance;

(E) Sensory abilities;

(F) Lumbar and cisternal punctures as needed to detect blockage or central nervous system infection - such as meningitis, syphilis, or multiple sclerosis;

(G) Myelography to diagnose a tumor, herniated disc, or other cause of nerve or spinal cord compression;

(H) Brain scans and computed tomography scans to discover causes of difficulties thought to be of cerebral origin;

(I) Angiography to determine cause of motor weakness, stroke, seizure or intractable headaches;

(J) Electroencephalogram to detect brain tumors, infections, dementias and information concerning the cause and type of seizure disorder; and

(K) Electromyography to assist in diagnosing muscular dystrophy and myasthenia gravis or polyneuropathy.

002.47 NURSING FACILITY (NF). A facility, or a distinct part of a facility, that:

(A) Meets the standards for hospital, skilled nursing, or nursing facility (NF) licensure established by Public Health, and all related requirements for participation as prescribed in federal law and regulations governing medical assistance under Title XIX of the Social Security Act;

(B) Is certified as a Title XIX NF under Medicaid. May also be certified as a Title XVIII skilled nursing facility (NF) under Medicare;

(C) Provides 24-hour, seven-day week registered nurse (RN) or licensed practical nurse (LPN) services, meaning full-time registered nurse (RN) on day shift, unless Public Health has issued a staffing waiver; and

(D) Has a current Medicaid provider agreement and a proof of certification on file with the Department.

002.48 NURSING FACILITY (NF) QUALITY ASSURANCE FUND. The fund created in Neb. Rev. Stat. § 68-1926 as the repository for provider tax payments remitted by nursing facilities and skilled nursing facilities.

002.49 PHYSICIAN'S CERTIFICATION. The physician's determination that the client requires the nursing facility level of care (NF LOC).

002.50 PREADMISSION SCREENING AND RESIDENT REVIEW (PASRR). A federal assessment process required of all applicants to and residents of Medicaid certified nursing facilities.

002.51 PRIOR AUTHORIZATION. Authorization of payment for certain nursing facility (NF) services based on determination of medical necessity.

002.52 PRIVATE PAY. An individual who does not meet the Medicaid eligibility requirements.

002.53 PROFESSIONAL SERVICES. Services provided by, or under the direct supervision of professional personnel, including physician services or nursing care by a registered nurse or licensed practical nurse.

002.54 PROGRAM OF ALL-INCLUSIVE CARE FOR THE ELDERLY (PACE). A program that provides comprehensive, coordinated health care and long-term services and supports for voluntarily-enrolled individuals. Program of All-inclusive Care for the Elderly (PACE) provides another alternative along the continuum of available long-term care services and supports to enable participants to continue to live in their homes and communities.

002.55 QUALITY ASSURANCE ASSESSMENT. The assessment imposed under the Nursing Facility Quality Assurance Assessment Act in Neb. Rev. Stat. § 68-1917.

002.56 RATE DETERMINATION. Per diem rates by the Department. These rates may differ from rates actually paid for nursing facility (NF) services for levels of care 101, 102, 103 and 104, adjusted to include the nursing facility (NF) quality assessment component.

002.57 RATE PAYMENT. Per diem rates paid under provisions of this chapter. The payment rate for levels of care 101, 102, 103, 104 and 105 is the applicable rate in effect for assisted living services under the Home and Community-Based Waiver Services for Aged Persons or Adults or Children with Disabilities adjusted to include the nursing facility (NF) quality assurance assessment component.

002.58 REHABILITATION. Provision of services to promote restoration of the client to their previous level of functioning.

002.59 REHABILITATIVE SERVICES. Services provided by or under the supervision of licensed or certified medical personnel, physical therapist, occupational therapist, respiratory therapist, speech pathologist, and audiologist.

002.60 RELATED CONDITION. An individual is considered to have a related condition when the individual has a severe, chronic disability that meets all of the following conditions:

(A) It is attributable to:

(i) Cerebral palsy or epilepsy; or

(ii) Any other condition, other than serious mental illness, found to be closely related to intellectual disability because this condition results in impairment of general intellectual functioning or adaptive behavior similar to that of persons with intellectual disability and requires treatment or services similar to those required for these persons.

(B) It is manifested before the person reaches age 22;

(C) It is likely to continue indefinitely;

(D) It results in substantial functional limitations in three or more of the following areas of major life activity:

(i) Self-care;

(ii) Understanding and use of language;

(iii) Learning;

(iv) Mobility;

(v) Self-direction; and

(vi) Capacity for independent living.

002.61 REVISIT FEES. Fees charged to health care facilities by the Secretary of Health and Human Services to cover the costs incurred under Department of Health and Human Services, Centers for Medicare and Medicaid Services, Program Management for conducting revisit surveys on health care facilities cited for deficiencies during initial certification, recertification or substantiated complaint surveys.

002.62 SIGNIFICANT CHANGE. A significant change is a decline or improvement in a resident’s status that:

(A) Will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions, is not self-limiting;

(B) Impacts more than one area of the residents health status; and

(C) Requires interdisciplinary review or revision of the care plan.

002.63 SKILLED NURSING FACILITY (SNF), MEDICARE. A facility, or distinct part, that:

(A) Meets the standards for hospital or skilled nursing licensure established by Public Health and all related requirements for participation as prescribed in federal law and regulations governing medical assistance under Title XIX of the Social Security Act;

(B) Is certified as a Title XVIII skilled nursing facility (SNF) under Medicare, may also be certified as a Title XIX nursing facility (NF) under Medicaid.

002.64 SPECIALIZED ADD-ON SERVICES FOR INDIVIDUALS WITH INTELLECTUAL DISABILITY OR A RELATED CONDITION. Specialized add-on services are services which result in a continuous, aggressive individualized plan of care and recommended and monitored by the individual’s interdisciplinary team (IDT). Specialized add-on services include habilitative services and are not provided by the nursing facility (NF). Habilitative services are medically necessary services intended to assist the individual in obtaining, maintaining, or improving developmental-age appropriate skills not fully acquired as a result of congenital, genetic, or early acquired health condition.

002.65 STRAIGHT-LINE METHOD. A depreciation method in which the cost or other basis of the asset, less its estimated salvage value, if any, is determined and the balance of the cost is distributed in equal amounts over the assigned useful life of the asset class.

002.66 SUMMARY OF FINDINGS REPORT. The summary and recommendation for services that addresses:

(1) The individual's diagnoses, medical, physical, functional, and psychosocial strengths or needs;

(2) The individual's need for any further evaluation;

(3) Recommendations for treatment or specialized add-on service needs and any referrals determined to be appropriate; and

(4) A summary of the findings.

002.66(A) SUMMARY OF FINDINGS REPORT INFORMATION. The Summary of Findings Report must be based on a compilation of supportive information provided by the facility, physician, mental health reviewer, and qualified intellectual disability professional (QIDP) through the preadmission screening and resident review process (PASRR).

002.67 SWING BED. Post-hospital skilled nursing and rehabilitation extended-care services, which must be provided by or under the direct supervision of professional or technical personnel and require skilled knowledge, judgment, observation, and assessment.

002.68 SWING BED FACILITY. A rural acute hospital which is certified to provide a skilled nursing facility level of care (NF LOC).

002.69 TERMINALLY ILL OR TERMINAL ILLNESS. The client is diagnosed with a medical prognosis that his or her life expectancy is six months or less if the illness runs its normal course.

002.70 30-MONTH CHOICE. A choice provided to an individual based on 30 months of continuous residence in a NF from time of admission to nursing facility (NF) care to the date of the Level II evaluation. The resident does not necessarily have to reside in the same nursing facility (NF) to meet the 30-month continuous residency requirement, but must reside in a nursing facility (NF) bed. Temporary absences from a nursing facility (NF) for inpatient hospital treatment for less than six months are not considered a break in residence.

002.71 URBAN. Douglas, Lancaster, Sarpy, and Washington Counties.

002.72 WAIVERED FACILITY. Facilities for which the State Certification Agency has waived professional nurse staffing requirements are classified as waivered if the total number of waivered days exceeds 90 calendar days at any time during the reporting period.

002.73 WEIGHTED RESIDENT DAYS. A facility's inpatient days, as adjusted for the acuity level of the residents in that facility.

003. GENERAL PROVIDER REQUIREMENTS . To participate in Medicaid, providers of nursing facility (NF) services must comply with all applicable provider participation requirements codified in 471 NAC 2 and 3. In the event that provider participation requirements in 471 NAC 2 or 3 conflict with requirements outlined in this 471 NAC 12, the individual provider participation requirements in 471 NAC 12 will govern.

004. GENERAL SERVICE REQUIREMENTS .

004.01 MEDICAL NECESSITY. Nursing facility (NF) clients must meet the medical necessity requirements in 471 NAC 1, and each client must be determined to meet nursing facility level of care (NF LOC) as specified in this chapter.

005. GENERAL BILLING AND PAYMENT FOR NURSING FACILITY (NF) SERVICES .

005.01 GENERAL BILLING REQUIREMENTS. Providers must comply with all applicable billing requirements codified in 471 NAC 3. In the event that individual billing requirements in 471 NAC 3 conflict with billing requirements outlined in this 471 NAC 12, the individual billing requirements in 471 NAC 12 will govern.

005.02 GENERAL PAYMENT REQUIREMENTS. Nebraska Medicaid will reimburse the provider for services rendered in accordance with the applicable payment regulations codified in 471 NAC 3. In the event that individual payment regulations in 471 NAC 3 conflict with payment regulations outlined in this 471 NAC 12, the individual payment regulations in 471 NAC 12 will govern.

005.03 GENERAL COST REPORTING REQUIREMENTS. The Department may require providers to submit certain cost reports for the calculation of reimbursement rates. Providers must submit such cost reports as requested and in the manner specified by the Department.

006. PREADMISSION SCREENING AND RESIDENT REVIEW (PASRR) . When an individual requests admission to or continuous residence in a Medicaid-certified nursing facility (NF), the facility must implement the preadmission screening and resident review (PASRR) as defined in this chapter. An individual who has an indication or diagnosis of serious mental illness, intellectual disability or a related condition, or a dual diagnosis may be admitted to a nursing facility (NF) or continue to reside in a nursing facility (NF) only when the individual is determined to be appropriate for nursing facility (NF) services through the preadmission screening and resident review (PASRR). The preadmission screening and resident review (PASRR) provides the following to an individual with a diagnosis or indication of serious mental illness, intellectual disability or a related condition, or a dual diagnosis:

(A) A determination whether the individual has serious mental illness, intellectual disability or a related condition, or a dual diagnosis;

(B) A determination whether the level of services provided by a nursing facility (NF) is appropriate to meet the individual's needs; and

(C) A recommendation for services that addresses the individual's needs in a nursing facility (NF) or in an alternative placement.

006.01 PURPOSE OF THE PREADMISSION SCREENING AND RESIDENT REVIEW (PASRR). The purpose of the preadmission screening and resident review (PASRR) is to:

(A) Determine the appropriateness of nursing facility (NF) care for persons with serious mental illness, intellectual disability or a related condition, or a dual diagnosis;

(B) Prevent the placement of individuals with serious mental illness, intellectual disability or a related condition, or a dual diagnosis in nursing facilities unless their medical needs clearly indicate that they require the level of care (LOC) provided by a nursing facility (NF);

(C) Coordinate services needs among the health care industry and the mental health and developmental disability systems;

(D) Comply with state and federal requirements mandating an evaluation process that facilitates the nursing facility’s (NF) responsibility to provide services and activities to attain and maintain the highest practical physical, mental, and psychosocial well-being of each resident; and

(E) Assist with the placement of persons found inappropriate for nursing facility (NF) care into more appropriate, least restrictive services.

006.02 LEVEL I SCREEN. A preadmission screening and resident review (PASRR) is required to be submitted to the Department for:

(1) All persons who have requested admission to a Medicaid certified nursing facility (NF);

(2) Any request for a first time admission or readmission to a Medicaid certified nursing facility (NF) for a resident who has been treated in an inpatient psychiatric setting or equally intensive service, including the crisis unit, and when the Department contractor has determined that the individual qualifies for such preadmission review per criteria provided in this chapter;

(3) Was previously formally discharged from a nursing facility (NF) and is applying for admission to the same or another Medicaid certified nursing facility (NF);

(4) Was evaluated through the preadmission screening and resident review (PASRR) Level II process more than 90 days before admission to a Medicaid certified nursing facility (NF);

(5) Was screened as a negative Level I but whose placement was delayed longer than 60 days from the previous Level I screen; and

(6) When a status change event occurs as specified below.

006.02(A) STATUS CHANGE. For the purpose of this chapter, the term “status change” references the obligation to complete a new Level I preadmission screening and resident review (PASRR) evaluation. The status change process is required for all nursing facility (NF) residents who:

(i) Have previously been screened with a negative outcome through the preadmission screening and resident review (PASRR) process but have been determined to exhibit signs, symptoms, or behaviors suggesting the presence of a diagnosis of serious mental illness or intellectual disability or related conditions;

(ii) Have demonstrated an increase in symptoms or behaviors to the extent that there is a change in mental health or intellectual disability treatment needs;

(iii) Have demonstrated a significant physical status improvement such that they are more likely to respond to special treatment for that condition or may be considered appropriate for a less restrictive placement alternative;

(iv) Have required inpatient psychiatric treatment. A Level II status change is required prior to the individual's readmission to the facility;

(v) Have been approved for nursing facility (NF) stay for a short term period and the individual's stay is expected to exceed the approved time frame; or

(vi) Current condition or treatment is significantly different than described in the resident’s current Level I or Level II determination.

006.03 LEVEL I IDENTIFICATION SCREEN OUTCOMES. The Nebraska Level I Preadmission Screening and Resident Review (PASRR) form must be submitted to the Department prior to an individual's admission to a Medicaid certified nursing facility (NF) and under those circumstances specified above. Outcomes are as follows:

(A) Negative screens - Negative Level I screen means the results of a Level I screen that indicate the individual does not require a Level II evaluation;

(B) Positive Level I screen means results of a Level I screen which indicate that an individual falls within federal requirements for a mandatory Level II evaluation;

(C) Questionable screens - In cases where information suggests the possibility of a serious mental illness or intellectual disability or related condition, the referral source must submit medical records information with the Nebraska Level I Preadmission Screening and Resident Review (PASRR) form, as applicable, to clarify the presence or absence of the suspected disorder. When an individual's condition suggests that some but not all criteria are met to qualify as mental illness or intellectual disability or related condition under the criteria provided in this chapter, the Department will exclude the individual from the preadmission screening and resident review (PASRR) Level II process and will forward notification to the referral source indicating that any later status change suggesting full qualification for such a condition should be forwarded to the Department for consideration of Level II need;

(D) Exempted hospital discharges and categorical determination - Requests for exemptions or categorical decisions must include supportive documentation. Both the exempted hospital discharge provision and the categorical determination options allow the individual to be admitted to a nursing facility (NF) without requiring performance of an on-site Level II evaluation. The options are indicated on the Nebraska Categorical Determinations and Exemptions form which offer either short term or categorical approvals, based upon certain presenting circumstances. Short term options allow for only brief admission, whereby further contact must be made with the Department to initiate re-screening through the Level I and arrangements for the Level II if the individual's stay is expected to exceed the approved time frame; and

(E) Positive Level I Screen - The reviewing agent will request medical records information which sufficiently supports that the individual meets criteria for a preadmission screening and resident review (PASRR) evaluation as indicated in this chapter. If the individual is identified as potentially having an intellectual disability or related condition, the Level I review agency will additionally request information regarding whether the presence of intellectual disability has been clinically diagnosed through psychological testing.

006.04 TRANSFERS. A nursing facility (NF) to nursing facility (NF) transfer does not require the completion of a new Nebraska Level I Preadmission Screening and Resident Review (PASRR) form or the completion of a new Level II preadmission screening and resident review (PASRR) evaluation if the transferring facility has completed the appropriate preadmission screening and resident review (PASRR) screening. The discharging facility must send a copy of the most recent Level I or II, as applicable, screening information to the admitting facility at the time of transfer. The Level II determination applies to nursing facility (NF) services and is not facility-specific. The only exception is for a nursing facility (NF) that is providing specialized services approved through a current Level II determination. If the client transfers to another nursing facility (NF) and the same specialized service cannot be provided, these determinations may not be transferred from one facility to another.

006.05 IDENTIFICATION CRITERIA.

006.05(A) IDENTIFICATION CRITERIA FOR INDIVIDUALS WITH SERIOUS MENTAL ILLNESS. An individual is considered to have a serious mental illness (SMI) and requires a Level II preadmission screening and resident review (PASRR) evaluation if the individual meets all three of the following three indicators:

(1) Diagnosis indicator: The individual has a psychiatric diagnosis which, by accepted clinical standards, is determined to be a serious and persistent psychiatric condition, diagnosable under the current edition of the Diagnostic and Statistical Manual of Mental Disorders. The mental disorder must be characterized as likely to lead to a chronic disability but cannot be a primary psychiatric diagnosis of dementia or a related disorder. For the purpose of this definition, Alzheimer's and organic disorders are considered related disorders to dementia. If dementia or a related disorder co-exists with a serious and persistent serious mental illness which is not a dementia, the dementia or related disorder must be predominant and progressive to exempt the co-occurring psychiatric condition from this indicator;

(2) Impairment and behavior indicators: Within the past six months, the psychiatric disorder has resulted in functional limitations in one or more of the following major life activities on a continuing or intermittent basis:

(a) Serious difficulty interacting appropriately and communicating effectively with other persons. Examples of such difficulty may include but are not limited to, possible history of altercations, evictions, firing, fear of strangers, avoidance of interpersonal relationships, and social isolation;

(b) Serious difficulty in sustaining focused attention for a sufficient period to complete tasks for which they should be medically capable. Examples of such difficulty may include but are not limited to concentration difficulties, inability to complete simple tasks within an established time period, frequent errors related to task completion, or need for assistance in completion of tasks; or

(c) Serious difficulty adapting to typical changes in circumstances. Examples of such difficulty may include but are not limited to agitation, exacerbated signs and symptoms of the psychiatric condition, withdrawal from the situation, or need for intervention by the mental health or judicial system.

(3) Duration of recent treatment: The treatment history indicates that the individual has experienced at least one of the following:

(a) Psychiatric treatment more intensive than outpatient care once within the past two years for a nursing facility (NF) resident or more than once in the past two years for a nursing facility (NF) applicant;

(b) Within the last two years, due to the mental disorder, experienced a major episode of significant disruption to the normal living situation, for which supportive services were required to maintain functioning at home or in a residential treatment environment, or which resulted in intervention by housing or law enforcement officials. For the purpose of this definition, major episodes of significant disruption may include an involuntary psychiatric hospitalization, suicidal attempts or gestures, 1:1 monitoring, or other issues which are safety-related or involved; or

(c) Within the past two years, residence in a psychiatric hospital which required a period of hospitalization greater than that which is typically required for acute stabilization.

006.05(A)(i) INDICATORS. In addition to the criteria listed in above, the following indicators may be considered evidence of a serious mental illness:

(1) The individual has a history of a serious mental illness;

(2) There is presenting evidence of a serious mental illness which includes possible disturbances in orientation, affect, or mood, and the primary psychiatric condition is not dementia, Alzheimer's disease or a related disorder. "Primary" means that the symptoms of the dementia supersede symptoms of any co-occurring psychiatric condition; and

(3) The individual has been prescribed a psychoactive medication on a regular basis, expressly for the indicators identified above.

006.05(A)(ii) DEMENTIA, ALZHEIMER'S DISEASE, OR RELATED DISORDER. An individual is considered not to require a preadmission screening and resident review (PASRR) Level II psychiatric evaluation if dementia or a related disorder can be ranked as primary over any additional co-occurring psychiatric disorders, where present, and the dementing condition meets established clinical standards specified in the current edition of the Diagnostic and Statistical Manual. In circumstances of dementia which co-occurs with other physical conditions but is said to be the primary psychiatric disorder, the facility must make a reasonable effort to provide documentation to the Department that the dementing condition is primary. If one of two psychiatric disorders is dementia, Alzheimer's disease, or a related disorder and the other psychiatric disorder is a serious mental illness, the Level II evaluation will be required if the facility cannot provide sufficient data to support a clear clinical ranking of primary dementia. For purposes of preadmission screening and resident review (PASRR), the neurological examination may be completed by a medical doctor. The physician's findings must be clearly substantiated and must focus on a physical examination and a psychological examination including mental status and cognitive functioning. Although a neurological examination on its own may corroborate a diagnosis of dementia, these examinations are not determinative alone. Other factors may be considered.

006.05(B) IDENTIFICATION CRITERIA FOR INDIVIDUALS WITH INTELLECTUAL DISABILITY OR A RELATED CONDITION. An individual is considered to have an intellectual Disability or a related condition and requires a Level II evaluation if the individual meets any of the following criteria:

(1) Suspicion or diagnosis of intellectual disability (ID): An individual is considered to have intellectual disability if he or she has a level of intellectual disability as described in the American Association on Mental Deficiency's Manual or Classification in Mental Deficiency (1983). Intellectual Disability refers to significantly sub-average general intellectual functioning existing concurrently with deficits in adaptive behavior and manifested during the developmental period; or

(2) Suspicion or presence of a Related Condition or Developmental Disability: Related condition is defined as a severe, chronic disability whose condition is:

(a) Attributable to cerebral palsy or epilepsy; or any other condition, other than mental illness (MI), found to be closely related to intellectual disability (ID) because the condition results in impairment of general intellectual functioning or adaptive behavior similar to that of a person with intellectual disability (ID) and requires treatment or services similar to those required for such persons;

(b) Manifested before the person reached age 22;

(c) Likely to continue indefinitely;

(d) Results in substantial functional limitations in three or more of the following areas of major life activity:

(i) Self-care;

(ii) Understanding and use of language;

(iii) Learning;

(iv) Mobility;

(v) Self-direction; or

(vi) Capacity for independent living.

006.05(B)(i) NO KNOWN DIAGNOSIS. In the absence of a known diagnosis of intellectual disability or a related condition, a suspicion or history of treatment by an agency serving individuals with such conditions should trigger the housing or receiving facility to contact the Department for a determination of need for Level II evaluation under the preadmission screening and resident review (PASRR) program.

006.06 NEGATIVE SCREENS. If a client does not require a Level II evaluation and is admitted to the nursing facility (NF), the facility must retain a copy of the Nebraska Level I Preadmission Screening and Resident Review (PASRR) form in the resident’s permanent nursing facility (NF) record.

006.06(A) MEDICAID PAYMENT. If a Medicaid-eligible client does not require a Level II evaluation and is admitted to the nursing facility (NF), Medicaid payment for nursing facility (NF) services can begin no earlier than the date of the Level I preadmission screening and resident review (PASRR) screen is completed.

006.07 CATEGORICAL DETERMINATIONS AND EXEMPTIONS. If the results of a Level I screen, based on current medical documentation, indicate that an individual has a diagnosis or an indication of serious mental illness, intellectual disability or a related condition, and meets one of the following conditions, the individual qualifies for a categorical determination, or an exempted hospital stay and does not require an on-site Level II evaluation prior to nursing facility (NF) admission. Admission to the nursing facility (NF) for an individual qualifying under a categorical determination or extended hospital stay may proceed only after approval is provided by Department. Options include:

(1) Categorical emergency seven day - The individual is being admitted pending further assessment in an emergency situation requiring protective services for a period not to exceed seven calendar days. Before admission can occur, documentation or verbal description of emergency need must be provided to, and approval must be secured by the Department. The Nebraska Level I Preadmission Screening and Resident Review (PASRR) form and Categorical Determination and Exemptions form must be submitted along with the above. If it is determined that the individual's stay in the nursing facility (NF) will continue beyond the approved seven-day time frame, the receiving facility must contact the Department as soon as the determination is made that continued stay will be required and no later than the seventh calendar day following admission, in order to arrange an on-site Level II evaluation;

(2) Categorical respite 30 day - The individual is being admitted to provide respite care for a period not to exceed 30 calendar days for in-home caregivers to whom the individual is expected to return. Before admission can occur, documentation supporting the need for respite services placement must be provided along with the Nebraska Level I Preadmission Screening and Resident Review (PASRR) form and Categorical Determination and Exemptions form to the Department. If it is determined that the individual's stay in the nursing facility (NF) will continue beyond the approved 30-day time frame, the receiving facility must contact the Department as soon as the determination is made that continued stay will be required and no later than the 30th calendar day following admission, in order to arrange an on-site Level II evaluation;

(3) Categorical progressed dementia with intellectual disability or related condition: The individual has intellectual disability or a related condition along with a co-occurring diagnosis of progressed dementia, Alzheimer's disease or related disorder. Both of the following must also be present: The diagnosis of dementia, Alzheimer's disease or related disorder must be considered the primary diagnosis and the individual must be considered to be in the advanced stages of this condition and no longer able to meaningfully participate in or benefit from a program of specialized services. Before admission can occur, medical records information which supports that the individual qualifies under this criterion must be provided to the Department or contractor along with Nebraska Level I Preadmission Screening and Resident Review (PASRR) form and Categorical Determination and Exemptions form;

(4) Categorical serious medical - The individual's medical condition renders him or her unable to benefit from a plan of specialized services and clearly meets criteria for nursing facility (NF) care. Applicable conditions include: coma, ventilator dependence, brain stem injury, or end-stage medical condition. In order to qualify, medical records information which support that the individual qualifies under this criterion must be provided along with Nebraska Level I Preadmission Screening and Resident Review (PASRR) form and the Categorical Determination and Exemptions form to the Department before the individual's admission can occur; or

(5) Exempted hospital discharge - Federal regulations also offer an exemption from the Level II preadmission screening and resident review (PASRR) process for individuals with serious mental illness or intellectual disability or related conditions who are being discharged from the hospital to the nursing facility (NF) for a nursing facility (NF) stay which is expected to not exceed 30 calendar days. The hospital must complete the Categorical Determinations and Exemptions form with a physician's certification to indicate necessity. Qualifying criteria for the exempted hospital discharge exemption are as follows:

(a) The individual meets criteria for serious mental illness or intellectual disability or a related condition as described in this chapter;

(b) The individual is being admitted to a nursing facility (NF) directly from a hospital after receiving acute inpatient medical care at the hospital, excluding inpatient psychiatric care;

(c) The individual requires nursing facility (NF) services for the condition for which they received care; and

(d) The individual's attending physician has certified on the hospital discharge orders or the nursing facility (NF) admission orders that admission to the nursing facility (NF) is likely to require less than 30 days of nursing facility (NF) services.

(6) 60 day convalescent option: The 60 day convalescent option is an allowable categorical exemption for an individual with a serious mental illness or intellectual disability or related condition. To qualify, the individual must require nursing facility level of care (NF LOC) following hospitalization from an acute physical illness and does not meet all of the criteria for an exempted hospital discharge exemption as defined above.

006.07(A) DOCUMENTATION OF CATEGORICAL DETERMINATIONS AND EXEMPTED HOSPITAL DISCHARGE. The facility must submit the Nebraska Level I Preadmission Screening and Resident Review (PASRR) form and Categorical Determination and Exemptions form with documentation supporting the request to the Department before admission for an individual with serious mental illness, intellectual disability, or a related condition may occur.

006.07(B) STAY BEYOND SPECIFIED LIMITS. If the individual with serious mental illness, intellectual disability, or a related condition qualified for a categorical determination or an exempted hospital discharge which involved a time limited admission, the Department must be contacted if the stay is expected to exceed the approved time frame and no later than the conclusion of the approved time frame in order to arrange an on-site subsequent Level II evaluation. The facility must coordinate such a contact through submission of an updated Level I preadmission screening and resident review (PASRR) to the Department. The on-site Level II evaluation will be completed by the fifth business day from the Level II referral date. Medicaid payment is not allowed beyond the specified time limits if a Level I status change is not completed and sent to the Department prior to the conclusion of the time frame.

006.07(C) MEDICAID PAYMENT. If the documentation supports the categorical determination or exemption, Medicaid payment can begin no earlier than the date the Nebraska Level I Preadmission Screening and Resident Review (PASRR) is completed. If the documentation does not support the categorical determination, a Level II evaluation must be initiated immediately. Medicaid payment can begin no earlier than the date of the Level II determination.

006.08 INDIVIDUALS WHO REQUIRE A LEVEL II EVALUATION. Following the first time identification when an individual requires a Level II evaluation, the Department will notify the individual or their legal representative that they have an indication or diagnosis of serious mental illness or intellectual disability or related condition and are being referred for a Level II evaluation. The nursing facility (NF), hospital, or other party must submit the signed release of information to the Department prior to conducting the Level II evaluation. If the Department determines that additional information is required to determine whether the individual has a condition warranting a Level II preadmission screening and resident review (PASRR) evaluation, the referring source must submit requested information to the Department by the request deadline. Failure to provide requested information by the request deadline may result in a cancelled preadmission screening and resident review (PASRR) determination review. Subsequently, a new Level I preadmission screening and resident review will be required to be submitted for review. The nursing facility (NF) retains a copy of the Preadmission Screening and Resident Review (PASRR) Level I form and the Release of Information form in the resident’s permanent file.

006.08(A) MEDICAID PAYMENT. If a Medicaid-eligible client requires a Level II evaluation and is admitted to the nursing facility (NF), Medicaid payment for nursing facility (NF) services can begin no earlier than the date of the preadmission screening and resident review (PASRR) final determination. If the initial Level II determination approval was time limited, continued payment will be allowed provided that a status change preadmission screening and resident review (PASRR) is submitted to the Department or its agent and the individual is determined to meet nursing facility (NF) preadmission screening and resident review (PASRR) placement criteria no later than the expiration date of the initial Level II evaluation.

006.08(B) ADMISSION TO A NEBRASKA FACILITY FROM ANOTHER STATE. The nursing facility (NF) must notify the Department of potential admissions and must complete the Nebraska Level I Preadmission Screening and Resident Review (PASRR) form and, as applicable, the Categorical Determinations and Exemptions form prior to the individual's admission to a Nebraska Medicaid-certified nursing facility (NF). If the individual is determined by the Department to require a Level II evaluation, the Level II determination must be completed before the applicant may be transferred to the Nebraska facility. In circumstances where the Department is unable to arrange an on-site evaluation in the transferring individual's home state, the Department must request medical records information to make document-based determination of need for nursing facility (NF) and need for specialized services, if indicated. If unable to make a determination of nursing facility (NF) need based upon Medicaid nursing facility level of care (NF LOC) criteria, Medicaid coverage for nursing facility (NF) services for the individual will be denied.

006.08(C) ADMISSION OF NEBRASKA RESIDENTS TO OUT-OF-STATE FACILITIES. If an individual is transferring from the State of Nebraska to an out-of-state Medicaid- certified nursing facility (NF), the preadmission process including the Level II evaluation, if required, must be completed before the individual leaves the state.

006.09 LEVEL II EVALUATION. The Level II evaluation process determines:

(1) Whether the individual has serious mental illness or intellectual disability or related condition as defined by federal regulations and as defined within this chapter;

(2) Whether the level of services provided by a nursing facility (NF) or another institutional placement is appropriate to meet the individual's needs; and

(3) For applicants determined to require nursing facility (NF) placement and for all evaluated nursing facility (NF) residents services which are required to meet the evaluated individual's needs are the responsibility of the receiving or retaining facility, except for specialized services, which are the responsibility of the State.

006.09(A) RETURNING FROM RECEIVING INTENSIVE TREATMENT SERVICES FOR SERIOUS MENTAL ILLNESS. If an individual is returning to a nursing facility (NF) from receiving intensive treatment services for serious mental illness, a new Level I screen is required to determine further screening requirements. If the Level I screen indicates that the individual meets serious mental illness criteria as indicated in this chapter, a Level II summary of findings report must be issued. The summary may be based upon a document-based review of the psychiatric facility's medical records, if an on-site Level II assessment was performed within the 90-day period and current documentation supports that the individual is sufficiently stable. An on-site evaluation is required if an on-site Level II has not been performed within the prior 90-day period or if the documentation does not sufficiently indicate adequate psychiatric stabilization.

006.09(B) FACILITY ACTION. For each individual who requires a Level II evaluation, the nursing facility (NF), hospital, or other party must obtain medical records information. The referring source must submit the information to the Department so that a determination of Level II need can be made.

006.09(C) MENTAL HEALTH EVALUATOR ACTION. For each individual with an indication or diagnosis of serious mental illness, the evaluator must complete a comprehensive review, which contains medical, functional, and psychosocial information. The on-site evaluation and the final validation and Summary of Findings Report must be completed by the third business day of the referral for an evaluation by the Level I screening agency to the on-site evaluator. Following completion of the on-site evaluation, evaluative data will be reviewed and countersigned by a board-eligible or board-certified psychiatrist who will validate whether the individual has a serious mental illness, summarize the medical and social history, provide recommendations to meet the service needs, and provide recommendations regarding placement needs. The final Level II determination must be completed by the fifth business day from the date of the Level II referral.

006.09(D) INTELLECTUAL DISABILITY OR RELATED CONDITION EVALUATOR ACTION. For each individual with an indication of intellectual disability or a related condition, the evaluator will complete the on-site evaluation. The on-site evaluation and the final determination and Summary of Findings Report will be completed by the fifth business day of the referral. Intellectual testing will be administered to establish a diagnosis if:

(1) Lack of social-historical information from a third party knowledgeable of the individual;

(2) The individual is not currently or has not received services from a community-based developmental disability (DD) provider;

(3) The individual is not currently or was not placed in an intermediate care facility for individuals with developmental disabilities (ICF/DD); or

(4) No indication of previous intelligence quotient (IQ) testing is available.

006.09(D)(i) INTELLIGENCE QUOTIENT (IQ) TESTING. Intelligence quotient (IQ) testing will only be performed as a last resort to substantiate an intellectual disability or related condition diagnosis.

006.09(D)(ii) ADAPTIVE BEHAVIOR. Adaptive behavior will always be assessed.

006.09(D)(iii) PSYCHOLOGICAL EVALUATION REPORT. The psychological evaluation report must include the following information:

(1) Type of tests administered to determine intelligence quotient (IQ) score and adaptive behavior functioning;

(2) Test scores;

(3) Interpretation of the findings;

(4) Recommendation;

(5) Diagnosis;

(6) Discussion of any other diagnosis and tests used to substantiate these findings; and

(7) Summary of adaptive and functional levels.

006.09(D)(iv) PSYCHOLOGICAL EVALUATION PROFESSIONALS. The psychological evaluation must be completed by licensed or certified professionals who meet one of the following criteria:

(a) A licensed psychologist;

(b) A licensed and certified clinical psychologist;

(c) A certified psychologist (Master of Science) in a clinical setting - a psychological evaluation completed by certified psychologist must be counter-signed by a licensed and certified clinical psychologist;

(d) A certified counselor (Master of Arts) - a certified counselor can only complete psychological evaluations as specified by the Department of Health and Human Services Division of Public Health’s Bureau of Examining Board.

006.09(D)(iv)(1) LICENSE AND CERTIFICATION. All licensure and certifications must be current and approved according to the Department of Health and Human Services Division of Public Health requirements.

006.09(D)(iv)(2) QUALIFIED INTELLECTUAL DISABILITY PROFESSIONAL. Medical, functionality and psychosocial information will be obtained by a qualified intellectual disability professional (QIDP). This protocol identifies the extent to which the individual's status compares with each of the following skill deficits typically associated with individuals with intellectual disability or related conditions:

(a) Ability to accomplish most self-care needs;

(b) Ability to comprehend simple commands;

(c) Ability to communicate most needs and wants;

(d) Ability to perform a task without systematic long term supervision or support;

(e) Ability to learn new skills without intensive, consistent training;

(f) Ability to apply skills learned in a training situation to other settings without intensive, consistent training;

(g) Ability to demonstrate behavior appropriate to the time, situation, or place without direct supervision;

(h) Demonstration of severe maladaptive behaviors which place the individual or others in jeopardy to health and safety;

(i) Ability or extreme difficulty in making decisions requiring informed consent;

(j) Other skill deficits or specialized training needs which necessitate the availability of trained intellectual disability (ID) personnel, 24 hours per day, to teach the individual functional skills; and

(k) Ability to commute independently.

006.09(E) PARTICIPATION IN THE LEVEL II EVALUATION. The mental health or qualified intellectual disability professional (QIDP) evaluator must contact the retaining facility to coordinate the time and date of the on-site evaluation and to assure that the release of information form has been completed and signed as required. If the individual has a legal representative, the facility must notify the legal representative of the scheduled assessment time and date and invite him or her to participate. The family also must receive notification from the facility of the pending evaluation and be allowed to participate, if available, with consent from the individual or their legal representative.

006.09(F) PRE-EXISTING DATA. Relevant evaluative data collected prior to the Level II evaluation may be used if the data is considered accurate and reflects the current functional status of the individual. To supplement existing data, the mental health reviewer or qualified intellectual disability professional (QIDP) must gather additional information necessary to assess proper placement and treatment.

006.10 HALTING THE LEVEL II EVALUATION. If, at any time during the Level II evaluation, it is found that the individual does not meet criteria for serious mental illness or intellectual disability or a related condition, the Level II evaluation must be halted and admission to the nursing facility (NF) can proceed according to standard procedures for admission. A halted Level II preadmission screening and resident review (PASRR) evaluation means that a nursing facility level of care (NF LOC) was not determined. If the individual's status changes, later suggesting the presence of serious mental illness or intellectual disability or a related condition, the Level I must be resubmitted to the Department as a status change.

006.11 FINAL DETERMINATION CRITERIA. The Department or contractor must use the following criteria to make the final determination for each individual who requires a Level II evaluation.

006.11(A) APPROPRIATE FOR NURSING FACILITY (NF) SERVICES. An individual with serious mental illness, intellectual disability or a related condition, is considered appropriate for Nursing Facility services if it is determined through a Level II evaluation that:

(i) Nursing needs are primary and may include treatment and monitoring of the individual's medical needs, a protective structured environment, assistance with activities of daily living (ADL), nursing supervision, and monitoring to avoid further deterioration or complications;

(ii) Nursing needs outweigh the individual's capacity for living in a less restrictive setting and require technical or professional nursing supervision on a 24-hour basis;

(iii) Mental health needs do not require specialized services but may require mental health services as part of the overall plan of care, to include but not limited to services such as medication monitoring, counseling and therapy, consultations with a psychiatrist; or

(iv) Intellectual disability or related condition needs do not require intensive treatment services but may require intellectual disability or related condition services as part of the overall plan of care, to include but not limited to services such as physical therapy, occupational therapy, speech, and social or recreational activities.

006.11(B) INAPPROPRIATE FOR NURSING FACILITY (NF) SERVICES. An individual with serious mental illness, intellectual disability or a related condition, is considered inappropriate for nursing facility (NF) services if it is determined through a Level II evaluation that they do not require nursing facility (NF) services but do require:

(i) Inpatient psychiatric treatment or equally intensive services;

(ii) Mental health, intellectual disability or developmentally disabled services at a level which is defined in this chapter as intensive treatment services; or

(iii) Alternative services.

006.12 NOTIFICATION OF FINAL DETERMINATION. The Department or its agent must make a final determination after reviewing the information obtained from the Level II evaluation and provide a Summary of Findings report indicating the results of the Level II evaluation. The nursing facility (NF) must incorporate all recommendations included in the Summary of Findings into the resident’s plan of care and update facility records with current diagnosis and other information resulting from the evaluation.

006.13 CHOICE. Individuals who have resided in a nursing facility (NF) for 30 continuous months may elect continued nursing facility (NF) residence if the preadmission screening and resident review (PASRR) evaluation determines that nursing facility (NF) care is inappropriate but specialized services, which can be provided by the State in the nursing facility (NF), as needed. The 30 months of continuous residence is calculated back from the first preadmission screening and resident review (PASRR) determination which found that the individual was not in need of nursing facility (NF) care. The initial choice provision and alternative placement options must be explained as appropriate. If the individual chooses to remain in the nursing facility (NF) under the choice provision, the nursing facility (NF) is required to incorporate the care recommendations into the overall plan of care as with any other individual who requires the Level II evaluation. Subsequent decisions of the choice option will be explained in written form to the individual or legal representative and will include a toll-free number if further explanation is needed or if the individual or legal representative chooses to reevaluate that option. Inquiries for further placement option discussion will be referred to the community-based developmental disability service provider (CBDDSP) or the behavioral health regions (BHR) by the Department or its agent for an on-site discussion. The choice stays with the individual until their status changes, including a change in determination from inappropriate for nursing facility (NF) care to appropriate for nursing facility (NF) care, a denial of specialized services, or if the individual leaves the nursing facility (NF). When a new admission occurs, a new Level II determination will be made.

007. NURSING FACILITY (NF) SERVICES .

007.01 STANDARDS FOR PARTICIPATION FOR NURSING FACILITIES. The nursing facility (NF) must meet:

(A) The Nebraska nursing home licensure, and Medicare and Medicaid certification standards as required by state statutes and 42 CFR 483, Subpart B, or if located outside of Nebraska, similar standards in that state;

(B) The facility type, program and operational definitions; and

(C) The definition of a nursing facility (NF) as defined in this chapter, and in section 1919 of the Social Security Act.

007.02 PROVIDER AGREEMENT. To participate as a provider the nursing facility (NF) must meet the standards in this chapter and must complete the appropriate provider agreement. The facility submits the completed and signed form to Medicaid for approval and enrollment as a provider.

007.03 MINIMUM DATA SET RESIDENT ASSESSMENT. The nursing facility (NF) must conduct an interdisciplinary assessment of every resident's functional capacity, regardless of payor source. This assessment must utilize the minimum data set (MDS). The facility must submit one copy of each assessment to the Department within 30 days of completion.

007.03(A) REGISTERED NURSE (RN) ASSESSMENT COORDINATOR. Each facility must designate a registered nurse (RN) assessment coordinator. The facility must inform the Department of the name of the assessment coordinator and must promptly inform the Department of any changes. The assessment coordinator must coordinate each assessment with the appropriate participation of health professionals. Each individual who completes a portion of an assessment must sign and certify as to the accuracy of that portion of the assessment. The assessment coordinator must sign and certify the completion of the assessment.

007.03(B) FREQUENCY OF ASSESSMENTS. An assessment must be completed:

(i) Initial admission: Must be completed by 14th day of resident's stay;

(ii) Annual reassessment: Must be completed within 12 months of most recent full assessment;

(iii) Significant change in status reassessment: Must be completed by the end of the 14th calendar day following determination that a significant change has occurred; and

(iv) Quarterly assessment: Must be completed no less frequently than once every three months.

007.03(C) OTHER CHANGES. The facility need not assess the resident if declines in a resident's physical, mental, or psychosocial well-being are attributable to:

(i) Discrete and easily reversible causes documented in the resident's record and for which facility staff can initiate corrective action;

(ii) Short-term acute illness, such as a mild fever secondary to a cold from which facility staff expect full recovery of the resident's pre-morbid functional abilities and health status; or

(iii) Well established, predictive cyclical patterns of clinical signs and symptoms associated with previously diagnosed conditions.

007.03(D) USE OF INDEPENDENT ASSESSORS. If the Department determines, under a survey by the Department of Health and Human Services Regulation and Licensure or otherwise, that assessments are not being completed or that there has been a knowing and willful false certification of information under this section, the Department may require for a period of time specified by the Department that resident assessments under this section be conducted and certified by individuals who are independent of the facility and who are approved by the Department. The facility is responsible for the reasonable payment of the individuals completing the assessment. The cost may be included in cost reports.

007.04 COMPREHENSIVE CARE PLAN. The facility must develop a comprehensive care plan for each client that includes measurable objectives and timetables to meet a client's medical, nursing, and psychosocial needs that are identified in a comprehensive assessment. The plan must be:

(A) Developed within seven days after completion of the comprehensive assessment;

(B) Prepared by an interdisciplinary team; and

(C) Periodically reviewed and revised by a team of qualified persons after each assessment, or at least quarterly. The plan must include recommendations of the Level II evaluation, if applicable.

007.05 ANNUAL PHYSICAL EXAMINATION. The Department requires that all nursing facility residents have an annual physical examination. The physician, based on their authority to prescribe continued treatment, determines the extent of the examination for clients based on medical necessity. For the annual physical exam, a complete blood count and urinalysis will not be considered routine and will be reimbursed based on the physician's orders. The results of the examination must be recorded in the client's medical record.

007.05(A) BILLING FOR THE ANNUAL PHYSICAL EXAMINATION. If the annual physical examination is performed solely to meet the Medicaid requirement, the physician must submit the appropriate professional claim to the Department. If the physical examination is performed for diagnosis or treatment of a specific symptom, illness, or injury and the client has Medicare or other third party coverage, the physician must submit the claim through the usual Medicare or other third party process.

007.06 PHYSICIAN SERVICES. The physician must see the client whenever necessary, but at least once every 30 days for the first 90 days following admission, and at least once every 60 days thereafter. At the time of each visit, the physician must:

(1) Review the client's total program of care, including medications and treatments;

(2) Write, sign, and date progress notes at each visit; and

(3) Sign all orders.

007.06(A) PHYSICIAN TASKS. In accordance with 42 CFR 483.40(f), the Department will allow all but the following required physician tasks in a nursing facility to be satisfied when performed by a nurse practitioner or physician's assistant who is not an employee of the facility but who is working in collaboration with a physician according to Nebraska statute and designation of duties:

(i) Initial certification;

(ii) Admission orders; and

(iii) Admission plan of care.

007.07 MEDICAL CARE AND SERVICES. The facility must ensure that admitted Medicaid clients receive appropriate medical care and services. If the appropriate medical care or service cannot be provided using facility staff, the facility must arrange for the care or service to be provided.

007.08 DENTAL CARE. Facilities must make arrangements for dental examinations as needed.

007.09 FREEDOM OF CHOICE. Each facility must ensure that any client may exercise their freedom of choice in obtaining covered services from any provider qualified to perform the services. Clients participating in Medicaid managed care must comply with the conditions of their managed care plan.

007.10 ROOM AND BED ASSIGNMENTS. Facility staff must maintain a permanent record of the client's room and bed assignments. This record must show the dates and reasons for all changes and be maintained in the nurses' notes in the health chart or medical record.

007.11 RESIDENTS' RIGHTS. The facility must protect and promote the rights of each resident as defined in 42 CFR 483.10. When the resident is unable to manage their own personal funds, and there is not a guardian or responsible family member, the facility must arrange for, or manage, the personal funds as specified in 42 CFR 483.10(c)(1) thru (8).

007.12 BED-HOLDING POLICIES FOR HOSPITAL AND THERAPEUTIC LEAVE. The facility must develop policies as defined in 42 CFR 483.15(d).

007.13 INITIAL NOTICE OF BED-HOLDING POLICIES. The facility must provide written information to the client and a family member or legal representative that specifies:

(A) The duration of the bed-hold policy during which the client is permitted to return and resume residence in the facility; and

(B) The facility's policies regarding bed-hold periods which must be consistent with 42 CFR 483.15(d).

007.14 NOTICE UPON TRANSFER. At the time of transfer, the facility must provide written notice to the client and a family member or legal representative which specifies the duration of the bed-hold policy.

007.15 PERMITTING THE CLIENT TO RETURN TO THE FACILITY. The facility must establish and follow a written policy under which a client whose leave exceeds the bed-hold period is re-admitted to the facility immediately upon availability of a bed if the client:

(A) Requires the services provided by the facility; and

(B) Is eligible for Medicaid nursing facility services.

007.16 FACILITY-TO-FACILITY TRANSFER. To transfer any Medicaid client from one facility to another, the transferring facility must:

(A) Obtain physician's written order for transfer;

(B) Obtain written consent from the client, his or her family, or guardian;

(C) Notify the Department that handles the client's case in writing, stating:

(i) The reason for transfer;

(ii) The name of facility to which the client is being transferred; and

(iii) The date of transfer;

(D) Transfer the following to the receiving facility:

(i) Necessary medical, social, and Preadmission Screening and Resident Review (PASRR) information;

(ii) Any non-standard wheelchair and wheelchair accessories, options, or components, including power operated vehicles;

(iii) Any augmentative communication devices with related equipment and software;

(iv) Supports; and

(v) Custom fitted or custom fabricated items; and

(E) Document transfer information in the client's record and discharge summary.

007.17 DISCHARGES. At the time of or no later than 48 hours after a client is discharged or expires, the facility must notify the Department that handles the client's case of:

(A) Date of discharge and the place to which the client was discharged; or

(B) Date of death.

007.18 DISCHARGE PLANNING. Before a client's discharge or deinstitutionalization, the facility staff must document in the medical record the actual implementation date of the discharge plan. Each nursing facility must maintain written discharge planning procedures for all Medicaid clients that describe:

(A) Which staff member of the facility has operational responsibility for discharge planning;

(B) The manner in, and methods by, which the staff member will function, including authority and relationship with the facility's staff;

(C) The time period in which each client's need for discharge planning will be determined, which period may not be later than seven days after the day of admission;

(D) The maximum time period after which the interdisciplinary team reevaluates each client's discharge plan;

(E) The resources available to the facility, the client, and the attending physician to assist in developing and implementing individual discharge plans; and

(F) The provisions for periodic review and reevaluation of the facility's discharge planning program.

007.19 INAPPROPRIATE LEVEL OF CARE (LOC). If it is determined that the client's present level of care is inappropriate:

(A) The present facility must provide services to meet the needs of the client and must refer to appropriate agencies for services until an appropriate living situation is available;

(B) The facility must document that other alternatives were explored and the responses;

(C) The facility must make documentation of active exploration for appropriate living situations available to the Department or their agent;

(D) The facility must work cooperatively with the preadmission screening and resident review referral (PASRR) process.

007.20 AT THE TIME OF DISCHARGE. At the time of the client's discharge, the facility must:

(A) Provide any information about the discharged client that will ensure the optimal continuity of care to those persons responsible for the individual's post-discharge care.

(B) Include current information on diagnosis, prior treatment, rehabilitation potential, physician advice concerning immediate care, and pertinent social information.

(C) Discharge the following items specifically purchased for and used by the client with the client:

(i) Any non-standard wheelchair and wheelchair accessories, options, and components, including power operated vehicles;

(ii) Any augmentative communication devices with related equipment and software;

(iii) Supports; and

(iv) Custom fitted or custom fabricated items.

007.21 APPEALS OF DISCHARGES, TRANSFERS, AND PREADMISSION SCREENING AND RESIDENT REVIEW (PASRR) DETERMINATIONS. A resident of a skilled nursing facility (SNF) or a nursing facility (NF) who receives a notice from the skilled nursing facility (SNF) or nursing facility (NF) of the intent to discharge or transfer the resident may appeal to the Department of Health and Human Services for a hearing on this notice. The appeal and hearing must be conducted under 465 NAC 2 and 6. An individual who is adversely affected by any Preadmission Screening and Resident Review (PASRR) determination may appeal to the Department of Health and Human Services for a hearing on the decision. The individual or legal representative will be instructed to contact the Department or contractor for information on appeals and to forward a written request for an appeal to the Department within 90 days of the date of the Preadmission Screening and Resident Review (PASRR) determination notice. The appeal and hearing must be conducted under 465 NAC 2.

007.22 PRIOR AUTHORIZATION. Medicaid requires authorization for the following services:

(A) Nursing facility services for clients under the age of 18;

(B) Special needs nursing facility (NF) services;

(C) Out-of-state nursing facilities;

(D) Room and board services for clients receiving hospice in a special needs nursing facility (NF);

(E) Swing bed services; and

(F) Specialized add-on services for clients with intellectual disabilities or related conditions residing in nursing facilities.

007.23 PHYSICIAN'S INITIAL CERTIFICATION. The physician must certify the medical necessity for nursing facility level of care (NF LOC) for all admissions. Documentation indicating certification must be maintained in the medical record. The physician must also certify the medical necessity for nursing facility level of care (NF LOC):

(A) For clients who became eligible after admission, the physician must certify medical necessity prior to requesting prior authorization for nursing facility level of care (NF LOC); and

(B) Proof of prior authorization must be maintained in the client's medical record in the facility or building where the client resides or in the client account file.

007.24 ADMISSION HISTORY AND PHYSICAL. The client must have a physical examination within 48 hours after admission unless an examination was performed within five days before admission.

007.25 SPECIFIC PAYMENTS.

007.25(A) MEDICAID PAYMENT RESTRICTIONS FOR NURSING FACILITIES. The Department must pay for a nursing facility service only when prior authorized, when prior authorization is required.

007.25(B) INITIAL CERTIFICATION. The Department must approve payment to a facility for services rendered to an eligible client beginning on the latest date:

(i) The client is admitted to the facility;

(ii) The client’s eligibility is effective, if later than the admission date; or

(iii) Of the intellectual disability screen.

007.25(C) DEATH ON DAY OF ADMISSION. If a client is admitted to a facility and dies before midnight on the same day, the Department allows payment for one day of care.

007.25(D) INAPPROPRIATE FOR NURSING FACILITY CARE. For those clients who, at the time of medical review determination, no longer meet nursing facility (NF) criteria for nursing facility (NF) services, the medical review must limit Medicaid payment for up to a maximum of 30 days, beginning with the date the medical review determines that nursing facility (NF) care is inappropriate. Time-limited authorizations exceeding 30 days may be made based on the client's potential for discharge as determined by the medical review.

007.25(E) EFFECT OF PREADMISSION SCREENING AND RESIDENT REVIEW (PASSR). Medicaid payment is available for nursing facility services provided to Medicaid- eligible clients who, as a result of Preadmission Screening and Resident Review (PASRR):

(1) Were found to require the nursing facility level of care (NF LOC); or

(2) Were found inappropriate for nursing facility care but through the 30-month choice have elected to remain in a nursing facility (NF).

007.25(E)(i) PREADMISSION SCREENING NOT PERFORMED. When a preadmission screening and resident review (PASRR) is not performed before admission, Medicaid payment for nursing facility services is available only for services provided after the preadmission screening and resident review (PASRR) is completed.

007.25(F) ITEMS INCLUDED IN PER DIEM RATES. The following items are included in the per diem rate:

(i) Routine services: Routine nursing facility (NF) services include regular room, dietary, and nursing services; social services and activity program as required by certification standards; minor medical supplies; oxygen and oxygen equipment; the use of equipment and facilities; and other routine services;

(ii) Injections: The patient's physician must prescribe all injections. Payment is not authorized for the administration of injections, since giving injections is considered a part of routine nursing care and covered by the long term care facility's reimbursement. Payment is authorized to the drug provider for drugs used in approved injections. Syringes and needles are necessary medical supplies and are included in the per diem rate;

(iii) Transportation: The facility is responsible for ensuring that all clients receive appropriate medical care. The facility must provide transportation to client services that are reimbursed by Medicaid. The reasonable cost of maintaining and operating a vehicle for patient transportation is an allowable cost and is reimbursable under the long term care reimbursement plan;

(iv) Contracted services: The nursing facility must contract for services not readily available in the facility:

(1) If the service is provided by an independent licensed provider who is enrolled in Medicaid the provider must submit a separate claim for each person served; and

(2) If the service is provided by a certified provider of medical care the nursing facility is responsible for payment to the provider. This expense is an allowable cost;

(v) Single room accommodations: Medicaid residents should be afforded equal opportunity to remain in or utilize single-room accommodations. Any facility that prohibits or requires an additional charge for Medicaid utilization of single-room accommodations must make an appropriate adjustment on its cost report to remove the additional cost of single-room accommodations. The facility must not make an additional charge for a therapeutically required single room nor is the facility required to make a cost report adjustment for this type of room. Each facility must have a written policy on single-room accommodations for all payers.

007.25(G) ITEMS NOT INCLUDED IN PER DIEM RATES. Items for which payment may be made to nursing facility (NF) providers and are not considered part of the facility's Medicaid per diem are listed below. To be covered, the client's condition must meet the criteria for coverage for the item as outlined in the appropriate Medicaid provider chapter:

(i) Any non-standard wheelchairs and wheelchair accessories, options, and components, including power-operated vehicles needed for the client's permanent and full time use. Standard wheelchairs are considered necessary equipment in a nursing facility to provide care and part of the per diem;

(ii) Air fluidized bed units and low air loss bed units; and

(iii) Negative pressure wound therapy.

007.25(H) PAYMENTS TO OTHER PROVIDERS. Items for which payment may be authorized to non-nursing facility (NF) providers and are not considered part of the facility's Medicaid per diem are listed below. To be covered, the client's condition must meet the criteria for coverage for the item as outlined in the appropriate Medicaid provider chapter. The provider of the service may be required to request prior authorization of payment for the service:

(i) Legend drugs, over-the-counter (OTC) drugs, and compounded prescriptions, including intravenous solutions and dilutants;

(ii) Personal appliances and devices, if recommended in writing by a physician, such as eye glasses and hearing aids;

(iii) Orthoses;

(iv) Prostheses; and

(v) Ambulance service.

007.25(I) MAY BE CHARGED TO RESIDENT'S FUNDS. Items that may be charged to residents' funds and are not considered as part of the facility's Medicaid per diem are:

(i) Telephone;

(ii) Television and radio for personal use, except cable service;

(iii) Personal comfort items, including smoking materials, notions, and novelties, and confections;

(iv) Cosmetic and grooming items and services that are specifically requested by the client and are in excess of the basic grooming items provided by the facility;

(v) Personal clothing;

(vi) Personal reading matter;

(vii) Gifts purchased on behalf of the client;

(viii) Flowers and plants;

(ix) Social events and entertainment offered outside the scope of the activities program required by certification;

(x) Non-covered special care services such as privately hired nurses or aides specifically requested by the client or family;

(xi) Specially prepared or alternative food requested instead of the food generally prepared by the facility, as required by certification; or

(xii) Single room, except when therapeutically required.

007.25(J) OTHER. The facility must meet the following requirements:

(i) The facility must not charge a client for any item or service not requested by the resident.

(ii) The facility must not require a resident to request any item or service as a condition of admission or continued stay.

(iii) The facility must inform the client requesting an item or service for which a charge will be made that there will be a charge for the item or service and what the charge will be.

007.25(K) PAYMENT FOR BED-HOLDING. The Department makes payments to reserve a bed in a nursing facility (NF) during a client's absence due to hospitalization for an acute condition and for therapeutically-indicated home visits. Therapeutically-indicated home visits are overnight visits with relatives and friends or visits to participate in therapeutic or rehabilitative programs. Payment for bed-holding is subject to the following conditions:

(1) A held bed must be vacant and counted in the census. The census must not exceed licensed capacity;

(2) Hospital bed-holding is limited to reimbursement for 15 days per hospitalization. Hospital bed-holding does not apply if the transfer is to the following: nursing facility, hospital nursing facility, swing-bed, a Medicare-covered special needs facility stay, or to hospitalization following a Medicare-covered special needs facility stay;

(3) Therapeutic leave bed-holding is limited to reimbursement for 18 days per calendar year. Bed-holding days are prorated when a client is a resident for a partial year;

(4) A transfer from one facility to another does not begin a new 18-day period;

(5) The client's comprehensive care plan must provide for therapeutic leave;

(6) Facility staff must work with the client, the client's family, or guardian to plan the use of the allowed 18 days of therapeutic leave for the calendar year; and

(7) Qualifying hospital and therapeutic leave days will be reimbursed at the facility’s bed-hold rate.

007.25(K)(i) SPECIAL LIMITS. When the limitation for therapeutic leave interferes with an approved therapeutic or rehabilitation program, the facility may submit a request for special limits of up to an additional six days per calendar year to Medicaid. Requests for special limits must include:

(1) The number of leave days requested;

(2) The need for additional therapeutic bed-holding days;

(3) The physician's orders;

(4) The comprehensive plan of care; and

(5) The discharge potential.

007.25(K)(ii) REPORTING. It is mandatory that the nursing facility (NF) report all bedholding days monthly. Facilities must report bedholding days. The nursing home days are adjusted to the actual number of days the client was present in the facility at 12:00 midnight.

008. SPECIALIZED ADD-ON SERVICES FOR CLIENTS WITH INTELLECTUAL DISABILITIES OR RELATED CONDITIONS RESIDING IN NURSING FACILITIES .

008.01 SPECIALIZED ADD-ON SERVICES FOR CLIENTS WITH INTELLECTUAL DISABILITIES OR RELATED CONDITIONS RESIDING IN NURSING FACILITIES. Medically necessary services intended to assist the nursing facility clients in obtaining, maintaining, or improving developmental-age appropriate skills. These services include habilitative training and are not provided by the nursing facility. These services are identified through the preadmission screening and resident review (PASRR) Level II assessment. Specialized add-on services must result in a continuous, aggressive individualized plan of care and be recommended and monitored by the individual’s interdisciplinary team. Each specialized add-on service must be prior authorized separately.

008.02 SPECIALIZED ADD-ON SERVICES.

008.02(A) HABILITATIVE SKILLS TRAINING. Habilitative skills training supports individuals to acquire new skills or increase skills in the areas of hygiene, self-advocacy, activities of daily living and communication. Habilitative skills can occur on-site but may be expanded to also occur in the community such as grocery stores, financial institutions, movie theatres, recreational centers or events, and social activities so the individual learns these skills in a variety of settings. Services are expected to include both formal training and opportunities to practice the skills in various settings. This service is provided with a staff to individual ratio of one to one. This service is provided to individuals in order to meet the goals and outcome measurements as outlined in the individual’s plan of care. Habilitative skills training consists of:

(1) Identification of skill needs requiring training with regard to individual rights and due process, advocating for their own needs, desires, future life goals and participation in the development of their plan of care, communication skills, personal hygiene skills, dressing skills, laundry skills, bathing skills, and toileting skills;

(2) Development and implementation of formal training goals related to identified skill needs; and

(3) Monitor and revise goals according to the individual’s response to training.

008.02(A)(i) LIMITATIONS. Limitations are as follows:

(1) Transportation is not included in the reimbursement rates. Transportation services can be billed separately for off-site habilitative skills only and is limited to travel to and from the habilitative service. The individual must be present in the vehicle.

(2) This service can be authorized in combination with but cannot be provided during the same time period as habilitative community inclusion.

(3) This service must exclude any services available through public education programs funded under the Individuals with Disabilities Education Act (IDEA). This includes services not otherwise available through public education programs in the individual’s local school district, including after school supervision and daytime services when school is not in session. Services cannot be provided during the school hours set by the local school district for the individual. Regular school hours and days apply for a child who receives home schooling.

008.02(B) HABILITATIVE COMMUNITY INCLUSION. Habilitative community inclusion supports individuals to increase independence and inclusion in their community. This service must occur in the community in a nonresidential setting, outside of the nursing facility (NF). Making connections with community members is a strong component of this service provision. This service is provided with a staff to individual ratio of one to one. This service is provided to individuals in order to meet the goals and outcome measurements as outlined in the individual’s plan of care. Habilitative community inclusion must be included in the individual’s care plan. Habilitative community inclusion services consist of:

(1) Identification of needed skills with regard to access and use of community supports, services and activities;

(2) Development and implementation of formal training goals related to:

(a) Community transportation and emergency systems;

(b) Accessing and participation in community groups, volunteer organizations, and social settings; and

(c) Opportunities to pursue social and cultural interests and building and maintaining interpersonal relationships; and

(3) Monitoring and revising goals according to the individual’s response to training.

008.02(B)(i) LIMITATIONS. Limitations are as follows:

(1) Habilitative community inclusion can supplement, but cannot replace, activities that would otherwise be available as part of the nursing facility (NF) activities program;

(2) Transportation is not included in the reimbursement rate and must be billed separately and is limited to travel to and from the habilitative service. The individual must be present in the vehicle; and

(3) This service must exclude any services available through public education programs funded under the Individuals with Disabilities Education Act (IDEA). This includes services not otherwise available through public education programs in the individual’s local school district, including after school supervision and daytime services when school is not in session. Services cannot be provided during the school hours set by the local school district for the individual. Regular school hours and days apply for a child who receives home schooling.

008.02(C) EMPLOYMENT ASSISTANCE. Employment assistance supports the individual through habilitative training to obtain gainful employment in their community. The goal is to provide the skills, tools, and supports to enable the individual to seek and obtain employment. This service is provided with a staff to individual ratio of one to one and may be provided at the nursing facility or in the community. This service is provided to individuals in order to meet the goals and outcome measurements as outlined in the individual’s plan of care. Employment assistance services consist of:

(1) Identification of the individual’s job preferences and skill needs;

(2) Identification of available employment opportunities in their community;

(3) Development and implementation of formal training goals related to the individual’s employment needs including application for employment, job readiness and preparation skills and appropriate work behavior; and

(4) Monitoring and revising goals according to the individual’s response to training.

008.02(C)(i) LIMITATIONS. Limitations are as follows:

(1) The individual’s service hours are determined by the assistance needed to reach employment goals;

(2) This service can be authorized in combination with but cannot be provided during the same time period as employment support;

(3) Transportation is not included in the reimbursement rate and must be billed separately and is limited to travel to and from the habilitative service. The individual must be present in the vehicle;

(4) This service must exclude any services available through public education programs funded under the Individuals with Disabilities Education Act (IDEA). This includes services not otherwise available through public education programs in the individual’s local school district, including after school supervision and daytime services when school is not in session. Services cannot be provided during the school hours set by the local school district for the individual. Regular school hours and days apply for a child who receives home schooling; and

(5) No employment assistance or support services are available to a resident of a nursing facility through a program funded by the Rehabilitation Act of 1973 in Nebraska.

008.02(D) EMPLOYMENT SUPPORT. Employment support supports the individual through habilitative training to maintain integrated and gainful employment after the individual has secured employment. The goal is to provide the skills, tools, and supports necessary for the individual to maintain employment. This service is provided with a staff to individual ratio of up to 1:4 and must be provided in the community. This service is provided to individuals in order to meet the goals and outcome measurements as outlined in the individual’s plan of care. Employment Support services consist of:

(1) Teaching appropriate work behavior related to punctuality, attendance and coworker relationships;

(2) Providing training and support for the individual to develop time management skills;

(3) Providing training and monitoring in order for the individual to learn the job tasks necessary to maintain employment;

(4) Providing social skills training in relation to the work environment; and

(5) Monitoring and revising goals according to the individual’s response to training.

008.02(D)(i) LIMITATIONS. Limitations are as follows:

(1) Payment for employment support excludes the supervisory activities rendered as a normal part of the business setting.

(2) This service can be authorized in combination with but cannot be provided during the same time period as employment assistance.

(3) Transportation is not included in the reimbursement rate and must be billed separately and is limited to travel to and from the habilitative service. The individual must be present in the vehicle.

(4) This service must exclude any services available through public education programs funded under the Individuals with Disabilities Education Act (IDEA). This includes services not otherwise available through public education programs in the individual’s local school district, including after school supervision and daytime services when school is not in session. Services cannot be provided during the school hours set by the local school district for the individual. Regular school hours and days apply for a child who receives home schooling.

(5) No employment assistance or support services are available to a resident of a nursing facility through a program funded by the Rehabilitation Act of 1973 in Nebraska.

008.02(E) NON-MEDICAL TRANSPORTATION. Non-medical transportation is provided in order for the individual to participate in specialized add-on services in a community setting.

008.02(E)(i) LIMITATIONS. Limitations are as follows:

(1) Transportation is limited to travel to and from a habilitative service according to the individual’s plan of care.

(2) The individual must be present in the vehicle.

(3) Purchase or lease of vehicles is not covered under this service.

(4) Is a separately billable service for off-site habilitative skills, off-site employment assistance, employment support, and habilitative community inclusion.

008.02(F) PRIOR AUTHORIZATION. For each specialized add-on service a prior authorization request must be submitted by the person or agency providing the service. Medicaid must receive the prior authorization request within 15 calendar days of the start date of the service. The person or agency must provide the following as part of the prior authorization process:

(1) The individual or resident’s Level II preadmission screening and resident review (PASRR) final summary determination which must include the recommended specialized add-on services;

(2) The individual or resident’s plan of care which must include these specialized add-on services;

(3) Specify the formal goals and objectives that address the individual or resident’s needs determined in the Level II preadmission screening and resident review (PASRR) final summary; and

(4) The frequency and duration of the service.

008.02(i) ADDITIONAL REQUIREMENTS. Specialized add-on services are provided only when prior authorized, recommended by the client’s interdisciplinary team and are included in the client’s plan of care. The interdisciplinary team includes but is not limited to the attending physician, a registered nurse and nurse aide with responsibility for the individual, a member of the food and nutrition services staff, to the extent possible the individual and the individual’s representative, and other appropriate staff or professionals in disciplines as determined by the individual’s needs or as requested by the individual. Specialized add-on services must meet professional standards of quality and be provided by qualified persons in accordance with each individual’s written plan of care.

008.02(ii) PAYMENTS. Specialized add-on services are paid to the providers of specialized add-on services. Payments to providers for medically necessary services, including specialized add-on services in excess of limitations for covered services identified elsewhere in the state plan, or not listed as specialized add-on services according to the state plan, require pre-authorization.

009. SERVICES FOR LONG TERM CARE CLIENTS WITH SPECIAL NEEDS .

009.01 LONG TERM CARE CLIENTS WITH SPECIAL NEEDS. Long term care clients with special needs means those whose medical or nursing needs are complex or intensive and are above the usual level of capabilities of staff and exceed services ordinarily provided in a nursing facility.

009.01(A) VENTILATOR-DEPENDENT CLIENTS. These clients are dependent on mechanical ventilation to continue life and require intensive or complex medical services on an on-going basis. The facility shall provide 24-hour registered nurse nursing coverage.

009.01(A)(i) CRITERIA FOR CARE. The client must:

(1) Require intermittent, but not less than 10 hours in a 24-hour period, or continuous ventilator support. They are dependent on mechanical ventilation to sustain life, or is in the process of being weaned from mechanical ventilation. This does not include individuals using continuous positive airway pressure (C-PAP) or Bi-level positive airway pressure (Bi-PAP) nasally. Patients requiring use of Bi-level positive airway pressure via a tracheostomy will be considered on a case-by-case basis;

(2) Be medically stable and not require intensive acute care services;

(3) Have care needs which require multi-disciplinary care;

(4) Require daily respiratory therapy intervention or modality support; and

(5) Have needs that cannot be met at a lesser level of care.

009.01(B) CLIENTS WITH BRAIN INJURY.

009.01(B)(i) CLIENTS REQUIRING SPECIALIZED EXTENDED BRAIN INJURY REHABILITATION. These clients must require and be capable of participating in an extended rehabilitation program. Their care must be:

(1) Primarily due to a diagnosis of acute brain injury; or

(2) Primarily due to a diagnosis of chronic brain injury following demonstration of significant improvement over a period of six months while receiving rehabilitative services based on approval by Nebraska Medicaid.

009.01(B)(i)(a) CRITERIA FOR CARE. The client must:

(i) Require physician services that exceed those described in 471 NAC 12-008.06;

(ii) Have needs that exceed the nursing facility level of care, that is, needs that cannot be met at a lower level of care such as a traditional nursing facility, assisted living, or a private home, as evidenced by:

(1) Complex medical needs as well as extended training or rehabilitation needs that together exceed the criteria for nursing facility level of care;

(2) Combinations of extended training or rehabilitative needs that together exceed the criteria for nursing facility level of care;

(3) Extended training or rehabilitation needs that require multi-disciplinary care; or

(4) Complex combinations of needs from various domains.

(iii) Be capable of participating in an extended training or rehabilitation program evidenced by:

(1) Ability to tolerate a full rehabilitation schedule daily;

(2) Being medically stable and free from complicating acute major medical conditions that would prohibit participation in an extended rehabilitation program;

(3) Possessing the cognitive ability to communicate some basic needs, either verbally or non-verbally;

(4) Being able to respond to simple requests with reasonable consistency, not be a danger to themselves or others, but may be confused, inappropriate, engage in non-purposeful behavior in the absence of external structure, exhibit mild agitation, or have severe attention, initiation, or memory impairment, minimum Level IV on the Rancho Los Amigos Coma Scale; or

(5) Being absent of addictive habits or behaviors that would inhibit successful participation in the training or rehabilitation program;

(iv) Have potential to benefit from an extended training or rehabilitation program resulting in reduced care needs, increased independence, and a reasonable quality of life as evidenced by:

(1) Possessing a current documented prognosis that indicates that the individual has the potential to successfully complete an extended training or rehabilitation program;

(2) Possessing the ability to learn compensatory strategies for, or to acquire skills of daily living in areas including, but not limited to transportation, money management, aide management, self medication, social skills, or other self cares which may result in requiring residency in a lower level of residential care; and

(3) Documentation supporting that they are making continuous progress in an extended training or rehabilitation program including transitional training for successful discharge or transfer.

009.01(B)(ii) CRITERIA FOR CARE OF CLIENTS REQUIRING LONG TERM CARE SERVICES FOR BRAIN INJURY. The client must:

(1) Have needs that exceed the nursing facility level of care as evidenced by:

(a) Combinations of medical, care or rehabilitative needs that together exceed the criteria for nursing facility level of care;

(b) Care that requires a specially trained, multi-disciplinary team;

(c) Complex care needs occurring in combinations from various domains; or

(d) Undetermined potential to benefit from extended training and rehabilitation program;

(2) Be capable of participating in clinical program as evidenced by:

(a) Being non-aggressive and non-agitated; and

(b) Being absent of addictive habits or behaviors that would inhibit participation in clinical program;

(3) Have potential to benefit from clinical program as evidenced by:

(a) Being cognitively aware of surroundings or events;

(b) Being able to tolerate open and stimulating environment;

(c) Being able to establish or tolerate routines;

(d) Being able to communicate verbally or non-verbally basic needs; and

(e) Requiring moderate to extensive assistance to preserve acquired skills.

009.01(C) OTHER SPECIAL NEEDS CLIENTS. These clients must require complex medical or rehabilitative care in combinations that exceed the requirements of the nursing facility level of care. These clients may also use excessive amounts of supplies, equipment, or therapies. The client must meet the criteria for one of the two following categories:

009.01(C)(i) CRITERIA FOR CARE OF CLIENTS WITH REHABILITATIVE SPECIAL NEEDS. The client must:

(1) Be medically stable and require physician services two to three times per week;

(2) Require multi-disciplinary care;

(3) Require care in multiple body organ systems;

(4) Require a complicated medical or treatment regimen, requiring observation and intervention by specially trained professionals, such as:

(a) Multiple stage 2, or at least one stage 3 or stage 4 decubiti with other complex needs;

(b) Multiple complex intravenous fluids, or nutrition with other complex needs;

(c) Tracheostomy within the past 30 day with other complex care needs;

(d) Intermittent ventilator use, less than ten hours in a 24-hour period, with other complex care needs;

(e) Respiratory therapy treatments or interventions more frequently than every six hours with other complex care needs;

(f) Initiation of Continuous Abdominal Peritoneal Dialysis (CAPD) or established Continuous Abdominal Peritoneal Dialysis requiring five or more exchanges per day with other complex care needs; or

(g) In room hemodialysis as required by a physician with other complex care needs;

(5) Require extensive use of supplies or equipment;

(6) Have professional documentation supporting that they are making continuous progress in the rehabilitation program beyond maintenance goals; and

(7) Have care needs that cannot be met at a lesser level of care.

009.01(C)(ii) CRITERIA FOR CARE OF PEDIATRIC CLIENTS WITH SPECIAL NEEDS. The client must:

(1) Be under age 21;

(2) Be medically stable;

(3) Require multidisciplinary care; and

(4) Require a complex medical or treatment regimen requiring observation and intervention by specially trained professionals, such as:

(a) Tracheostomy care or intervention with other complex needs;

(b) Intermittent ventilator use, less than ten hours in a 24-hour period, with other complex needs;

(c) Respiratory therapy treatments or interventions more than every six hours with other complex care needs; or

(d) Multiple complex care needs that in combination exceed care needs usually provided in a nursing facility.

009.01(D) EXCEPTION. Under extenuating circumstances, the Department may approve an exception to the criteria for care of long term care clients with special needs.

009.02 FACILITY QUALIFICATIONS. To be approved as a provider of services for long term care clients with special needs, a Nebraska facility providing services to special needs clients must be licensed by the Nebraska Department of Health and Human Services Regulation and Licensure as a hospital or a nursing facility and be certified to participate in the Nebraska Medical Assistance Program. Out-of-state facilities must meet licensure and certification requirements of that state's survey agency. Out-of-state placement of clients will only be considered when their special needs services are not available within the State of Nebraska as found in 471 NAC 1. The facility must demonstrate the capacity or capability to provide highly skilled multi-disciplinary care. The facility must ensure that its professional nursing staff have received appropriate training and have experience in the area of care pertinent to the individual client's special needs. The facility must have the ability to provide the necessary professional services as the client requires. The facility must:

(A) Demonstrate the capability to provide highly skilled multidisciplinary care;

(B) Ensure that its staff have received appropriate training and are competent to care for the identified special needs population that is being served;

(C) Be able to provide the necessary professional services that the special needs clients require;

(D) Have the physical plant adaptations necessary to meet the client’s special needs;

(E) Establish admission criteria and discharge plans specific to each special needs population being served;

(F) Have a separate and distinct unit for the special needs program;

(G) Establish written special program criteria with policy and procedures to meet the needs of an identified special needs group as defined in this chapter;

(H) Have written policies specific to the special needs unit regarding:

(i) Emergency resuscitation;

(ii) Fire and natural disaster procedures;

(iii) Emergency electrical back-up systems;

(iv) Equipment failure;

(v) Routine and emergency laboratory or radiology services; and

(vi) Emergency transportation.

(I) Maintain the following documentation for special needs clients:

(i) A comprehensive multidisciplinary and individualized assessment of the client’s needs before admission. The client’s needs dictate which disciplines are involved with the assessment process. The assessment must include written identification of the client’s needs that qualify the client for the special program as defined in this chapter. The initial assessment and the team’s review and decisions for care must be retained in the client’s permanent record;

(ii) A copy of the admission “MDS 2.0 Basic Assessment Tracking Form” (Minimum Data Set), and Form DPI-OBRA1, “Identification Screen”. These are to be maintained as part of the client’s permanent record;

(iii) A minimum of daily documentation or assessment or intervention by a Registered Nurse or other professional staff as dictated by the client’s needs;

(iv) A record of physician’s visits; and

(v) A record of interdisciplinary team meetings to evaluate the client’s response and success toward achieving the identified program goals and the team’s revisions, additions, or deletions to the established program plan;

(J) Maintain financial records; and

(K) Provide support services necessary to meet the care needs of each individual client and these must be provided under existing contracts or by facility staff as required by Medicare and Medicaid for nursing facility certification.

009.03 APPROVAL PROCESS. Nebraska Medicaid pays for a special need nursing facility service when prior authorized. Each admission shall be individually prior authorized.

009.03(A) PRIOR TO ADMISSION. A written comprehensive and individualized assessment completed by the facility must be sent to the Department. The assessment and accompanying documentation must address how the client meets the criteria for special needs care as defined in this chapter. It is the facility’s responsibility to assess, gather and obtain this information and submit it to the Department for prior authorization and before admission. Initial approval or denial will be given after Medicaid staff reviews the submitted information. It is the facility’s responsibility to obtain and provide any missing or additional information requested by the Department. The initial approval will be delayed until all information is received by the Department. The Pre-Admission Screening Level I Screen and Level II Evaluation, when applicable, must be completed before admission and the Level II findings and reports must accompany the packet of information sent to the Department for funding authorization.

009.03(A)(i) OTHER CLIENTS. Facilities serving the needs of individuals who are ventilator-dependent and other special needs clients must include the individualized admission assessment completed by the facility and other documentation which must include:

(1) Current medical information that documents the client’s current care needs;

(2) Historical information that impacts the client’s care needs;

(3) Discharge summary of any facility stays within the past 6 months;

(4) Current physical, cognitive, or behavioral status;

(5) Justification for special needs level of care; and

(6) Identification of major areas of preliminary care planning and an estimate of services needed to reach the proposed goals.

009.03(A)(ii) BRAIN INJURIES. Facilities serving the needs of clients with brain injuries shall submit the individualized admission assessment completed by the facility and the following documentation which must include:

(1) Current medical information that documents the client’s current care needs, including a letter from the client’s primary care physician indicating the potential for successful rehabilitation;

(2) Historical information that impacts the client’s care needs;

(3) Discharge summaries of any facility stays within the past year;

(4) All discharge or service summaries of any rehabilitative services received since the qualifying injury;

(5) An Individualized Educational Plan (IEP) of any client under age 21 if one exists;

(6) An Individual Program Plan (IPP) and discharge statement or meeting for any client receiving or who has received services from the Developmental Disabilities System since the qualifying injury;

(7) The written plan from Vocational Rehabilitative services if the client is receiving or has received since the qualifying injury;

(8) Current physical, cognitive, or behavior status; and

(9) Identification of major areas of preliminary care planning and an estimate of services needed to reach the proposed goals.

009.03(B) INITIAL APPROVAL. Based on the pre-admission assessment, initial approval or denial will be given by the Department for a 90-day admission, for assessment and development of a special needs plan of care. During this 90-day period, the individual will be receiving special needs care for the purposes of determining the potential for benefit from longer-term participation in the special needs program. At the end of 30 days, the Department will be provided a special needs formal plan of care, developed by the full interdisciplinary team. By the end of the 60th day, a report will be provided to the Department establishing demonstrated potential to benefit from the additional special needs programming, and estimating the time needed to complete the special needs plan of care, or recommendations to a lesser level of care.

009.03(B)(i) IN-STATE FACILITY PLACEMENT. Within 15 days of the date of admission to the nursing facility or the date Medicaid eligibility is determined facility staff shall:

(1) Complete an admission Form MC-9-NF or submit electronically the standard Health Care Services Review Request for Review and Response transaction (ASC X12N 278);

(2) Attach a copy of Form DM-5 or physician's history and physical;

(3) Attach a copy of Form DPI-OBRA1; and

(4) Submit all information to the Department.

009.03(B)(i)(a) ASSESSMENT. Facility staff must make a comprehensive assessment of the resident’s needs within 14 days of admission, using the Minimum Data Set (MDS), and transmit it electronically to the Department.

009.03(B)(i)(b) APPROVAL. The Department shall determine final approval for the level of care and return the forms to the local office and the facility. Approval of payment may be time-limited.

009.03(B)(ii) OUT-OF-STATE FACILITY PLACEMENT. Within 15 days of the date of admission to the nursing facility or the date Medicaid eligibility is determined, facility staff shall:

(1) Complete an admission Form MC-9-NF or submit electronically the standard Health Care Services Review Request for Review and Response transaction (ASC X12N 278);

(2) Attach a copy of Form DM-5 or physician's history and physical;

(3) Attach a copy of Form DPI-OBRA1 where applicable;

(4) Attach a copy of their state-approved Minimum Data Set; and

(5) Submit all information to the Department.

009.03(B)(ii)(a) APPROVAL. The Department shall determine final approval for the level of care and return the forms to the local office and the facility. Approval of payment may be time-limited.

009.04 UTILIZATION REVIEW. The Department will review records and programs established for authorized Medicaid client stays in a Special Needs program on a quarterly basis. These reviews can be conducted on-site or by submitting requested documentation to the Department. Upon completion of a review, Department staff may determine that a client no longer meets the criteria as established in this chapter. The Department will notify the facility in writing of this finding.

009.04(A) COMPREHENSIVE PLAN OF CARE. The facility must submit copies of the initial comprehensive plan of care and subsequent interdisciplinary team meetings that document the client's progress or lack of progress toward the client’s established program outcomes or goals to the Department quarterly.

009.04(A)(i) MONTHLY REVIEWS. Nebraska Medicaid requires monthly reviews for extended brain injury rehabilitation stays beyond two years.

009.04(A)(ii) RIGHT TO CONTEST A DECISION. See 471 NAC 2.

009.05 PAYMENT FOR SERVICES FOR LONG TERM CARE CLIENTS WITH SPECIAL NEEDS. Payment for services to all special needs clients must be prior authorized by the Department.

009.05(A) OUT-OF-STATE FACILITIES. The Department pays out-of-state facilities participating in Medicaid at a rate established by that state's Medicaid program at the time of the establishment of the Nebraska Medicaid provider agreement. The payment is not subject to any type of adjustment.

009.06 ALL REQUIREMENTS APPLY. The requirements of 471 NAC 12 apply to services provided under 471 NAC 12.010 unless otherwise specified in 471 NAC 12.010.

009.07 IN-HOME SERVICES FOR CERTAIN DISABLED CHILDREN. This section applies to children age 18 or younger with severe disabilities living in their parents' home, also referred to as the "Katie Beckett" program. Services for special needs children are a skilled level of care provided by a certified Home Health agency, licensed registered nurses or licensed practical nurses. These providers must have necessary training and experience in the care of ventilator-dependent, pulmonary, or other special needs clients. This level of care is highly skilled, provided by professionals in amounts not normally available in a skilled nursing facility, but available in the hospital. Lack of these services would normally result in continued hospitalization or institutionalization of these children. The cost of in-home services must be less than the cost of hospitalization. The child must meet one of the following definitions to qualify for the Katie Beckett program:

(1) Ventilator-Dependent Clients: These clients are ventilator-dependent and require intensive medical services or continual observation on an on-going basis;

(2) Pulmonary Clients: These clients must require complex respiratory or medical care, in combinations which exceed the needs of the skilled nursing client. These clients may also use excessive amounts of supplies and equipment; or

(3) Other Special Needs Clients: The clients must require complex medical or rehabilitative care in combinations, which exceed the requirements of the skilled nursing client. These clients may also use excessive amounts of supplies, equipment, or therapies.

009.07(A) APPROVAL. Department approval for this level of care is required.

009.08 INTERMEDIATE SPECIALIZED SERVICES FOR PERSONS WITH SERIOUS MENTAL ILLNESS. Nebraska Medicaid covers intermediate specialized services (ISS) for persons with serious mental illness. Intermediate Specialized Services (ISS) are covered for those individuals who have been identified by the Level II Preadmission Screening and Resident Review (PASRR) evaluation and through the Intermediate Specialized Services (ISS) evaluation process as needing services to maintain or improve their behavioral or functional levels above and beyond services that nursing facilities normally provide, but who do not require the continuous and aggressive implementation of an individualized plan of care, as “specialized add-on services” is defined by Preadmission Screening and Resident Review (PASRR) regulations in this chapter. These individuals need more support than nursing facilities would normally provide, but not at a “specialized services” level.

009.08(A) ALL REQUIREMENTS APPLY. The requirements of 471 NAC 12 apply to Intermediate Specialized Services (ISS) providers unless otherwise specified.

009.08(B) INTERMEDIATE SPECIALIZED SERVICES (ISS) FOR INDIVIDUALS WITH SERIOUS MENTAL ILLNESS. Intermediate Intensive Treatment Services (ISS) for Individuals with Serious Mental Illness means services necessary to prevent avoidable physical and mental deterioration and to assist clients in obtaining or maintaining their highest practicable level of functional and psycho-social well being. Services are characterized by:

(i) The client’s regular participation, in accordance with their comprehensive care plan, in professionally developed and supervised activities, experiences, and therapies; and

(ii) Activities, experiences, and therapies that reduce the client’s psychiatric and behavioral symptoms, improve the level of independent functioning, and achieve a functional level that permits reduction in the need for intensive mental health services.

009.08(C) PROGRAM COMPONENTS. Intermediate Specialized Services (ISS) is designed to:

(i) Provide and develop the necessary services and supports to enable clients to reside successfully in a nursing facility without the need of more intensive services;

(ii) Maximize the client's participation in community activity opportunities, and improve or maintain daily living skills and quality of life;

(iii) Facilitate communication and coordination between any providers that serve the same client;

(iv) Decrease the frequency and duration of hospitalization and inpatient mental health (MH) services;

(v) Provide client advocacy, ensure continuity of care, support clients in time of crisis, provide and procure skill training, ensure the acquisition of necessary resources, and assist the client in achieving social integration;

(vi) Expand the individual’s comprehensive care plan to assure that it includes interventions to address: community living skills, daily living skills, interpersonal skills, psychiatric emergency and relapse, medication management including recognition of signs of relapse and control of symptoms, mental health services, substance abuse services, and other related areas necessary for successful living in the community;

(vii) Provide the individualized support and rehabilitative interventions as identified through the comprehensive care planning process to address client needs in the areas of: community living skills, daily living skills, interpersonal skills, psychiatric emergency and relapse, medication management including recognition of signs of relapse and control of symptoms, mental health services, substance abuse services, and other related services necessary for successful living in the community;

(viii) Monitor client progress in the services being received and facilitate revision to the comprehensive care plan as needed;

(ix) Provide therapeutic support and intervention to the client in time of crisis and, if hospitalization is necessary, facilitate, in cooperation with the inpatient treatment provider, the client's transition back into the client’s place of residence upon discharge;

(x) Establish hours of service delivery that ensure program staff are accessible and responsive to the needs of the client, including scheduled services that include evening and weekend hours; and

(xi) Provide or otherwise demonstrate that each client has on call access to a mental health provider on a 24 hour, 7 days per week basis.

009.08(D) CRITERIA FOR ISS. For Intermediate Specialized Services (ISS), the client must have been evaluated through the Preadmission Screening and Resident Review (PASRR) process and the Intermediate Specialized Services (ISS) evaluation process, and been determined to not need intensive treatment services based on the outcomes of the Level II evaluation and the Intermediate Specialized (ISS) Services Evaluation Process. The Intermediate Specialized Services (ISS) Evaluation Process must include evaluation by a team which must consider an individual’s long term residence in a mental health facility, higher levels of aggression, and higher levels of medical need. The client must be currently diagnosed with a mental, behavioral, or emotional disorder of sufficient duration to meet diagnostic criteria specified within the current version of DSM or ICD-9-CM equivalent except DSM “V” codes, substance use disorders, developmental disorders, and dementia which are excluded, unless they co-occur with another diagnosable serious mental illness.

009.08(E) COMPREHENSIVE CARE PLAN DEVELOPMENT. The Department or its designee will refer clients authorized for Intermediate Specialized Services (ISS) to the most appropriate providers, consistent with client choice. The Intermediate Specialized Services (ISS) provider must work with the client to complete a comprehensive care plan that includes:

(i) An assessment of the client's strengths and needs in that service domain according to the requirements of the Level II evaluation and the Intermediate Specialized Services evaluation process; and

(ii) The Resident Assessment.

009.08(F) MOVEMENT BETWEEN INTENSIVE TREATMENT SERVICES, INTERMEDIATE SPECIALIZED SERVICES (ISS), AND REGULAR NURSING FACILITY SERVICES. Individuals’ needs change over time and level of service intensity must change to appropriately meet those needs. Nursing facility staff and other service providers must identify changes in level of need as they occur. Such changes would include a decline in psychiatric stability that requires intensive treatment services or marked decrease in the need for Intermediate Specialized Services (ISS).

009.08(F)(i) INCREASE IN SERVICE NEEDS. Nursing facility staff must request review by the consulting psychiatrist when Intermediate Specialized Services (ISS) are not sufficient to meet a client’s needs. Based on the findings of the consulting psychiatrist, the client may be moved to an inpatient facility for receipt of intensive treatment services.

009.08(F)(i)(1) RETURNING FROM RECEIVING INTENSIVE TREATMENT SERVICES FOR MENTAL ILLNESS. For Intermediate Specialized Services (ISS) clients, this process must follow procedures at 471 NAC 12-007.09(A) and 12-010.08(D).

009.08(F)(ii) DECREASE IN SERVICE NEEDS. When the need for Intermediate Specialized Services (ISS) decreases, regular services that the nursing facility would normally provide may be sufficient. In addition to the normal discharge planning process, Intermediate Specialized Services (ISS) facility staff must request review by the Intermediate Specialized Services (ISS) evaluation team. With the team’s approval, the client may be transferred to regular nursing facility services.

009.08(G) TRANSFERS. For Intermediate Specialized Services (ISS) clients, transfers between nursing facilities will not require a Level I screen or Level II Preadmission Screening and Resident Review (PASRR) evaluation. A Tracking Form must be completed and faxed to the Department for clients with a Preadmission Screening and Resident Review (PASRR) determination.

009.08(H) STANDARDS FOR PROVIDER PARTICIPATION. Intermediate Specialized Services (ISS) providers may be any nursing facility certified to participate in Medicaid and Medicare. If the Intermediate Specialized Services (ISS) provider subcontracts with service providers, they must be Medicaid enrolled providers. All providers of Intermediate Specialized Services (ISS) must be approved and meet all applicable requirements under Title 471 NAC 2, Provider Participation and other applicable sections of the NAC. However, for the purposes of effectiveness and efficiency in delivering these services, the Department approves Intermediate Specialized Services (ISS) providers through a proposal process, and certifies all or part of a facility to provide Intermediate Specialized Services (ISS). The Department will announce, through public notice, when it will entertain facility proposals. These announcements will detail to potential Intermediate Specialized Services (ISS) providers the primary locations, number of beds, architectural standards, staffing requirements, and any other information to assist facilities with their proposals.

009.08(I) STAFF REQUIREMENTS. The facility must maintain a sufficient number of staff with the required training, competencies, and skills necessary to meet the client’s needs. Training must be approved by the Department and specific to the delivery of Intermediate Specialized Services (ISS) and related mental health services. At a minimum, the Intermediate Specialized Services (ISS) facility must have a consulting psychiatrist. It must develop and implement a comprehensive care plan for each Intermediate Specialized Services (ISS) client, ensure necessary monitoring and evaluation and must modify the care plan when appropriate. Staff must have the skills to care for the clients, know how to respond to emergency and crisis situations and fully understand client rights. The facility must provide care and treatment to clients in a safe and timely manner and maintain a safe and secure environment for all residents.

009.08(I)(i) STAFF CREDENTIALING. The facility must ensure that:

(1) Any staff person providing a service for which a license, certification, registration, or credential is required holds the license, certification, registration, or credential in accordance with applicable state laws;

(2) The staff have the appropriate license, certification, registration, or credential before providing a service to clients including training specific to the delivery of Intermediate Specialized Services and related mental health services; and

(3) It maintains evidence of the staff having appropriate license, certification, registration, or credential.

009.08(I)(ii) INITIAL ORIENTATION. The facility must provide staff with orientation before the staff person having direct responsibility for care and treatment of clients receiving Intermediate Specialized Services (ISS) provides services to clients. The training must include:

(1) Client rights;

(2) Job responsibilities relating to care and treatment programs and client interactions;

(3) Emergency procedures including information regarding availability and notification;

(4) Information on any physical and mental special needs of the clients of the facility;

(5) Information on abuse, neglect, and misappropriation of money or property of a client and the reporting procedures;

(6) De-escalation techniques;

(7) Crisis intervention strategies;

(8) Behavior management planning and techniques;

(9) The role of medication in psychiatric treatment;

(10) Cardiopulmonary resuscitation and medical first aid; and

(11) Strength-based services and the recovery model.

009.08(I)(iii) DOCUMENTATION. The facility must maintain documentation of staff initial orientation and training.

009.08(I)(iv) ONGOING TRAINING. The facility must provide each staff person ongoing training in topics appropriate to the staff person’s job duties, including meeting the needs, preferences, and protecting the rights of the clients in the facility.

009.08(J) CLIENT RIGHTS. The facility must ensure that clients rights are ensured in accordance with 42 CFR 483.10 and 175 NAC 12.

009.08(K) UTILIZATION REVIEW. The Department or its designee will provide utilization review for Intermediate Specialized Services (ISS). This includes assessing the appropriateness of the intensity of services and providing ongoing utilization review of the client's progress in relation to the comprehensive care plan. At least annually, the Department or its designee will reassess clients receiving Intermediate Specialized Services (ISS), and will review and approve new service recommendations and continued eligibility for Intermediate Specialized Services (ISS).

009.08(L) PAYMENT. The Department pays for Intermediate Specialized Services (ISS) as specified in this chapter.

010. MEDICAID HOSPICE BENEFIT .

010.01 STANDARDS FOR PARTICIPATION. To participate in Medicaid, a hospice must be a public agency or private organization or a subdivision of either that is primarily engaged in providing care to terminally ill individuals and is certified for participation in Medicare as a hospice.

010.01(A) PROVIDER ENROLLMENT. To complete the provider enrollment process, the hospice must meet the following conditions:

(i) The hospice must have a signed, written and non-resident-specific contract with each certified nursing facility (NF) or intermediate care facility for individuals with developmental disabilities (ICF/DD); and

(ii) The hospice must complete and submit a Medicaid provider agreement in entirety to Medicaid for each contracted nursing facility (NF) or intermediate care facility for individuals with developmental disabilities (ICF/DD).

010.02 COVERED SERVICES. Nebraska Medicaid must pay the hospice for the client's room and board in the facility when the following conditions are met:

(1) The hospice and the facility must have a written agreement under which the hospice is responsible for the professional management of the client's hospice care;

(2) The client must be eligible for Medicaid benefits;

(3) The client must have elected to receive the Medicare or Medicaid hospice benefit;

(4) The client must reside in a Medicaid-certified bed in the facility;

(5) Prior authorization requirements must be met;

(6) The client is an adult; and

(7) The preadmission screening and resident review (PASRR) must be completed before the client is admitted to the facility.

010.02(A) COVERED SERVICES FOR CHILDREN. Nebraska Medicaid must pay the facility for the client’s room and board expense in a nursing facility (NF) or intermediate care facility for individuals with developmental disabilities (ICF/DD) if the client is a child 18 years old or younger.

010.03 PRIOR AUTHORIZATION REQUIREMENTS. The following steps must be completed before Medicaid authorizes room and board payment to the hospice:

(1) The hospice must obtain prior authorization for the actual hospice service when Medicaid is the primary payer;

(2) The hospice must obtain prior authorization for special needs and out-of-state nursing facility payment by paper or electronically. An MC-9NF or Nursing Facility Level of Care Determination Form must be submitted with attachments according to the requirements listed in this chapter;

(3) The hospice contracted nursing facility (NF) must comply with all assessment requirements as stated in this chapter. For intermediate care facility for individuals with developmental disabilities (ICF/DD) level of care (LOC) see 471 NAC 31;

(4) For a new admission to a nursing facility (NF), the hospice must submit the following to Medicaid:

(a) Nebraska Level I Preadmission Screening and Resident Review (PASRR) form;

(b) Form MC-9NF, or Nursing Facility Level of Care (NF LOC) Determination Form;

(c) A copy of the DM-5 or history and physical;

(d) The hospice plan of care and certification;

(e) A list of hospice covered medications and pharmacy notification; and

(f) A list of hospice covered medical appliances, supplies, and therapies and provider notification;

(5) If the client is Medicaid eligible and already residing in the nursing facility (NF), the hospice must complete and submit to Medicaid:

(a) Form MC-9NF, or Nursing Facility Level of Care Determination Form;

(b) Hospice plan of care and certification;

(c) List of hospice covered medications and pharmacy notification; and

(d) List of hospice covered medical appliances, supplies, and therapies and provider notification.

010.03(A) PRIOR AUTHORIZATION EXCEPTION. When a client is eligible for the Medicare hospice benefit, prior authorization for the nursing facility (NF) room and board, not a Medicare hospice benefit, is not required for payment by Medicaid with the exception of out-of-state and special needs residents as identified in this chapter.

010.03(B) REQUIRED ASSESSMENTS. The hospice contracted nursing facility must comply with all assessment requirements as stated in this chapter.

010.04 PAYMENT TO THE HOSPICE. Medicaid’s payment to the hospice must be based on the rate established by the Department for the nursing facility (NF) in which the client resides, based on the assessment for each individual. The hospice must make payment to the nursing facility (NF) for the client's room and board according to the contract between the facility and the hospice.

010.05 BILLING. The hospice must bill the Department on the appropriate claim form or electronic format.

010.05(A) NURSING FACILITY BILLING. The nursing facility (NF) must not bill Medicaid for room and board for any adult client that has elected to receive the hospice benefit.

010.05(A)(i) EXCEPTION. The nursing facility (NF) must continue to bill Medicaid for room and board for clients under the age of 18.

011. CIVIL MONEY PENALTY (CMP) .

011.01 COLLECTION AND USE OF CIVIL MONEY PENALTY (CMP) FUNDS. The Nebraska Civil Money Penalty (CMP) Program is administered by the Department in accordance with Section 1919(h)(3)(C)(ii)(IV)(ff) of the Social Security Act, 42 CFR 488.400 through 488.456 and Nebraska Revised State Statutes 71-2097 to 71-20,101.

011.01(A) ASSESSMENT OF PENALTY. The Division of Public Health of the Department of Health and Human Services is authorized to act as the survey and certification agency for the Medicaid program pursuant to Neb. Rev. Stat. 81-604.03. The Division of Public Health notifies the Department of any violation by a nursing facility (NF), as defined in Neb. Rev. Stat. 71-2097. Civil penalties will be determined pursuant to Neb. Rev. Stat. 71-2097 to 71-20,101. Upon the recommendation of the Civil Money Penalty (CMP), the Department issues a certified letter to the provider according to 42 CFR 488.434.

011.01(B) APPEAL. See 471 NAC 2.

011.02 CIVIL MONEY PENALTY (CMP) EMERGENCY PAYMENTS. Civil money penalty (CMP) funds collected by the State are applied to actions for the protection of the health or property of nursing facility residents.

011.02(A) EMERGENCY FUND REASONS. Funds may be allocated for the following reasons:

(i) To cover payment for the non-reimbursed costs of protecting residents or relocating residents to other facilities in the event of a qualifying natural disaster or nursing facility (NF) closure;

(ii) State costs related to the operation of a facility pending correction of deficiencies or closure;

(iii) Reimbursement of residents for personal funds or property lost at a facility as a result of actions by the facility or by individuals used by the facility to provide services to residents; and

(iv) Other activities that benefit nursing home residents as provided in 42 C.F.R. 488.433.

011.02(B) NURSING FACILITY (NF) CONTINGENCY TEAM. Upon notification to the nursing facility (NF) contingency team of the existence of an emergency situation the contingency team convenes. The team includes the Division of Public Health Licensure Unit, Office of Long Term Care Facilities, a representative from Medicaid, the State Long Term Care Ombudsman, a representative from the Nebraska Department of Health and Human Services Public Relations, and the Department legal counsel for Long Term Care Facilities. The team considers the situation and options and recommends access to funds for the relocation of residents or the maintenance of facility operations until such a time as relocation can occur.

011.02(C) FINAL APPROVAL FOR USE OF CIVIL MONEY PENALTY (CMP) FUNDS. The final determination to submit the request to Centers for Medicare and Medicaid Services (CMS) for use of Civil Money Penalty (CMP) funds is made by the Department Chief Executive Officer (CEO). Per CFR 42 488.433 (b) all activities and plans for utilizing Civil Money Penalty (CMP) funds, including any expense used to administer grants utilizing Civil Money Penalty (CMP) funds, must be approved in advance by Centers for Medicare and Medicaid Services (CMS).

011.03 CIVIL MONEY PENALTY GRANT FUNDING. This program is funded through the collection of Civil Money Penalties (CMPs) imposed against nursing facilities as a result of survey deficiencies. Eligible applicants must apply for grant funding during the designated application period and submitting it as directed by the Department.

011.03(A) ELIGIBLE APPLICANTS. Civil Money Penalty (CMP) grant funding may be requested by eligible stakeholders, which include:

(i) Nebraska Medicaid-participating nursing facilities and their residents;

(ii) Professional and state nursing facility (NF) associations and advocacy groups;

(iii) Consumer advocacy organizations;

(iv) Resident or family councils;

(v) Nursing facility (NF) resident quality improvement organizations; private contractors; and

(vi) Other groups approved by Medicaid indicating an interest in the care and well-being of nursing facility (NF) residents.

011.03(B) ELIGIBLE PROJECTS. Civil Money Penalty (CMP) grant funding is considered for the following projects:

(i) Culture change;

(ii) Resident or family councils;

(iii) Direct improvements to quality of care or resident protection;

(iv) Quality improvement activities or resources;

(v) Consumer information; and

(vi) Training in facility improvement initiatives for staff to:

(1) Improve performance; or

(2) Develop new or innovative approaches to improve the quality of life and care for residents.

011.03(C) PROHIBITED USE OF CIVIL MONEY PENALTY (CMP) FUNDS. Civil Money Penalty (CMP) fund requests will not be considered if any of the following apply:

(i) Conflict of interest or the appearance of a conflict of interest;

(ii) Long-term projects, with a duration greater than 3 years;

(iii) Duplication of payment that is already appropriated from state or federal sources;

(iv) Capital improvement projects;

(v) Temporary manager salaries; or

(vi) Ineligible recipients. This includes nursing facilities (NFs) who were cited with an immediate jeopardy (IJ) violation or harm at deficiency level H or I during their previous standard survey. Any exceptions must be approved through Centers for Medicare and Medicaid Services (CMS).

011.03(D) GRANT FUND DETERMINATION. Designated Medicaid and Public Health staff review grant applications based upon compliance with Civil Money Penalty (CMP) laws and regulations. The final decision is made by the Director of Medicaid. Final approval is granted by Centers for Medicare and Medicaid Services (CMS).

012. NURSE AIDES IN NURSING FACILITIES .

012.01 GENERAL RULE. An individual may be employed by a certified facility as a nurse aide only if all of the following requirements have been met:

(A) That individual is competent to provide nursing and nursing-related services;

(B) The nurse aide has met the training and competency requirements found at 42 CFR 483.75, 150 and 154, or that individual has been deemed or determined competent as provided in 42 CFR 483.150;

(C) The nurse aide has met the requirements set out in Neb. Rev. Stat. § 71-6038 and 6039; and

(D) The nurse aide has not:

(i) Been found guilty of abusing, neglecting, or mistreating residents by a court of law; or

(ii) Had a finding entered into the State nurse aide registry concerning abuse, neglect, or mistreatment of residents or misappropriation of their property under the provisions of this chapter.

012.02 FACILITY RESPONSIBILITY.

012.02(A) REGISTRY VERIFICATION. Before allowing an individual to serve as a nurse aide, a facility must contact the State nurse aide registry and verify that the individual has met competency evaluation requirements unless:

(i) The individual is a full-time employee currently participating in a training and competency evaluation program approved by the State; or

(ii) The individual can prove that he or she has recently successfully completed a training and competency evaluation program or competency evaluation program approved by the State and has not yet been included in the registry. Facilities must follow up to ensure that the individual actually becomes registered.

012.02(B) MULTI-STATE REGISTRY VERIFICATION. Before allowing an individual to serve as a nurse aide, a facility must seek information from every State nurse aide registry the facility believes will include information on the individual.

012.02(C) DUTY TO REPORT. A facility must report any knowledge it has of actions by a court of law against an employee that would indicate unfitness for service as a nurse aide or other facility staff to the State nurse aide registry or licensing authorities.

012.03 NURSE AIDE REQUIREMENTS.

012.03(A) PURPOSE. This section incorporates the requirements of 42 CFR 483.13, 75, 150, 151, 152, 154 and 156; and 42 CFR 488.332 and 335, effective as of October 1, 1995, regarding nurse aides and the nurse aide registry.

012.04 ESTABLISHMENT OF NURSE AIDE REGISTRY.

012.04(A) PURPOSE. A registry of nurse aides is established and maintained by the State for the purpose of providing a central data bank of individuals who are eligible to function as nurse aides in certified facilities. The State Medicaid agency contracts with the State Survey and Certification agency to operate and maintain the registry. Pursuant to federal requirements found at 42 CFR 483.151 and 42 CFR 483.152 and State statute, the State approves training and competency programs for nurse aides. Those provisions are found at Neb. Rev. Stat. § 71-6039 and 172 NAC 108.

012.04(B) REGISTRY ELIGIBILITY. The registry must comply with the following:

(i) To be included on the nurse aide registry as eligible to function as a nurse aide, an individual must meet the requirements in this chapter;

(ii) An individual may be deemed or determined competent for eligibility for placement on the registry as provided in 42 CFR 483.150;

(iii) Adverse findings of abuse, neglect, or misappropriation of property are placed on the registry after a determination by the State survey and certification agency; and

(iv) No monetary charges related to registration of individuals on the registry are imposed.

012.04(C) REGISTRY CONTENT. The registry contains the following information on each individual who has successfully completed a nurse aide training and competency evaluation program, or who has completed a competency evaluation and has been found to be competent to function as a nurse aide pursuant to this chapter:

(i) The individual’s full name;

(ii) Information necessary to identify each individual;

(iii) The date the individual became eligible for placement in the registry;

(iv) With a finding of abuse, neglect, or misappropriation of property by the individual, the following information is included, this information must be placed on the registry within ten working days of the finding and remains on the registry permanently, unless the finding was made in error, the individual was found not guilty in a court of law, or the State is notified of the individual’s death:

(1)Documentation of the investigation, including the nature of the allegation and the evidence that led to the conclusion that the allegation was valid;

(2)If the individual chose to have a hearing, its date and outcome; and

(v) If the individual chooses to dispute the allegation, their statement;

(vi) Information related to the provisions of 471 NAC 12-012.04(A), items 3 and 4a; and

(vii) Documentation of the ineligibility of individuals who have performed no nursing or nursing-related services for a period of 24 consecutive months.

012.04(D) REMOVAL OF REGISTRY CONTENT.

012.04(D)(i) REMOVAL OF FINDINGS OF NEGLECT FROM NURSE AIDE REGISTRY. In the case of a finding of neglect under this chapter, a nurse aide may petition the State survey and certification agency in writing, to have the findings removed from the registry provided that:

(1) The employment and personal history of the nurse aide does not reflect a pattern of abusive behavior or neglect;

(2) The neglect involved in the original finding was a singular occurrence; and

(3) More than one year has lapsed since the finding of neglect was added to the nurse aide registry.

012.04(D)(ii) CONTENT OF PETITION. Petitions may be submitted on a form provided by the Department, or may be submitted in other written format as long as the petition includes the following:

(1) The subject matter of the petition;

(2) Employment history;

(3) A signed release of information for employer references;

(4) A statement indicating why the petitioner believes the findings of neglect should be removed from the registry; and

(5) Information regarding any education or rehabilitation efforts that the individual has completed since the finding of neglect was placed on the registry.

012.04(D)(iii) REVIEW OF PETITION. The State survey and certification agency will:

(1) Contact past employers to determine if the petitioner had any documented incidents of abusive or neglectful behavior during their employment as a nurse aide that resulted in any employment action including counseling;

(2) Conduct a review of records to determine if criminal conviction information is recorded;

(3) Review the petition and all other requested information to determine whether the petitioner's findings of neglect should be removed from the registry. Consideration will be given to the following factors in making the determination:

(a) The amount and degree of neglect involved in the original incident;

(b) The severity of the potential negative resident outcome;

(c) The severity of the actual negative resident outcome;

(d) The opinion of the individual's employer at the time of the incident regarding removing the finding from the registry, including the employer's willingness to rehire the individual;

(e) Any rehabilitation or education completed by the individual since the incident;

(f) Employer reports, to ensure a majority do not identify personal action taken regarding abusive or neglectful behavior; and

(g) The criminal background report to determine if there is a history of mistreatment findings, including instances of domestic abuse, the granting of a restraining order which has not been overturned, or any conviction of any crime involving violence or the threat of violence.

012.04(D)(iv) REVIEW OUTCOME. Based on factors identified above, the State survey and certification agency may:

(1) Remove the finding from the registry;

(2) Require the individual to demonstrate successful completion of a state-approved nurse aide training and competency evaluation program prior to the finding being removed from the registry;

(3) Require the individual to complete a rehabilitation or education program prior to the finding being removed from the registry; or

(4) Implement any combination of the above sanctions.

012.04(D)(v) NOTIFICATION. Conditions for notification.

012.04(D)(v)(1) REMOVAL. If the State survey and certification agency determines the findings of neglect should be removed from the nurse aide registry, the petitioner will be notified in writing within 150 days of receipt of the petition.

012.04(D)(v)(2) ADDITIONAL ACTIONS. If the State survey and certification agency determines the findings of neglect should not be removed from the registry or that additional actions are required for removal, the individual will be notified in writing within 150 days of receipt of the petition of their right to request a hearing to contest the determination. Hearings must be requested in writing within 30 days from the state of the denial notice. Hearings will be conducted in accordance with this chapter.

012.04(D)(v)(3) PERMANENT FINDINGS. If a new finding of neglect is placed on the individual's registry listing after the previous finding of neglect has been removed, the new finding will remain on the registry permanently with no opportunity for review.

012.04(E) DISCLOSURE OF INFORMATION. The date the individual became eligible for placement in the registry, documentation of any investigation, including the nature of the allegation and the evidence that led to the conclusion that the allegation was valid, if there was a hearing its date and outcome, and if the individual disputes the allegation their statement, is disclosed to all requesters. This information is:

(i) Provided to the individual affected when adverse findings on them are placed in the registry, or

(ii) Provided to the individual upon their request. Individuals on the registry must have sufficient opportunity to correct any misstatements or inaccuracies contained in the registry.

012.05 INVESTIGATION OF COMPLAINTS AND PLACEMENT OF ADVERSE FINDINGS.

012.05(A) REVIEW OF ALLEGATIONS. The State survey and certification agency reviews all allegations of resident neglect and abuse, and misappropriation of resident property by nurse aides. If there is reason to believe, either through oral or written evidence that an individual used by a facility to provide services to residents could have abused or neglected a resident or misappropriated a resident’s property, the State investigates the allegation.

012.05(B) NOTIFICATION. If the State survey and certification agency makes a preliminary determination, based on oral or written evidence and its investigation, that the abuse, neglect or misappropriation of property occurred, the following are notified in writing within ten working days of the State's survey and certification agency's investigation:

(1) The individuals implicated in the investigation; and

(2) The current administrator of the facility in which the incident occurred.

012.05(B)(i) CONTENT OF NOTICE. The notice includes the following:

(1) The nature of the allegation;

(2) The date and time of the occurrence;

(3) The right to a hearing; and

(4) The survey and certification agency’s intent to report the substantiated findings in writing, once the individual has had the opportunity for a hearing, to the nurse aide registry or appropriate licensure authority;

(5) The fact that the individual’s failure to request a hearing in writing within 30 days from the date of the notice will result in the survey and certification agency reporting the substantiated findings to the nurse aide registry or appropriate licensure authority;

(6) The consequences of waiving the right to a hearing;

(7) The consequences of a finding through the hearing process that the alleged resident abuse or neglect, or misappropriation of resident property did occur; and

(8) The fact that the individual has the right to be represented by an attorney at the individual’s own expense.

012.05(C) CONDUCT OF THE HEARING AND JUDICIAL REVIEW. The hearing is conducted under the following provisions:

(i) The hearing and the hearing record are completed within 120 days from the day the State survey and certification agency receives the request for a hearing;

(ii) The hearing is held at a reasonable place and time convenient for the individual;

(iii) The hearing will be conducted in accordance with the provisions of the Nebraska Administrative Procedure Act; and

(iv) Any individual aggrieved by a final decision following a hearing may seek judicial review of that decision. Procedures for said review are governed by the provisions of the Nebraska Administrative Procedure Act.

012.05(D) FACTORS BEYOND THE INDIVIDUAL’S CONTROL. A finding that an individual has neglected a resident will not be made if the individual demonstrates that such neglect was caused by factors beyond the control of the individual.

012.05(E) REPORT OF FINDINGS. If the finding is that the individual has neglected or abused a resident or misappropriated resident property or if the individual waives the right to a hearing, the State survey and certification agency, which may not delegate this responsibility, reports the findings in writing within ten working days to the following:

(i) The individual;

(ii) The current administrator of the facility in which the incident occurred;

(iii) The administrator of the facility that currently employs the individual, if different than the facility in which the incident occurred;

(iv) The licensing authority for individuals used by the facility other than nurse aides, if applicable; and

(v) The nurse aide registry for nurse aides. The findings must be included in the registry within 10 working days of the findings.

History

• Effective 2022-06-06

Chapter 14 Occupational and Physical Therapy Services

Neb. Admin. Code tit. 471, ch. 14 Occupational and Physical Therapy Services {#sec-471-nac-14 omnilex-key=us-ne-regs-official--title-471--471 NAC 14}

TITLE 471 NEBRASKA MEDICAL ASSISTANCE PROGRAM SERVICES

CHAPTER 14 OCCUPATIONAL AND PHYSICAL THERAPY SERVICES

001. SCOPE AND AUTHORITY. These regulations govern the services provided under Nebraska’s Medicaid program as defined by Nebraska Revised Statute (Neb. Rev. Stat.) §§ 68‑901 et seq.

002. DEFINITIONS.

002.01 INTERVENTION. A therapeutic procedure defined by the Current Procedural Terminology (CPT) manual of the American Medical Association.

002.02 MOBILIZATION OR MANUAL THERAPY. A group of techniques comprising a continuum of skilled passive movements to the joints or related soft tissues, or both, throughout the normal physiological range of motion that are applied at varying speeds and amplitudes, without limitation.

002.03 OCCUPATIONAL THERAPIST (OT). A person holding a current license to practice occupational therapy (OT).

002.04 OCCUPATIONAL THERAPY (OT). The use of purposeful activity with individuals who are limited by physical injury or illness, psychosocial dysfunction, developmental or learning disabilities, or the process of aging, in order to maximize independent function, prevent further disability, and achieve and maintain health and productivity. Occupational therapy (OT) encompasses evaluation, treatment, and consultation, and may include:

(A) Remediation or restoration of performance abilities that are limited due to impairment in biological, physiological, psychological, or neurological processes;

(B) Adaptation of task, process, the environment, or the teaching of compensatory techniques, in order to enhance performance;

(C) Disability prevention methods and techniques which facilitate the development or safe application of performance skills; and

(D) Health promotion strategies and practices which enhance performance abilities.

002.05 OCCUPATIONAL THERAPY ASSISTANT (OTA). A person holding a current license to assist in the practice of occupational therapy (OT).

002.06 PHYSICAL AGENT MODALITIES. Modalities that produce a bio-physiological response through the use of water, temperature, sound, electricity, or mechanical devices.

002.07 PHYSICAL THERAPIST (PT). A person licensed to practice physical therapy (PT).

002.08 PHYSICAL THERAPIST ASSISTANT (PTA). A person certified as a physical therapist assistant (PTA).

002.09 PHYSICAL THERAPY (PT) OR PHYSIOTHERAPY. Physical therapy or physiotherapy means:

(A) Examining, evaluating, and testing individuals with mechanical, physiological, and developmental impairments, functional limitations, and disabilities or other conditions related to health and movement and, through analysis of the evaluative process, developing a plan of therapeutic intervention and prognosis while assessing the ongoing effects of the intervention;

(B) Alleviating impairment, functional limitation, or disabilities by designing, implementing, or modifying therapeutic interventions, which does not include the making of a medical diagnosis, but which may include any of the following:

(i) Therapeutic exercise;

(ii) Functional training in home, community, or work integration or reintegration related to physical movement and mobility;

(iii) Therapeutic massage;

(iv) Mobilization or manual therapy;

(v) Recommendation, application, and fabrication of assistive, adaptive, protective, and supportive devices and equipment;

(vi) Airway clearance techniques;

(vii) Integumentary protection techniques;

(viii) Non-surgical debridement and wound care;

(ix) Physical agents or modalities;

(x) Mechanical and electrotherapeutic modalities; and

(xi) Patient-related instruction;

(C) Purchasing, storing, and administering topical and aerosol medication in compliance with applicable rules and regulations of the Board of Pharmacy regarding the storage of such medication;

(D) Reducing the risk of injury, impairment, functional limitation, or disability, including the promotion and maintenance of fitness, health, and wellness; and

(E) Engaging in administration, consultation, education, and research.

002.10 TAKE HOME SUPPLIES. Expendable or specified reusable supplies required for care of a medical condition and used in the beneficiary’s home.

002.11 WORK HARDENING. An occupational rehabilitation program that is focused on assisting the injured worker to return to the job while minimizing the risk of re-injury.

002.12 TREATING PRACTITIONER. Providers licensed and authorized to order therapy services and to prescribe durable medical equipment, prosthetics, orthotics, and medical supplies (DMEPOS) include physicians, nurse practitioners, clinical nurse specialists, andphysician assistants.

003. PROVIDER REQUIREMENTS.

003.01 GENERAL PROVIDER REQUIREMENTS. To participate in Nebraska Medicaid, providers of physical therapy (PT) and occupational therapy (OT) services must comply with all applicable provider participation requirements codified in these regulations .

003.02 SPECIFIC PROVIDER REQUIREMENTS.

003.02(A) LICENSED OCCUPATIONAL THERAPIST ASSISTANTS (OTA) AND CERTIFIED PHYSICAL THERAPIST ASSISTANTS (PTA). Nebraska Medicaid does not enroll occupational therapy assistants (OTA) or physical therapy assistants (PTA) as providers. Services provided by an occupational therapy assistant (OTA) are covered by Nebraska Medicaid when all requirements of this chapter are met.

004. SERVICE REQUIREMENTS.

004.01 MEDICAL NECESSITY. Medical necessity requirements are outlined in these regulations. . Services and supplies that do not meet the requirements are not covered.

004.02 SERVICE CRITERIA. Nebraska Medicaid covers occupational therapy (OT) and physical therapy (PT) services when the following criteria are met:

(i) The service is an evaluation; or

(ii) The service is restorative therapy with a medically appropriate expectation that the beneficiary’s condition will improve significantly within a reasonable period of time; or

(iii) The service is recommended in an approved individual program plan (IPP), and the beneficiary is receiving services through one of the following waiver programs:

(1) Developmental Disabilities (DD) Adult Comprehensive Services Waiver;

(2) Developmental Disabilities (DD) Adult Residential Services Waiver;

(3) Developmental Disabilities (DD) Adult Day Services Waiver;

(4) Community Supports Waiver; or

(5) Home and Community Based Services Waiver for Children with Developmental Disabilities and their Families.

004.03 SERVICES FOR BENEFICIARIES AGE 21 AND OLDER. For beneficiaries age 21 and older, Nebraska Medicaid covers a combined total of 60 therapy sessions per fiscal year . The combined total of 60 therapy sessions per fiscal year includes all occupational therapy (OT), physical therapy (PT), and speech therapy sessions provided to the beneficiary.

004.04 COVERED SERVICES. Nebraska Medicaid covers occupational therapy (OT) or physical therapy (PT) services when the following criteria are met:

(1) The services are ordered by a licensed physician, nurse practitioner (NP), or a treating practitioner;

(2) The services are medically necessary;

(3) The services are such that only a licensed occupational therapist (OT) or physical therapist (PT) can safely and effectively perform the service; and

(4) The services are offered through a home health agency.

004.04(A) MAINTENANCE PROGRAM. The occupational therapist (OT) or physical therapist (PT) must:

(i) Evaluate the beneficiary’s needs;

(ii) Design a maintenance program; and

(iii) Instruct the beneficiary, family members, or nursing facility staff in carrying out the program.

004.04(B) ORTHOTIC APPLIANCES AND DEVICES. Nebraska Medicaid covers orthotic appliances and devices when medically necessary for the beneficiary’s condition, and when the orthotic appliance or device is used during the therapy session.

004.04(C) SUPPLIES. Nebraska Medicaid covers supplies used during the course of treatment that require application by the occupational therapist (OT) or physical therapist (PT) when they are not incidental to the procedure.

004.05 NON-COVERED OCCUPATIONAL THERAPY (OT) OR PHYSICAL THERAPY (PT) SERVICES. Nebraska Medicaid does not cover occupational therapy (OT) or physical therapy (PT) services in the following situations:

(A) Maintenance therapy ;

(B) Therapy for hardening, vocational, prevocational assessment, and training;

(C) Therapy for functional capacity evaluations, educational testing, drivers training, training in non-essential self-help or recreational activities, training related to a learning disability or attention disorder, visual perception training, or treatment of psychological conditions;

(D) In-service training for nursing facility staff which is not beneficiary specific;

(E) Rental of equipment; or

(F) Take home supplies.

005. BILLING AND PAYMENT FOR OCCUPATIONAL THERAPY (OT) AND PHYSICAL THERAPY (PT) SERVICES.

005.01 GENERAL BILLING REQUIREMENTS. Providers must comply with all applicable billing requirements codified in these regulations .

005.02 BILLING INSTRUCTIONS. The provider must bill Nebraska Medicaid using the appropriate claim form or electronic format.

005.03 USUAL AND CUSTOMARY CHARGE. The provider or the provider's authorized agent must submit the provider's usual and customary charge for each procedure code listed on the claim.

005.04 MEDICAL NECESSITY DOCUMENTATION. The provider must provide the following information when submitting a claim for occupational therapy (OT) or physical therapy (PT) services:

(A) The date of illness or injury onset;

(B) The date the occupational therapy (OT) or physical therapy (PT) plan established;

(C) The date occupational therapy (OT) or physical therapy (PT) services started; and

(D) The number of occupational therapy (OT) or physical therapy (PT) visits from onset.

005.05 HOME HEALTH AGENCY. Services offered through a home health agency require prior authorization.

005.06 PAYMENT FOR INDIVIDUAL PROVIDERS. Claims are paid by Nebraska Medicaid for covered occupational therapy (OT) or physical therapy (PT) services at the lower of:

(1) The provider's submitted charge; or

(2) The allowable amount for that Healthcare Common Procedure Coding System (HCPCS) or Current Procedural Terminology (CPT) procedure code in the Nebraska Medicaid Practitioner Fee Schedule in effect on the date that the service was rendered.

History

• Effective 2026-06-28

Chapter 15 Personal Assistance Services

Neb. Admin. Code tit. 471, ch. 15 Personal Assistance Services {#sec-471-nac-15 omnilex-key=us-ne-regs-official--title-471--471 NAC 15}

001. SCOPE AND AUTHORITY . Medicaid personal assistance services are defined in federal regulations at 42 Code of Federal Regulations (CFR) 440.167, and are an optional Medicaid benefit. Personal assistance services are provided to persons with disabilities and chronic conditions of all ages to enable them to accomplish tasks they would normally do for themselves if they did not have a disability. Personal assistance services activities are limited to those activities that are required to maintain the client’s health and safety. The regulations govern the services provided under Nebraska’s Medicaid program as defined by Nebraska Revised Statue (Neb. Rev. Stat.) §§ 68-901 et seq.

002. DEFINITION OF TERMS . The following definitions apply:

002.01 CARETAKER. Defined in Neb. Rev. Stat. § 38-2219 of the Nurse Practice Act, which explains health maintenance activities, to mean a person who is:

(A) Directly and personally involved in providing care for a minor child or incompetent adult; and

(B) The parent, foster parent, family member, friend, or legal guardian of such minor child or incompetent adult.

002.02 CLIENT. The individual eligible for personal assistance services. For the purposes of these regulations, a reference to a client may include the client’s guardian, legal representative, or any person authorized to act on the participant’s behalf.

002.03 COMPETITIVE INTEGRATED EMPLOYMENT. Working a minimum of 40 hours per month at minimum wage.

002.04 DEPARTMENT. The Nebraska Department of Health and Human Services.

002.05 INCOMPETENT ADULT. Someone who does not have the capability and capacity to make an informed decision.

002.06 LICENSED RESIDENTIAL SERVICE PROGRAM. An assisted living facility, center for persons with developmental disabilities, group home for the developmentally disabled, mental health center, substance abuse treatment center, or respite care service program. These programs are licensed by the Nebraska Department of Public Health.

002.07 PROVIDER OR PERSONAL ASSISTANCE SERVICE PROVIDER. The individual who actually performs the personal assistance service(s) in accordance with this chapter.

003. PROVIDER REQUIREMENTS .

003.01 GENERAL PROVIDER REQUIREMENTS. To participate in the Nebraska Medicaid program, providers of personal assistance services will comply with all applicable provider participation requirements codified in 471 Nebraska Administrative Code (NAC) 1, 2, and 3.

003.02 SERVICE SPECIFIC PROVIDER REQUIREMENTS.

003.02(A) PARTICIPATION STANDARDS. All providers are Medicaid providers as defined under 471 NAC 2 and will meet the following standards:

(i) Follow all applicable Department policies and procedures including those found in NAC 465, 471, 473, 474 and 480. Bill only for services which are authorized and actually provided;

(ii) Accept payment as payment in full for the agreed upon service(s) unless the client has been assigned a portion of the cost by the Department. Provider will not charge clients any difference between the agreed upon rate and private pay rate;

(iii) Spouses or parents of minor children are not eligible to be providers;

(iv) Not engage in any activity that influences service approval or utilization if they are an employee of the Department or, the relative of a Department staff person.

(v) Retain all records related to provider enrollment and service provision, including financial records. Records will be maintained for retention periods in compliance with federal and state law, but no record will be destroyed prior to expiration of a six year retention period;

(vi) Allow federal, state, or local offices responsible for program administration or audit to review service records, in accordance with 45 CFR 74.20 - 74.24; and 42 CFR 431.107. Inspections, reviews, and audits may be conducted on site;

(vii) A provider of personal assistance services is not an employee of the Department or of the State;

(viii) Any false claims including claims submitted electronically, statements, documents, or concealment of material fact may be prosecuted under applicable state or federal laws;

(ix) Respect every client's right to confidentiality and safeguard confidential information;

(x) Understand and accept responsibility for the client's safety and property;

(xi) Not transfer this agreement to any other entity or person;

(xii) Not use any federal funds received to influence agency or congressional staff;

(xiii) Not engage in or have an ongoing history of criminal activity that may be harmful or may endanger individuals for whom they provide services. This may include a substantiated listing as a perpetrator on the child and adult central registries of abuse and neglect;

(xiv) Agency providers agree to allow Department staff to review agency policies regarding hiring and reporting to ensure that appropriate procedures regarding abuse, neglect, and law violations are in place;

(xv) Have the knowledge, experience, and skills necessary to perform the tasks of patient care and Electronic Visit Verification (EVV);

(xvi) Be capable of recognizing signs of distress in client and know how to access available emergency resources if a crisis situation occurs;

(xvii) Report changes to appropriate Department staff;

(xviii) Report all incidents in which there is reasonable cause to believe a client has been subjected to abuse, neglect, or exploitation. All such incidents will be reported to law enforcement and the Department;

(xix) Be age 19 or older if an individual provider; or assure that agency staff who assume the following roles are age 19 or older: director, administrator, agency representative for signing legal documents, or provider of in-home client services;

(xx) Not be a recipient of personal assistance services or similar services; and

(xxi) Providers entering the client’s home to provide services will not be accompanied in the client’s home by any individuals, including the provider’s minor children, whose presence is unnecessary to the provision of services to the client, or who are not authorized to provide services to the client. This does not apply when the provider shares a home with the client.

003.02(B) SPECIALIZED PROVIDER QUALIFICATIONS. A personal assistance services provider is considered to be specialized when they provide proof of one or more of the following:

(i) Has passed the Nebraska certified nurse aide equivalency test and can provide evidence of this to the Department;

(ii) Is a licensed registered nurse or licensed practical nurse and presents a copy of the certificate or license to the Department; or

(iii) Has a total of 4,160 hours of experience as a personal assistance service provider and can provide evidence to the Department.

003.02(C) DENIAL, TERMINATION, AND SANCTION OF PERSONAL ASSISTANCE SERVICES PROVIDERS. Refer to 471 NAC 2.

003.02(D) REPORTS OF ABUSE OR NEGLECT. The following provisions apply when reports of abuse or neglect by a provider have been received.

003.02(D)(i) ADULT PROTECTIVE SERVICES AND CHILD PROTECTIVE SERVICES. Medicaid providers are subject to Adult Protective Services and Child Protective Services Central Registry checks to determine if any substantiated reports of abuse or neglect by the provider exist. For services being provided in the same location the provider lists as their home, members of the household may also be checked in the Central Registries to determine if any substantiated reports of abuse or neglect exist.

003.02(D)(ii) REPORTS OF ABUSE OR NEGLECT. If a report of abuse or neglect concerning a provider, or a household member when service is provided in the same location the provider lists as their home address, as a perpetrator is substantiated, Department staff will immediately terminate the service provider agreement. If a report of abuse or neglect is shown as investigation in progress or substantiated, the Department will not enroll the provider.

003.02(E) DENIAL OR TERMINATION OF ENROLLMENT. Refer to 471 NAC 2.

003.02(E)(i) DENIAL OR TERMINATION OF ENROLLMENT. Refer to 471 NAC 2.

003.02(E)(ii) VOLUNTARY WITHDRAWAL. Written notice to the provider applicant is not required if the provider voluntarily withdraws from the enrollment process.

003.02(F) SERVICE PROVIDER AGREEMENT. Refer to 471 NAC 2.

003.02(G) PROVIDER APPEALS. Refer to 471 NAC 2.

003.02(H) PROVIDER RESPONSIBILITIES. An approved provider must:

(i) Adhere to all general provider standards in the service provider agreement and listed in this chapter;

(ii) Perform the personal assistance services described on the service plan;

(iii) Ensure that personal assistance services are provided in a manner that is consistent with the client’s choice, needs and desire to live independently;

(iv) Participate in the review of the client’s service plan as described in this chapter, if and when the client requests them to participate;

(v) Recognize changes in the client’s condition as it relates to the service plan, and report them to the Department;

(vi) Providers are responsible for completion of their electronic claims and any additional required documents prior to submitting them for processing. Providers are also responsible for knowing and understanding the tasks they are authorized to perform for each client they serve;

(vii) Accurately document services related to the service plan that are provided to and on behalf of the client, in the provider Electronic Visit Verification (EVV) system and submit electronic claims for payment;

(viii) Confirm that services were received in the manner authorized according to Department procedures;

(ix) Disclose necessary medical information to all clients for whom services are being provided, to allow for the safety of both client and provider;

(x) Retain the following materials for six years:

(1) Documentation that supports provision of services to each client served;

(2) Any other documentation determined necessary by the Department to support selection and provision of services under a service plan;

(3) Financial information related to the personal assistance services that are necessary to allow for an independent audit under Medicaid;

(4) Documentation that supports requests for payment; and

(5) Provider agreements with the Department;

(xi) Give adequate notice to the client when unable to provide scheduled services and terminating service provision; and

(xii) Not harm or exploit the client or client’s household members, including acts of physical or verbal abuse, theft, or misuse of household belongings, personal funds, prescriptions, or other medical supplies.

003.02(I) PROVIDER NOTICE. When a client’s personal assistance services are being changed in any way or terminated, the Department will provide written notice to the provider of the change in service provision or termination of payment for personal assistance services.

004. ELIGIBILITY AND AUTHORIZATION .

004.01 GENERAL SERVICE REQUIREMENTS.

004.01(A) MEDICAL NECESSITY. Medical necessity requirements outlined in 471 NAC 1 apply to the provision of personal assistance services, and are hereby incorporated as if fully rewritten herein.

004.01(B) ELIGIBILITY AND AUTHORIZATION.

004.01(B)(i) ELIGIBILITY CRITERIA. The Department must determine that a client meets all of the following eligibility criteria:

(1) Is a current Medicaid client;

(2) Needs personal assistance services to live in the community;

(a) But does not have needs that require more intensive services than those listed in this chapter due to an acute health care level;

(3) Is not receiving or eligible for personal assistance services or similar staff support based on their residence or place of employment;

(a) EXCEPTION. An individual residing in a licensed residential service program may only be eligible for personal assistance services under this regulation if it is needed to maintain competitive integrated employment and if it would not duplicate any services already received; and

(4) Lives in a residence that is not a hospital, nursing facility, intermediate care facility, prison, or other institution.

004.01(B)(ii) ASSESSMENT AND SERVICE PLAN. The client must participate in the development of the assessment and service plan by stating his or her service needs and preferences, and jointly determining the units of service needed. If the client is not cooperative in the process, the client is not eligible for services. The Department makes the final determination of units authorized.

004.01(B)(ii)(1) EMPLOYER APPOINTMENT OF AGENT FORM. Before authorization of a personal assistance service provider, the Department must obtain the client’s signature on Internal Revenue Service Form FA-65, Employer Appointment of Agent.

004.01(B)(iii) AUTHORIZATION.

004.01(B)(iii)(1) PRIOR AUTHORIZATION. Personal assistance services must be authorized before actual provision of the service, based on the assessment of need and development of the service plan.

004.01(B)(iii)(2) AUTHORIZATION PERIOD. Services must be authorized based on the client’s service needs for a period not to exceed a maximum of one year from the service authorization begin date.

004.01(B)(iii)(2)(a) AUTHORIZATION PERIOD OF PROVIDERS. A provider of personal assistance services may only be authorized until the end date of the client’s existing authorization for services.

004.01(B)(iii)(2)(b) AUTHORIZATION OF MULTIPLE PROVIDERS. The client must work with the Department to determine the maximum number of units each provider will be authorized to provide. It is the client’s responsibility to determine the day-to-day schedule of each provider.

004.01(B)(iii)(3) LIMITATION. Personal assistance services are limited to a maximum of 40 hours per seven-day period. Only the Department, not the approved service provider, may increase the maximum number of units for which the client is eligible per week, within the 40-hour per seven-day maximum. Any services provided in excess of 40 hours per seven-day period must receive prior authorization from the Department.

004.01(B)(iii)(4) RELATIONSHIP TO SERVICE PLAN. Personal assistance services authorized must relate directly to the tasks needed to be performed by someone else and that are essential to remain in the home, as listed on the service plan.

004.01(B)(iv) REVIEW OF SERVICE PLAN AND RE-AUTHORIZATION. Personal assistance services may be re-authorized at the end of an authorization period, which is at least annually, based on continued eligibility and a review of the service plan. The Department will review the service plan together with the client a minimum of once every 12 months, or whenever the client’s service needs change.

004.02 SPECIFIC SERVICE REQUIREMENTS.

004.02(A) ESSENTIAL SERVICES. Personal assistance services are based on individual needs and criteria that must be determined through an assessment and development of a service plan that relates directly to the needs identified in the assessment. These services include:

(i) Basic personal hygiene including, but are not limited to, providing or assisting with bathing; shampoo, hair grooming; nail care; oral hygiene; shaving; and dressing;

(ii) Toileting and bowel and bladder care including, but are not limited to, assisting to and from bathroom, on and off toilet or commode, diapering, bedpan; external cleansing of perineal area; maintenance bowel care; and changing or emptying catheter bag;

(iii) Mobility, transfers, and comfort including, but are not limited to, assisting with ambulation with and without aids; repositioning; encouraging active range-of-motion exercises; assisting with passive range-of-motion exercise; and assisting with transfers with or without mechanical devices;

(iv) Nutrition services, including, but are not limited to, preparing meals; planning and preparing special diets; assisting with fluid intake; and feeding; or

(v) Medication services, including, but not limited to, assisting with administration of medications; reminding appropriate persons when prescriptions need to be refilled.

004.02(B) SUPPORTIVE SERVICES. When any of the services listed in 471 NAC 15-004.02(A), items i-v are essential to enable the client to remain in the home and community, the following supportive services can also be provided:

(i) Housekeeping tasks necessary to maintain the client in a healthy and safe environment, including changing the client’s bed linens, laundering the client’s bed linens and personal clothing, light cleaning in essential areas of the home used by the client; purchasing of food once per week, and cleaning client’s dishes; and

(ii) Accompanying and assisting the client with any mobility, transfers, or other needed services for physician office visits, or on other trips to obtain medical diagnosis or treatment when the client is unable to travel alone.

004.02(C) SPECIALIZED PROCEDURES. Specialized procedures that would enable a person to live in their home and community may be performed by a personal assistance service provider at the direction of a competent client or of a caretaker. Such procedures are considered ‘health maintenance activities’ under the Nebraska Nurse Practice Act, Neb. Rev. Stat. § 38-2219. The client’s attending physician or registered nurse must determine that these procedures can safely be performed in the home and community by an approved personal assistance service provider under the client’s direction.

004.02(D) SERVICES OUTSIDE A CLIENT’S HOME. When any of the services listed in 471 NAC 15-004.02(A), items i-v are essential to enable the client to remain in the home and community, personal assistance services may be provided outside of a client’s home, including at the client’s worksite when the client is engaged in competitive integrated employment. Services provided may only include those authorized tasks that might otherwise be needed in the home and community, and if at a worksite, may not be tasks which essentially perform the job the client was hired to do. Accompanying and assisting the client with needed services when the client has work-related travels is also allowable.

004.02(D)(i) LICENSED RESIDENTIAL SERVICE PROGRAMS. An individual residing in a licensed residential service program may only be eligible for personal assistance services under this regulation if it is needed to maintain competitive integrated employment.

004.03 NON-COVERED SERVICES. Personal assistance services do not include the following:

(A) Personal assistance services not documented in the service plan;

(B) Personal assistance services provided by a parent of a minor child or spouse;

(C) Housekeeping services that are not an integral part of a covered personal assistance service;

(D) Services provided without authorization;

(E) Companion services, which provide for a person to be present without specific tasks be completed;

(F) Services provided when a client is not Medicaid eligible;

(G) Services that are defined as personal assistance services in 471 NAC 15-004.02 but are being paid by the Department under some other arrangement or funding source; and

(H) Clients receiving similar personal assistance services under another Medicaid service or program are not eligible for personal assistance services.

005. BILLING AND PAYMENT FOR PERSONAL ASSISTANCE SERVICES .

005.01 BILLING.

005.01(A) GENERAL BILLING REQUIREMENTS. Providers will comply with all applicable billing requirements located in 471 NAC 3, and with all applicable billing requirements for the Electronic Visit Verification (EVV) system.

005.02 PAYMENT.

005.02(A) GENERAL PAYMENT REQUIREMENTS. Medicaid will reimburse the provider for services rendered in accordance with the applicable payment regulations codified in 471 NAC 3. Services must be delivered before they can be billed. Providers cannot provide services to more than one client at a time. Medicaid will not pay for services that were not performed during the actual hours noted by the provider in the Electronic Visit Verification (EVV) system.

005.02(B) SPECIFIC PAYMENT REQUIREMENTS.

005.02(B)(i) FREQUENCY OF BILLING. Providers may not bill more frequently than weekly but must bill at least monthly. Claims must be submitted within six months from the date of service in accordance with 471 NAC 3.

005.02(B)(ii) PROVIDER RATES. Rates are set by the Department, and are contained in the Nebraska Medicaid Personal Assistance Service Rate Listing.

005.02(B)(iii) PROVIDER SOCIAL SECURITY TAX WITHHOLDING.

005.02(B)(iii)(1) AFFECTED PROVIDERS. When required by law, the Department withholds Social Security taxes from provider payments. The employee’s share of Social Security tax is withheld from provider payments only when in-home service is provided by an individual not affiliated with an agency. The Department, upon receiving a signed Internal Revenue Service Form FA-65, Employer Appointment of Agent, acts on behalf of clients who receive in-home services to withhold mandatory Federal Insurance Contribution Act taxes from individual providers and pays the client’s matching tax share to the Internal Revenue Service.

005.02(B)(iii)(2) EARNINGS TAXED FOR SOCIAL SECURITY. Affected providers are subject to Social Security tax payment for each calendar year in which they are paid a federally determined amount or more for services provided to one client. The Department withholds this tax from all payments to affected providers. If a provider’s earnings do not reach this annual amount for Federal Insurance Contribution Act services per client, the amount withheld for that year is refunded to the provider. The Department remits to the Internal Revenue Service an amount equal to the current Social Security tax rate for specified in-home services. Half of this amount is withheld from the provider as the employee’s share; the other half is provided by the Department on behalf of the client employer.

005.02(B)(iv) PROVIDER PAYMENT PROCESS. Providers must confirm that services were received in the manner authorized according to Department procedures.

006. CLIENT RIGHTS AND RESPONSIBILITIES .

006.01 CLIENT RIGHTS. Clients, or if the clients not able to exercise these rights, a designated, responsible party who is able to perform these functions for the client, who are found to be eligible for personal assistance services have the right to:

(A) Identify their service needs;

(B) Determine their preferred approved provider, which may include selecting from a Medicaid enrolled list of providers;

(C) Identify a possible provider who meets the minimum qualifications as described in this chapter;

(D) Direct their personal assistance services;

(E) Receive services according to the service plan, free from risk of harm or exploitation, including physical and verbal abuse, theft and misuse of household belongings, personal funds, prescriptions or other medical supplies; and

(F) Dismiss a provider if not satisfied with the provision of services.

006.02 CLIENT RESPONSIBILITIES. Clients receiving personal assistance services must:

(A) Disclose necessary medical information to the personal assistance service provider to ensure the safety of both the client and provider;

(B) Notify the Department of any changes in their medical condition or service needs;

(C) Schedule provider(s) within the parameters of the Service Authorization Notice;

(D) Notify the Department if the provider is not performing the tasks for which they are authorized;

(E) Notify the Department of any harm or exploitation by the provider, including physical and verbal abuse, theft and misuse of household belongings, personal funds, prescriptions or other medical supplies;

(F) Validate service delivery in a manner that includes, but is not limited to, the date and location of service delivery, arrival and departure times of provider, and verification of service delivery by both the provider and client, or their authorized representative;

(G) Sign the Internal Revenue Service Form FA-65, “Employer Appointment of Agent”;

(H) Be at home or other designated location when the provider arrives to carry out scheduled authorized tasks;

(I) Ensure that the provider is free from risk of harm while performing the authorized tasks;

(J) Follow the terms of the service plan;

(K) Formulate a back-up plan for provision of services, including the selection of an approved back-up personal assistance services provider, in case of provider emergency; and if a provider emergency arises, initiate the back-up plan for provision of services; and

(L) Direct their personal assistance services.

006.03 CLIENT NOTIFICATION. The Department will send written notice of denial, reduction, or termination of services to the client. Notice to clients must contain: a clear statement of the action to be taken; a clear statement of the reason for the action; a specific regulation citation which supports the action; and a complete statement of the client’s right to appeal.

006.03(A) NOTICE OF REDUCTION OR TERMINATION OF SERVICES. Notice of reduction or termination of services must be mailed at least ten calendar days before the effective date of action. Refer to NAC Title 465 for additional computation excluding the day of the event, last day of the period, and holidays and weekend mailings.

006.03(A)(i) EXCEPTION. If the termination of personal assistance services is because of loss of Medicaid eligibility, the effective date of the termination must match the effective date of the termination of Medicaid eligibility.

006.03(B) CHANGES TO AUTHORIZATION. The Department will notify the client in writing of any change in the authorized service, including:

(i) Change in service tasks to be provided;

(ii) Change in authorized units;

(iii) Change in approved provider; or

(iv) Change in authorization period.

006.03(C) DENIAL AND TERMINATION REASONS. The Department will provide notice of denying or terminating eligibility for the following reasons:

(i) The client has no personal assistance service need;

(ii) The client’s needs are being met by another source;

(iii) The client has not supplied needed information to complete the eligibility process;

(iv) The client fails to meet the specified eligibility criteria in this chapter;

(v) The Department and the client cannot agree on the specific component(s) of the service plan, including services to be provided, and number of units to be authorized;

(vi) The client voluntarily closes their personal assistance services case;

(vii) The client moves out of Nebraska;

(viii) The client dies;

(ix) The Department loses contact with the client and their whereabouts are unknown;

(x) The client has not made themselves available to the provider(s) at scheduled times by being home or at other designated locations, three or more times in a 30-day period;

(xi) The client or household member has demonstrated violence toward the provider(s);

(xii) The client has provided an unsafe and dangerous environment in which the provider(s) has been expected to work;

(xiii) An authorization period is ending and the client has not acted upon the Department’s written notice of the need for re-authorization; or

(xiv) The client fails to comply with any of the client responsibilities in this chapter.

006.03(D) ADVANCE NOTICE NOT REQUIRED. Ten-day notice, in accordance with 15-006.03 and 477 NAC 9, is not required in the following situations:

(i) The Department has factual information confirming the death of a client;

(ii) The Department receives a clear written statement signed by a client that they no longer wish to receive services;

(iii) The client has been admitted to a nursing facility, intermediate care facility for persons with developmental disabilities, or institution for mental disease;

(iv) The client’s whereabouts are unknown; or

(v) The client has been accepted for Medicaid services by another state.

006.04 CLIENT APPEALS OF ADVERSE ACTIONS. Persons who request, apply for, or receive services may appeal any adverse action or inaction of the Department in accordance with NAC Title 465.

History

• Effective 2022-06-06

Chapter 16 Pharmacy Services

Neb. Admin. Code tit. 471, ch. 16 Pharmacy Services {#sec-471-nac-16 omnilex-key=us-ne-regs-official--title-471--471 NAC 16}

001. SCOPE AND AUTHORITY . The regulations govern the services provided under Nebraska’s Medicaid program as defined by the Medical Assistance Act (Nebraska Revised Statute §§ 68-901 et seq).

002. DRUG UTILIZATION REVIEW . As a condition of participation, the provider is required to:

(A) Provide prospective drug utilization review before dispensing each prescription. This includes screening for:

(i) Therapeutic duplication;

(ii) Drug disease contraindications;

(iii) Drug interactions;

(iv) Incorrect dosage or duration;

(v) Drug allergies; and

(vi) Clinical abuse and misuse;

(B) Provide patient counseling on all matters which, in the provider's professional judgment, are deemed significant, including:

(i) Name and description of the medication;

(ii) Route, dosage form, duration of therapy;

(iii) Directions for use;

(iv) Adverse reactions, contraindications;

(v) Storage; and

(vi) Refill information; and

(C) Maintain adequate patient profiles which may include:

(i) Name, address, phone number, date of birth, and gender;

(ii) Individual history;

(iii) Comprehensive listing of medications; and

(iv) Relevant comments.

003. COVERED SERVICES . Nebraska Medicaid covers outpatient drugs in accordance with the Omnibus Budget Reconciliation Act of 1990 including:

(A) Legend drugs;

(B) Compounded prescriptions; and

(C) Over-the-counter drugs indicated as covered on the Nebraska Point of Purchase System or listed on the Nebraska Medicaid Pharmacy Program website.

004. COMPOUNDED PRESCRIPTIONS . A compounded prescription is a mixture of ingredients which the provider prepares in the pharmacy.

004.01 REIMBURSEMENT FOR COMPOUNDED PRESCRIPTIONS. Reimbursement for compounded prescriptions will be limited to those ingredients which are indicated as covered on the Nebraska Point of Purchase System or listed on the Nebraska Medicaid Pharmacy Program website. Any mixture of drugs which results in a commercially available over-the-counter preparation is not considered a compounded prescription.

005. OVER-THE-COUNTER DRUGS . Covered drugs include only over-the-counter drugs indicated as covered on the Nebraska Point of Purchase System or those listed on the Nebraska Medicaid Pharmacy Program website. Over-the-counter drugs must be prescribed by a licensed practitioner.

006. TOBACCO CESSATION COUNSELING . In addition to a physician or mid-level practitioner, only a licensed pharmacist, meeting Department conditions of participation listed above as a Tobacco Cessation Counselor, may provide tobacco cessation counseling.

006.01 TOBACCO CESSATION COUNSELING CONDITIONS OF PARTICIPATION. As a condition of participation as a Tobacco Cessation Counselor, the provider must:

(A) Be a licensed pharmacist;

(B) Complete a Department-approved tobacco cessation counselor training;

(C) Maintain current training as a Tobacco Cessation counselor as required by the Department;

(D) Complete and sign a new provider agreement, indicating the employing pharmacy as the "pay to" provider, and submit proof of completing the Department-required training as part of the provider agreement completion process, or upon request by the Department;

(E) Provide Tobacco Cessation counseling which is separate and distinct from the prospective drug utilization review required in this chapter and is not related to the dispensing of any drug product; and

(F) Provide feedback to the physician or mid-level practitioner who ordered the services.

007. PRESCRIPTION REFILLS . Prescription refills must be performed and recorded in a manner consistent with existing State and Federal laws, rules, and regulations. Automatic refills are not allowed. All prescription refills must be initiated by a request from the prescriber, client, or an authorized representative. If the client is residing in a facility, a nurse or other authorized agent of the facility pursuant to a valid prescriber’s order may initiate the request for refill.

008. NON-COVERED DRUGS . Payment by Nebraska Medicaid will not be approved for:

(A) Requests for quantities not in compliance with the requirements of this chapter;

(B) Experimental drugs or drugs not approved by the Food and Drug Administration;

(C) Drugs or other items not prescribed for a medically accepted indication;

(D) Drugs or other items prescribed or recommended for weight control or appetite suppression;

(E) Any alcoholic beverage;

(F) Drug Efficacy Study Implementation Program drugs identified as Less Than Effective or Identical, Related, or Similar with an indicator value assigned by the Food and Drug Administration of either 5 or 6;

(G) Personal care items;

(H) Medical supplies and certain drugs for nursing facility and intermediate care facility patients;

(I) Over-the-counter drugs not listed on the Nebraska Medicaid Pharmacy Program website;

(J) Drugs or other items used for cosmetic purposes or hair growth;

(K) Baby foods, milk substitutes, or metabolic agents normally supplied by the Department;

(L) Drugs distributed or manufactured by certain drug manufacturers or labelers which have not agreed to participate in the drug rebate program;

(M) Products used to promote fertility;

(N) Medications dispensed as partial month fills for nursing facility or group home residents when dispensed by more than one pharmacy;

(O) Medications dispensed to replace products which have been recalled by the drug manufacturer;

(P) Drugs, or other products of manufacturers or labelers identifiable as non-covered on the Nebraska Point of Purchase System or on the Nebraska Medicaid Pharmacy Program website;

(Q) Drugs, classes of drugs, or therapeutic categories of drugs which are Medicare Part D Drugs and Medicare Part D Covered supplies or equipment, for all individuals eligible for benefits under Medicare Part D, whether or not the individual is enrolled in a Medicare Part D Plan;

(R) Drugs or classes of drugs approved by the Federal Food and Drug Administration for treatment of sexual or erectile dysfunction, or drugs or classes of drugs which are being used for the treatment of sexual or erectile dysfunction. Drugs or classes of drugs which are approved by the Federal Food and Drug Administration for treatment of sexual or erectile dysfunction and for conditions other than treatment of sexual or erectile dysfunction, and are prescribed for those other conditions may be covered, but Nebraska Medicaid may require prior authorization; and

(S) Automatic refills.

009. LIMITATIONS AND REQUIREMENTS FOR CERTAIN DRUGS .

009.01 PRIOR AUTHORIZATION. The Department requires authorization be granted prior to payment for certain drugs. Should a practitioner dispense a prescription prior to the actual authorization, he or she takes a business risk payment for the prescription can be denied.

009.01(A) PRIOR AUTHORIZATION RESPONSE. The Nebraska Point of Purchase contractor or the Department will respond to any request for prior authorization within 24 hours of receipt of the request.

009.01(B) APPROVAL DECISION. The Nebraska Point of Purchase contractor or the Department will notify the provider prescribing the drug or the pharmacy dispensing the drug if the authorization has been granted, the eligible dates of the authorization, and the identification of the provider who requested the authorization. The prior authorization is given for the drug, the client, and the prior authorization dates.

009.01(C) DENIAL DECISION. The Nebraska Point of Purchase contractor or the Department will notify the provider prescribing the drug or the pharmacy dispensing the drug if coverage is denied.

009.01(D) EMERGENCY DECISION. The Nebraska Point of Purchase contractor or the Department will authorize dispensing up to a 72-hour supply of a covered outpatient prescribed medication for cases meeting the definition of a medical emergency as outlined in chapter two of this title.

009.01(E) UNKNOWN DECISION. If the provider prescribing the drug or the pharmacy dispensing the drug has not received an authorization from the Nebraska Point of Purchase contractor or the Department, payment may be denied.

009.01(F) VERIFYING STATUS OF REQUESTS. The pharmacy can verify the status of prior authorization requests for prescriptions by submitting a claim via the Nebraska Point of Purchase System. If the prior authorization request has not been approved, the pharmacy may contact the Nebraska Point of Purchase contractor or the Department for prior authorization.

009.02 PRODUCTS REQUIRING PRIOR APPROVAL. Identifiable products requiring approval prior to payment are designated as such on the Nebraska Point of Purchase System or on the Nebraska Medicaid Pharmacy Program website. Reasons for prior authorization include:

(A) Product Based Controls. Prior authorizations falling under this category are products where there are medically appropriate alternative treatments which are more cost-effective for the Department;

(B) Utilization Controls. Prior authorizations falling under this category generally apply to the quantity of medication or duration of therapy approved; and

(C) Scope Controls. Scope controls ensure a drug is used for an approved or medically accepted indication, is clinically appropriate, medically necessary, and cost-effective;

(i) Medications which have been approved by the Federal Food and Drug Administration for multiple indications may be subject to a scope-based prior authorization when at least one of the approved indications places the drug in a therapeutic category or treatment class for which a prior authorization is required;

(ii) Prior authorization may be required to assure compliance with Federal Food and Drug Administration approved and medically accepted indications, dosage, duration of therapy, quantity, or other appropriate use criteria including pharmacoeconomic consideration; or

(iii) Prior authorization may be required for certain non-standard dosage forms of medications when the drug is available in standard dosage forms.

009.03 PREFERRED DRUG LIST.

009.03(A) PREFERRED DRUG LIST. The Medicaid Prescription Drug Act of 2008 requires the Department to establish and maintain a Preferred Drug List for the Medicaid program with the aid of the Pharmaceutical and Therapeutics Committee. Individual drugs will be designated as preferred or non-preferred within therapeutic classes of prescribed drugs reviewed by the Pharmaceutical and Therapeutics Committee. Drugs designated as preferred drugs can be prescribed for Medicaid clients without prior authorization from the Department; however some Preferred Drugs may have clinical claim limits to ensure appropriate use. The Preferred Drug List and other related activities are not construed to replace, prohibit, or limit other lawful activities of the Department not specifically permitted or required by the Act. Drugs classified as Preferred Drugs will be eligible for supplemental rebates as described under the provisions of this title. The Department will maintain an updated Preferred Drug List in electronic format and will make the list available to the public from the Nebraska Medicaid Pharmacy Program website. Drugs and classes of drugs included on the Preferred Drug List will be reviewed annually. Changes will be communicated to providers at least 30 days prior to implementation.

009.03(B) DRUGS INCLUDED ON THE PREFERRED DRUG LIST. The Department will include on the Preferred Drug List prescribed drugs which are found to be therapeutically equivalent to or superior to other drugs within a therapeutic class, and the net cost of the drugs are equal to or less than other drugs within a therapeutic class after consideration of applicable rebates or discounts negotiated by the Department or its designated contractor. All classes of medications are considered for inclusion on the preferred drug list (PDL) except the antidepressants, antipsychotics or anticonvulsant medications.

009.03(C) NON-PREFERRED DRUGS. Medications designated as non-preferred on the Preferred Drug List will be subject to prior authorization. The Pharmaceutical and Therapeutics Committee will develop criteria for use of medications with non-preferred status. A health care provider may prescribe a drug designated as non-preferred on the Preferred Drug List to a Medicaid client without prior authorization by the Department if the provider certifies:

(i) The client is achieving therapeutic success with a course of medication for Human Immunodeficiency Virus, Multiple Sclerosis, cancer, or immunosuppressant therapy; or

(ii) The client has experienced a prior therapeutic failure with a medication designated as a Preferred Drug.

010. DRUG UTILIZATION REVIEW . The Department is authorized by federal statute to conduct a Drug Utilization Review program. The Drug Utilization Review program consists of prospective drug review, retrospective drug review, the application of explicit predetermined standards, and an educational program. The purpose of the Drug Utilization Review program is to improve the quality of pharmaceutical care by ensuring prescriptions are appropriate and medically necessary and not likely to result in adverse medical results.

010.01 DRUG UTILIZATION REVIEW BOARD. The Department or the Department’s contractor utilizes a Drug Utilization Review Board to review and analyze available clinical and economic data. The Drug Utilization Review Board reviews and makes recommendations based on predetermined standards submitted to them by the Department or the Department’s contractor and, in concert with retrospective review of claims data, makes recommendations for educational interventions, prospective Drug Utilization Review, and the prior authorization process.

010.02 REVIEW FOR PRIOR AUTHORIZATION RECOMMENDATION. The Drug Use Review Board will, upon the Department’s request, review drugs or classes of drugs and make recommendations to the Department regarding drugs or classes of drugs for prior authorization. The Department makes the final decision on which drugs or classes of drugs will require prior authorization. For those drugs which will require prior authorization, the Drug Utilization Review Board will develop and recommend prior authorization criteria to the Department. The Department may accept, reject, or modify the recommended criteria. The Department will communicate information related to prior authorization criteria on the Nebraska Medicaid Pharmacy Program website. The Drug Utilization Review Board will review existing prior authorization criteria annually.

010.03 MANUFACTURER REQUESTS FOR DRUG REVIEW. The manufacturer or any interested party may request a drug or class of drugs on prior authorization be placed on the agenda of a Drug Utilization Review board meeting, but no drug or class of drugs will be placed on the Drug Utilization Review agenda more than once every 12 months without the consent of the Drug Utilization Review director, in consultation with the Department’s Pharmacy Consultant. The manufacturer of the drug may request the Drug Utilization Review director waive the 30-day notification rule when asking to have its product placed on the agenda.

011. PHARMACY SERVICES FOR CLIENTS RESIDING IN CERTAIN CARE FACILITIES .

011.01 NON-COVERED ITEMS. Nebraska Medicaid does not cover hydrogen peroxide, rubbing alcohol, and over-the-counter enemas as pharmacy services for clients residing in a nursing facility or intermediate care facility. The nursing facility or intermediate care facility may be reimbursed for these items under the Department's payment plan for nursing facility and intermediate care facility services. For clients residing in nursing facilities and intermediate care facilities, the Department does not cover medical supplies or durable medical equipment as pharmacy services.

011.02 REPLACEMENT COST. Providers cannot duplicate medication, at the Department’s expense, for clients residing in facilities. The pharmacy or the facility is responsible for providing a replacement. Providers cannot bill the Department for medication which was destroyed upon a client’s discharge.

011.03 PROFESSIONAL DISPENSING FEES. Pharmacies providing medications to nursing facility and intermediate care facility patients are allowed one professional dispensing fee per recipient and drug per month.

011.04 UNIT DOSE DEFINITIONS.

011.04(A) TRADITIONAL BOTTLE METHOD. Dispensing multiple tablets and capsules in one vial or bottle. This excludes systems such as cassettes, individually packaged doses on cards containing multiple doses, and all similar systems.

011.04(B) UNIT DOSE. A system of drug packaging, dispensing, returning, billing, and crediting by a unit dose provider.

011.04(C) UNIT DOSE PACKAGING. Drug packaging approved by the Nebraska Board of Pharmacy.

011.04(D) UNIT DOSE DISPENSING. The provision to the patient of a 14-day or less supply of a drug in unit dose packaging.

011.04(E) UNIT DOSE RETURNING. The process of returning unit dose packaged drugs to the dispensing pharmacy.

011.04(F) UNIT DOSE BILLING. Billing the Department one time per calendar month for the quantity of drug used by the patient during the month, with the exceptions described in this chapter. The quantity used is the difference between the quantity dispensed and the quantity returned. The date of service for each unit dose billing must be consistent from month to month.

011.04(G) UNIT DOSE CREDITING. A process of issuing credits by the pharmacy to the Department for drugs accepted for return into inventory which were previously billed to and covered by the Department.

011.04(H) UNIT DOSE PROVIDER. A pharmacy approved by the Department as a unit dose provider. Initial approval is contingent upon written agreement by the provider and demonstration by the provider, to the satisfaction of the Department, of the provider’s ability to use unit dose packaging, unit dose dispensing, unit dose returning, unit dose billing, and unit dose crediting. Continuing approval is contingent upon the provider’s actual performance as specified in the written agreement.

011.05. REIMBURSEMENT. The Department will only reimburse unit dose providers for prescribed drugs dispensed to Medicaid clients residing in facilities.

011.06 DRUGS RETURNED FOR CREDIT. Providers which accept returns of dispensed drugs from long term care facilities must credit the Department for those drugs. A drug cost level, below which credits will not be mandatory, may be established by the Department.

012. MEDICAL SUPPLIES AND DURABLE MEDICAL EQUIPMENT . Any medical supply or durable medical equipment indicated as covered on the Nebraska Point of Purchase System or on the Nebraska Medicaid Pharmacy Program website is covered as a pharmacy service under this chapter.

013. QUANTITY LIMITATIONS . The Department imposes the following quantity limitations on certain drugs.

013.01 QUANTITIES NOT ALLOWED. Payment from Nebraska Medicaid will not be approved for:

(A) More than a three month supply of any maintenance medication;

(B) More than a one month supply of any controlled substance; and

(C) More than a one month supply of any injectable medication except insulin and those injectable drugs with a duration of greater than one month from one dose.

013.02 QUANTITIES. The following types of limits may be utilized to ensure appropriate utilization and billing:

(A) Maximum quantity over time;

(B) Maximum daily dose;

(C) Maximum days’ supply per fill;

(D) Maximum quantity per fill;

(E) Minimum quantity per fill;

(F) Maximum cost per fill;

(G) Tablet splitting; and

(H) Number of units to require medication be submitted in multiples of the package size.

013.03 INJECTIONS. The Department applies the following limitations to injectable drug products:

(A) Only those injections which are either self-administered by the client or are administered for the client at the client's place of residence are reimbursable. Injections administered by the provider or hospital are not reimbursable through the pharmacy services program;

(B) Whenever available and necessity warrants, multi-dose vials of medication are dispensed rather than single-dose vials or unit-dose syringes;

(C) Single-dose syringes may be reimbursed at the proportionate cost of a multi-dose vial;

(D) Maintenance injectable medications which are not reconstituted or admixed by the pharmacy prior to administration to the patient are dispensed and billed for the full month's supply;

(E) Non-maintenance injectable medications and those injectable medications which must be reconstituted or admixed by the pharmacy prior to administration to the patient including subcutaneous, intramuscular, and intravenous medication delivery by large volume parenteral, piggyback, syringe pump, or other methods may be provided at the pharmacist's discretion. Courses of therapy of ten days or less duration are billed at the end of the course of therapy. Courses of therapy of greater than ten days duration are billed at the end of the course of therapy or after each ten days of therapy;

(F) Injectable medications administered by implanted or similar devices may not be billed to the pharmacy services program when the device is filled in the clinic or hospital; and

(G) Total parenteral nutrition is billed through the Durable Medical Equipment and Medical Supplies program. This includes the amino acids, carbohydrates, lipids and all additives. All total parenteral nutrition-compatible additives are billed through the supplier program regardless of who completes the addition of the ingredient or the method of administration.

013.04 MAINTENANCE DRUGS. The Department requires any other maintenance drug or any drug used in a chronic manner be prescribed and dispensed in a minimum of a one-month supply. Providers will not reduce prescriptions which are written for quantities larger than a month's supply to a month's supply. The Department considers prescription splitting to be fraudulent except when such reduction is done to comply with State or Federal regulations or statute.

013.05 EXCEPTIONS TO QUANTITY LIMITATIONS. The Department allows the following exceptions to the quantity limitations of this subsection only for those clients receiving medications through a non-unit-dose system, except where noted otherwise:

(A) When the prescriber first introduces a maintenance drug to a patient's course of therapy, the prescriber may prescribe a smaller quantity as his or her judgment dictates. Pharmacists must indicate this is the initial filling of the medication when filing the drug claim. Any subsequent dispensing of this maintenance drug must be prescribed and dispensed in at least a month's supply;

(B) When the prescriber’s professional judgment indicates these quantities of medication are not in the patient's best medical interest, the prescriber may prescribe as his or her judgment directs. This includes limitations for lock-in clients. The pharmacist must maintain documentation when an exception is being made to the Department's requirements;

(C) The Department will consider replacement of any lost, misplaced, or stolen drug products for clients only when the pharmacy provider or prescriber documents the conditions requiring replacement. The Department will require additional information prior to replacing controlled substances;

(D) Schedule II drugs are an exception to the quantity limitations. This also applies to unit dose systems, unless the Schedule II drug is used in a chronic or maintenance manner; and

(E) The Department will accept certain original shelf package sizes of medication, under the following conditions:

(i) An original shelf package of 480 ml or less when not packaged in the pint size, is sufficient for the quantity limitations requirement for liquids. This also applies to unit dose systems;

(ii) An original shelf package of l00 tablets or capsules, or less when not available in the 100 tablet or capsule size, for seldom-prescribed solid dosage drugs is sufficient for the quantity limitations requirement;

(iii) Original shelf packages of l00 tablets or capsules of routinely prescribed drugs are not acceptable as sufficient for fulfillment of the quantity limitations requirement. The full month's supply must be prescribed and dispensed; and

(iv) Ready-made ointments and creams, when used in a chronic or maintenance manner, may be dispensed in an original shelf package size provided the original size is closest to the needed amount of medication. This also applies to unit dose systems.

014. UTILIZATION . Since it is the pharmacist's professional responsibility to ascertain drugs are being utilized according to the prescriber's directions and no abuse or overuse exists, the Department will not reimburse pharmacists for prescriptions which demonstrate a lack of this professional obligation. Providers are required to maintain patient record systems or other adequate records to prevent these errors in dispensing. The Department's professional staff is responsible for determining whether a claim violates the Department's regulations. The Nebraska Point of Purchase system will identify drug claims when potential overuse exists, and these claims will be denied.

014.01 TOBACCO CESSATION. Medicaid covers tobacco cessation services as practitioner and pharmacy services under the following conditions:

(A) Tobacco cessation counseling visits with an enrolled medical provider or pharmacist tobacco cessation counselor may be a combination of intermediate or intensive tobacco cessation counseling visits;

(B) Tobacco cessation products are covered by Medicaid as a pharmacy service for those clients meeting Federal Food and Drug Administration approved dosing and age guidelines who require this particular assistance. Tobacco cessation counseling provided by a Tobacco Cessation counselor must be ordered by the physician or mid-level practitioner; and

(C) Nebraska Tobacco Free Quitline: In conjunction with tobacco cessation products, recipients are encouraged to be enrolled in and active with the Nebraska Tobacco Free Quitline. Referral to the Quitline may be made by a medical professional or a self-referral. Recipient access to the Nebraska Tobacco Free Quitline is unlimited.

015. PAYMENT FOR PHARMACY SERVICES .

015.01 PROFESSIONAL DISPENSING FEES.

015.01(A) DISPENSING FEE. The fee-for-service professional dispensing fee will be assigned to each claim payment based on the lesser of methodology described below.

015.01(B) DISPENSING PHYSICIANS. The Department assigns a professional dispensing fee to a dispensing physician only when there is no pharmacy within a 25-mile radius of the physician's place of practice.

015.02 REIMBURSEMENT METHODOLOGY. Payment levels for all drugs will not exceed, in the aggregate, upper levels of reimbursement established by federal law.

015.02(A) BRAND NECESSARY CERTIFICATION OF DRUGS. The Federal Upper Limit or State Maximum Allowable Cost limitations will not apply in any case where the prescribing physician certifies a specific brand is medically necessary. In these cases, the usual and customary charge or National Average Drug Acquisition Cost will be the maximum allowable cost. The prescriber must certify that a brand name is medically necessary.

015.03 PRICING INSTRUCTIONS. Pharmacists will not, under any circumstances, submit charges to the Department which exceed the pharmacy's usual and customary charge.

015.03(A) PRICING. Any loss leader, shelf, sale, cash only, coupon certificate, or newspaper and brochure ad prices which are in effect on the date the prescription is dispensed will be considered the pharmacy's usual and customary charge to the general public.

015.03(B) PRICE MATCHING. When a pharmacy lowers its usual and customary price for a prescription, all claims submitted to Nebraska Medicaid for the same drug and quantity dispensed during that business day will also be billed at the lowered price.

015.04 PAYMENT METHODOLOGY.

015.04(A) LEGEND DRUGS, NON-LEGEND DRUGS, AND COMPOUNDED PRESCRIPTIONS. The Nebraska Medicaid Drug Program is required to reimburse ingredient cost for covered outpatient legend and non-legend drugs at the lowest of:

(i) The usual and customary charge to the public;

(ii) The National Average Drug Acquisition Cost, plus the established professional dispensing fee;

(iii) The Affordable Care Act Federal Upper Limit plus the established professional dispensing fee; or

(iv) The calculated State Maximum Allowable Cost, plus the established professional dispensing fee.

015.04(B) BACKUP INGREDIENT COST BENCHMARK. If the National Average Drug Acquisition Cost is not available, the allowed ingredient cost will be the lesser of Wholesale Acquisition Cost + 0%, State Maximum Allowable Cost, or the Affordable Care Act Federal Upper Limit plus the established professional dispensing fee.

015.04(C) SPECIALTY DRUGS. Specialty drugs will be reimbursed at National Average Drug Acquisition Cost. If National Average Drug Acquisition Cost is not available, then the Backup Ingredient Cost Benchmark will apply.

015.04(D) DRUG PRICING PROGRAM. Covered legend and non-legend drugs, including specialty drugs, purchased through the Federal Public Health Service’s 340B Drug Pricing Program by covered entities which carve Medicaid into the 340B Drug Pricing Program will be reimbursed at the 340B actual acquisition cost, but no more than the 340B ceiling price plus the established professional dispensing fee. A 340B contract pharmacy under contract with a 340B covered entity described in section 1927 (a)(5)(B) of the Act is not covered.

015.04(E) FEDERAL SUPPLY SCHEDULE. Facilities purchasing drugs through the Federal Supply Schedule will be reimbursed at no more than their actual acquisition cost plus the established professional dispensing fee.

015.04(F) CLOTTING FACTOR.

(i) Pharmacies dispensing Antihemophilic Factor products will be reimbursed at the lesser of methodology plus the established professional dispensing fee. If National Average Drug Acquisition Cost is not available, the lesser of methodology for the allowed ingredient cost will be the Wholesale Acquisition Cost + 0%, the Average Sales Price + 6%, or the Affordable Care Act Federal Upper Limit; and

(ii) Pharmacies dispensing Antihemophilic Factor products purchased through the Federal Public Health Service’s 340B Drug Pricing Program by pharmacies which carve Medicaid into the 340B Drug Pricing Program will be reimbursed at the 340B actual acquisition cost, but no more than the 340B ceiling price plus the established professional dispensing fee.

015.04(G) DRUGS PURCHASED AT NOMINAL PRICE. Facilities purchasing drugs at Nominal Price, outside of Federal Public Health Service’s 340B Drug Pricing Program or Federal Supply Schedule, will be reimbursed by their actual acquisition cost plus the established professional dispensing fees.

015.04(H) INVESTIGATIONAL DRUGS. Excluded from coverage.

015.04(I) TRIBAL RATES. Tribal pharmacies will be paid the federal encounter rate.

015.04(J) CERTIFIED LONG-TERM CARE. Pharmacies providing covered outpatient prescription services for Certified Long-Term Care beneficiaries will be reimbursed for ingredient cost using the lesser of methodology plus the established professional dispensing fee.

015.04(K) UNIT DOSE PRESCRIPTIONS. The Department defines unit dose in this chapter. Unit dose providers are allowed one professional dispensing fee per recipient and drug per month.

015.04(L) SALES TAX. The State of Nebraska is tax exempt; therefore, providers do not charge sales tax on claims to the Department.

015.04(M) THIRD PARTY LIABILITY. The pharmacy provider will bill any third party resource for claims before billing Medicaid. All third party resources available to Medicaid clients must be utilized for all or part of their medical costs before Medicaid. Third party resources are any individual, entity, or program which is, or may be, liable to pay all or part of the cost of any medical services furnished to a client.

016. BILLING REQUIREMENTS .

016.01 DRUG CLAIMS. Claims for pharmacy services must meet the requirements listed in the Nebraska Point of Purchase System user's manual. The same standards apply to non-Point of Purchase system claims.

016.02 MEDICAL SUPPLIES AND DURABLE MEDICAL EQUIPMENT CLAIMS. Providers must bill electronically using the standard Health Care Claim: Professional transaction or the Health Insurance Claim Form to submit claims for medical supplies and durable medical equipment unless otherwise stipulated.

016.03 ELECTRONIC MEDIA CLAIM REQUIREMENTS. While the Department utilizes the Nebraska Point of Purchase System, providers are responsible for any errors, omissions, or inappropriate billings submitted by themselves or on their behalf by billing agents. The submission of any electronic media claim for reimbursement by the provider or by an approved company or organization on behalf of an approved provider constitutes certification of:

(A) The services or items for which payment is claimed were provided in compliance with the provisions of Title VI of the Civil Rights Act of 1964 and section 504 of the Rehabilitation Act of 1973;

(B) The amounts claimed are in accordance with the Department's regulations, and no additional charge, other than Medicaid copayment, has been or will be claimed;

(C) Each service is documented and the documentation is open to audit by the Department or its agents; and

(D) The charge does not exceed the pharmacy's usual and customary charge to the general public.

History

• Effective 2021-12-26

Chapter 18 Physicians' Services

Neb. Admin. Code tit. 471, ch. 18 Physicians' Services {#sec-471-nac-18 omnilex-key=us-ne-regs-official--title-471--471 NAC 18}

TITLE 471 NEBRASKA MEDICAL ASSISTANCE PROGRAM SERVICES

CHAPTER 18 PHYSICIANS' SERVICES

001. SCOPE AND AUTHORITY. These regulations govern the services provided under Nebraska’s Medicaid program as defined by Nebraska Revised Statute (Neb. Rev. Stat.) §§ 68-901 et seq.

002. DEFINITIONS. The following definitions apply:

002.01 COMPREHENSIVE INTERDISCIPLINARY TREATMENT. The collaboration of medicine, psychology, nutrition science, speech-language therapy, occupational therapy (OT), social work, and other appropriate medical and behavioral disciplines in an integrated program.

002.02 CONSULTING PHYSICIAN. A physician whose services include history taking, examination of the individual, and, in each case, furnishing to the attending physician an opinion regarding diagnosis or treatment. A physician providing clinical laboratory services for individuals of other physicians is not considered a consulting physician.

002.03 EMERGENCY MEDICAL CONDITION. A medical behavior or condition, the onset of which is sudden, manifesting itself by symptoms of sufficient severity such that the absence of immediate medical attention could result in:

(A) Placing the health of the individual or with respect to a pregnant woman, the health of the woman or her unborn child, in serious jeopardy;

(B) Serious impairment to such person's bodily functions; or

(C) Serious dysfunction of any bodily organ or part.

002.04 FEEDING AND SWALLOWING CLINIC. A specialized facility which provides assessment, treatment, ongoing support, and follow-up care for infants and children experiencing feeding difficulties.

002.05 INDEPENDENT CLINICAL LABORATORY. A laboratory which is independent both of an attending or consulting physician's office and of a hospital.

002.06 LABORATORY SERVICES. Microbiological, serological, chemical, hematological, radio bioassay, cytological, immunohematological, or pathological examinations or procedures performed on materials derived from the individual to provide information for the diagnosis or treatment of a disease, or an assessment of the medical condition of the individual.

002.07 NON-PATIENT. A beneficiary who is not directly receiving outpatient services other than diagnostic testing services from the hospital, but the hospital provides all or part of the required clinical diagnostic testing for the beneficiary. The beneficiary is not physically present at the hospital.

002.08 PHYSICIAN CLINIC SERVICES. The professional activity, any drugs and supplies used during that professional encounter, and any other billable service provided in the physician clinic area.

002.09 RADIOLOGY SERVICES. Medically necessary services in which x-rays or rays from radioactive substances are used for diagnostic or therapeutic services and associated medical services necessary for the diagnosis and treatment of an individual.

003. PROVIDER REQUIREMENTS.

003.01 GENERAL PROVIDER REQUIREMENTS. To participate in Nebraska Medicaid, providers of physician services must comply with all applicable provider participation requirements in this title . .

003.02 INDEPENDENT CLINICAL LABORATORIES. An independent clinical laboratory must have a separate provider agreement with Nebraska Medicaid. In addition to the provider agreement, independent clinical laboratories must meet the following requirements:

(A) When state or applicable local law requires licensing of independent clinical laboratories, the laboratory must be licensed under the law; and

(B) The laboratory must meet the health or safety requirements of the United States Secretary of Health and Human Services.

003.03 PROVIDERS OF PORTABLE X-RAY SERVICES. To be approved as a Nebraska Medicaid provider, providers of portable x-ray services must be certified by the Centers for Medicare & Medicaid Services (CMS) . Each provider must submit to Nebraska Medicaid a copy of the appropriate Nebraska Medicaid approved certification form , and remain in compliance with federal regulations . An out-of-state portable x-ray provider must provide Nebraska Medicaid with verification of certification from the Centers for Medicare & Medicaid Services (CMS) . Enrollment as a Nebraska Medicaid provider will be approved or denied based on the certification information received from the Centers for Medicare & Medicaid Services (CMS) .

003.03(A) APPLICABILITY OF HEALTH AND SAFETY STANDARDS. Providers of portable x-ray services, except physicians who provide immediate personal supervision during the administration of diagnostic x-ray services, must comply with all health and safety standards in Nebraska regulations .

003.04 PROVIDERS OF NURSE MIDWIFE SERVICES. A nurse midwife is approved for enrollment in Nebraska Medicaid under a group provider agreement with the physician with whom they have a practice agreement.

003.05 PROVIDERS OF NURSE PRACTITIONER (NP) SERVICES. A nurse practitioner (NP) may provide services within the specialty areas in which they hold certification. They must be enrolled in accordance with the provider agreement.

003.06 FEEDING AND SWALLOWING CLINIC. Along with the completed appropriate Nebraska Medicaid approved provider agreement form , the provider must submit a program overview which demonstrates the following components of service are available within the program:

(A) Interdisciplinary team evaluation which provides information to team members on the beneficiary’s medical status, nutrition and diet status, and also addresses feeding and behavioral concerns. In the process of the interdisciplinary team evaluation, the team must review and consider information from other available resources such as attending or referring physician, nursing facility (NF) , and school;

(B) Assessment by an occupational therapist (OT) of the beneficiary’s tone and posture to determine seating and positioning for feeding and for the video fluoroscopy procedure;

(C)Examination by a speech-language pathologist to assess the beneficiary’s oral structures and clinical swallowing evaluation;

(D)A video fluoroscopy swallow study to determine conditions which are most favorable for a safe, efficient swallow and management of feeding problems;

(E) Assessment of oral motor function and feeding behaviors. Depending on the needs of the beneficiary, some or all of the team members may be involved in this component. This assessment includes presentation of a variety of amounts and types of foods and liquids to the beneficiary to provide additional information used to establish therapeutic intervention;

(F) Conference by team members to review findings, establish priorities, and coordinate treatment and follow-up recommendations; and

(G)Presentation of a plan of care to the beneficiary or family, including instruction, demonstration, and written recommendations for feeding procedures at home and in other environments.

004. SERVICE REQUIREMENTS.

004.01 MEDICAL NECESSITY. Physicians' services may be provided at the physician's office, the beneficiary’s home, a hospital, a long-term care facility (LTC), or elsewhere. Additionally, Nebraska Medicaid covers medically necessary physicians' services are covered within program requirements which are provided:

(A) Within the scope of the practice of medicine or osteopathy as defined by Nebraska state law; and

(B) By, or under the personal supervision of, an individual licensed under Nebraska state law to practice medicine or osteopathy.

004.02 PRIOR AUTHORIZATION. For services provided to beneficiaries enrolled in a managed care program, physicians must follow the prior authorization requirements of the applicable managed care plan. For all other beneficiaries, physicians must request prior authorization from Nebraska Medicaid before providing:

(1) Medical transplants;

(2) Abortions;

(3) Cosmetic and reconstructive surgery;

(4) Bariatric surgery for obesity;

(5) Out-of-state services, except emergency services provided out-of-state;

(6) Established procedures of questionable clinical efficacy ;

(7) Procedures which tend to be redundant when performed in combination with other procedures;

(8) New or recently developed procedures of unproven clinical efficacy and health outcomes value;

(9) Certain drug products;

(10) All attended sleep studies; or

(11)Ventricular assist device.

004.02(A) PRIOR AUTHORIZATION PROCEDURES. Prior to providing the service, a request for prior authorization must be submitted by the physician .

004.02(A)(i) REQUEST FOR ADDITIONAL EVALUATIONS. Additional evaluations may be requested, and the provider must submit them, when Nebraska Medicaid determines the medical history for the request is questionable or when there is not sufficient information to support the requirements for authorization.

004.02(A)(ii) NOTIFICATION PROCESS. Upon determination of approval or denial, written notification is provided, as applicable, to the physician submitting the request, the caseworker, and the medical review organization.

004.02(A)(iii) VERBAL AUTHORIZATION PROCEDURES. A verbal authorization may be issued when circumstances are of an emergency nature or urgent to the extent a delay would place the beneficiary at risk of not receiving medical care. When a verbal authorization is granted, the physician must submit the appropriate Nebraska Medicaid approved form must be submitted within 14 calendar days of the verbal authorization.

004.02(A)(iv) BILLING AND PAYMENT REQUIREMENTS. Claims submitted to Nebraska Medicaid for services requiring prior authorization will not be paid without written or electronic approval. A copy of the approval documentation issued by Nebraska Medicaid is not needed for submission with the claim unless instructed to do so as part of the authorization notification.

004.02(B) PRIOR AUTHORIZATION FOR PRESCRIPTION DRUGS. Authorization is required to be granted prior to payment for certain drugs or items. Prior authorization may pertain to either certain drugs prescribed, or certain physician administered drugs. Physicians wishing to prescribe these drugs must obtain prior authorization by submitting the request to either the Nebraska point of sale contractor, Nebraska Medicaid, or its designee. In cases of medical emergency, the Nebraska point of sale contractor or Nebraska Medicaid will authorize dispensing a 72 hour supply of a covered outpatient prescribed medication .

004.02(C) PRODUCTS REQUIRING PRIOR APPROVAL. Identifiable products requiring approval prior to payment are designated as such on the Nebraska point of sale system or on Nebraska Medicaid’s website. The following prescribed products require prior approval:

(i) Sunscreen;

(ii) Certain modified versions, combinations, double-strength entities, or products considered by Nebraska Medicaid to be equivalent to drug products contained on the state maximum allowable cost or federal upper limit listings in this title ;

(iii) Human growth hormone;

(iv) Erythropoietin;

(v) Drugs or supplies intended for convenience use;

(vi) Drugs used for prevention of infection with respiratory syncytial virus;

(vii) Certain drugs or classes of drugs used for gastrointestinal disorders;

(viii) Certain drugs or classes of drugs used for relief of pain, discomfort associated with musculoskeletal conditions, inflammation, or fever;

(ix) Certain drugs or classes of drugs used for relief of cough or symptoms of the common cold, influenza, or allergic conditions;

(x) Certain drugs or classes of drugs used for both non-covered services or indications and for covered services or indications;

(xi) Certain drugs or classes of drugs on the state maximum allowable cost or federal upper limit listings;

(xii) Certain drugs or classes of drugs upon initial availability or marketing or when Nebraska Medicaid coverage begins;

(xiii) Certain drugs or classes of drugs used for tobacco cessation; and

(xiv) Certain drugs or classes of drugs determined by the Pharmaceutical and Therapeutics Committee to not be placed onto the preferred drug list (PDL).

004.02(D) PRIOR AUTHORIZATION FOR PHYSICIAN ADMINISTERED DRUGS. The following drugs administered in the clinical setting require prior authorization:

(i) Any drug used for the prevention of respiratory syncytial virus infections;

(ii) Certain drugs used for the treatment of multiple sclerosis;

(iii) Enzyme replacement therapy (ERT) or lysomal storage disorders;

(iv) Immunoglobulin E (IgE) blocker therapies for asthma;

(v) Certain drugs or classes of drugs upon initial availability or marketing or when Nebraska Medicaid coverage begins; and

(vi) Drugs not covered under the Nebraska Medicaid Early and Periodic Screening Diagnostic, and Treatment (EPSDT) program.

004.02(E) PRIOR AUTHORIZATION FOR BARIATRIC SURGERY. Prior authorization requests must include documentation of each of the three following subsections:

(i) Medical diagnosis;

(ii) Body mass index (BMI) 35 or greater with at least one of the following co-morbidities:

(1) Type 2 Diabetes Mellitus including recent laboratory results and current medications;

(2) Medically refrectory hypertension, including current medications, antihypertensive, and blood pressure readings;

(3) Hyperlipidemia, including recent lab results and current medications;

(4) Cardiovascular disease;

(5)Coronary artery disease (CAD), congestive heart failure (CHF), dyslipidemia, including recent laboratory results and current medications;

(6)Obstructive sleep apnea, including sleep study results and treatment;

(7) Obesity-hypoventilation syndromes;

(8)Gastroesophageal reflux disease (GERD), including test results and current medications being used to manage the symptoms;

(9)Osteoarthritis, including information about the beneficiary’s ability to ambulate, assistive devices used, and any medications being ; or

(10)Idiopathic intracranial hypertension (Pseudotumor cerebri); and

(iii) Preoperative evaluation within six months of the scheduled surgery that includes:

(1) Nutritional consultation that includes:

(a) Diet and physical activity history and patterns of previous weight loss and regain;

(b) Counseling on steps to modify current problem eating behaviors;

(c) Counseling on postoperative dietary modifications; and

(d) Determination of the beneficiary’s motivation to comply with dietary modifications to reduce the risk of postoperative complications.

(2) Psychiatry or psychology consultation that includes:

(a) Evaluation of the beneficiary to determine readiness for surgery and lifestyle change;

(b) Assessment for major mental health disorders, psychosocial functioning, alcohol and substance use disorder, and maladaptive eating behaviors; and

(c) Adequate treatment as needed, to maximize successful postoperative outcomes.

(3) Medical clearance that includes:

(a) Evaluation of cardiac and pulmonary risk;

(b) Nutritional, hormonal, and other lab parameters as indicated;

(c) No history of tobacco use, or tobacco cessation has been attempted prior to surgery; and

(d) Beneficiary’s understanding of surgical risk, postoperative compliance, and follow-up.

004.02(F) PRIOR AUTHORIZATION FOR TRANSPLANT SERVICES. Prior authorization is required of all transplant services. Physicians must request and receive prior authorization before performing any transplant service or related donor service. The request for authorization must include, at a minimum:

(i) The beneficiary’s name, Nebraska Medicaid identification number, and date of birth;

(ii) Diagnosis, pertinent past medical history and treatment, prognosis with and without the transplant, and the procedures for which the authorization is requested;

(iii) Name of the hospital, city, and state where the services will be performed, including the National Provider Identifier (NPI) of the provider;

(1) All providers must be enrolled with Nebraska Medicaid before services are performed;

(iv) Name of the physician who will perform the surgery if other than the physician requesting authorization; and

(v) A physician specializing in the specific transplantation must also supply the following:

(1) The screening criteria used in determining if the beneficiary is an appropriate candidate for a liver, heart, allogenic, intestinal, or multi-visceral transplant;

(2) The results of the screening for the beneficiary ; and

(3) A written statement by the physician:

(a) Recommending the transplant;

(b) Certifying and explaining why the transplant is medically necessary as the only clinical, practical, and viable alternative to prolong the beneficiary’s life in a meaningful, qualitative way and at a reasonable level of functioning;

(c) Including a psycho-social evaluation for solid organ transplants; and

(d)For heart, lung, liver, stem cell, bone marrow, allogeneic, or intestinal or multi-visceral transplants, a second physician specializing in the specified transplant must also supply the above required information.

004.02(G) PRIOR AUTHORIZATION FOR COSMETIC AND RECONSTRUCTIVE SURGERY. In addition to the prior authorization requirements included in this chapter, the surgeon who will be performing the cosmetic or reconstructive surgery must submit a request to Nebraska Medicaid. This request must include the following:

(i) An overview of the medical condition and medical history of any conditions caused or aggravated by the condition;

(ii) Photographs of the involved area when appropriate to the request;

(iii) A description of the procedure being requested, including any plan to perform the procedure when it requires a staged process; and

(iv) When appropriate, additional information regarding the medical history may be submitted by the beneficiary’s primary care physician.

004.02(H) PRIOR AUTHORIZATION OF RADIOLOGY PROCEDURES. All non-emergency outpatient computerized tomography (CT) scans, magnetic resonance angiogram (MRA) scans, magnetic resonance imaging (MRI) scans, magnetic resonance spectroscopy (MRS) scans, nuclear medicine cardiology scans, positron emission tomography (PET) scans, and single photon emission computed tomography (SPECT) will require prior authorization. These prior authorization requirements apply for all Nebraska Medicaid beneficiaries enrolled in fee-for-service programs and must be completed prior to the scan being performed. These requirements do not apply to these scans when performed during an inpatient hospitalization or as an emergency through the hospital’s emergency department.

004.02(I) PRIOR AUTHORIZATION FOR COMPREHENSIVE INTERDISCIPLINARY TREATMENT FOR A SEVERE FEEDING DISORDER. Prior authorization is required for all services before the services are provided. The requesting physician must submit a request to Nebraska Medicaid including the following information or explanation as appropriate to the case:

(i) A referral from the primary care physician which includes current appropriate medical evaluations or treatment plans;

(ii) Medical records for the last year which include height and weight measurements; and

(iii) Any records from feeding and swallowing clinic evaluations and other therapeutic interventions which have occurred.

004.03 DEFINITIONS AND TERMS OF COMMONALITY. The Current Procedural Terminology (CPT) contains terms and phrases common to the practice of medicine. Claims for physicians' services must be coded according to the definitions in the Current Procedural Terminology (CPT). At the request of Nebraska Medicaid, the provider must submit copies of the beneficiary’s medical records to document the level of care provided. If the requested documentation is not provided or is insufficient in contents, payment may be withheld or recouped.

005. SERVICE-SPECIFIC REQUIREMENTS.

005.01 FACILITY-BASED PHYSICIAN CLINICS. Physician clinic services provided in a hospital location or a facility under the hospital’s licensure are considered to be a physician service, not an outpatient hospital service.

(A) Facility or hospital-based non-emergency physician clinics are not recognized for billing, reimbursement, or cost reporting purposes except for itinerant physicians as defined in this chapter .

(B) Services and supplies incident to a physician’s professional service provided during a specific encounter are covered and reimbursed as physician clinic services if the service or supply is:

(i) Of the type commonly furnished in a physician’s office;

(ii) Furnished as an incidental, although integral, part of the physician professional service; and

(iii) Furnished under the direct personal supervision of the physician.

005.02 HOSPITAL ADMISSION DIAGNOSTIC PROCEDURES. In addition to the previously defined medical necessity requirements, the following will be considered to determine whether a diagnostic procedure performed as part of the admitting procedure to a hospital is reasonable and medically necessary:

(A) The test is specifically ordered by the attending physician, or a hospital staff physician responsible for the beneficiary when there is no attending physician;

(B) The test is medically necessary for the diagnosis or treatment of the beneficiary’s condition; and

(C) The test does not unnecessarily duplicate:

(i) The same test performed on an outpatient basis before admission; or

(ii) The same test performed in connection with a separate, but recent, hospital admission.

005.03 MINOR SURGICAL PROCEDURES. Reimbursement for excision of lesions of the skin or subcutaneous tissues include all services and supplies necessary to provide the service. Additional reimbursement is not made for suture removal to the physician who performed the initial services, or to a hospital. If the sutures are removed by a non-hospital-based physician who is not the physician who provided the initial service, separate payment may be approved for the suture removal.

005.04 TREATMENT FOR OBESITY. There will be no payment made for services provided when the sole diagnosis is obesity. While obesity is not itself considered an illness, there are conditions which can be caused by or aggravated by obesity. Treatment for obesity may be covered when the services are an integral and necessary part of a course of treatment or treatment for covered co-morbidities.

005.04(A) INTESTINAL BYPASS SURGERY. Intestinal bypass surgery for treatment of obesity is not covered.

005.04(B) BARIATRIC SURGERY FOR OBESITY. Bariatric surgery for beneficiaries with obesity may be covered when the surgery is medically appropriate for the beneficiary, and is performed to correct an illness which either causes obesity or was aggravated by obesity. Proof of accreditation must be submitted with each prior approval request. This procedure must be performed at a facility that is one of the following:

(1) Accredited by the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP); or

(2) A children’s hospital that has a comprehensive multidisciplinary bariatric surgery program and provides access to an experienced surgeon who employs a team that is capable of long-term follow-up of the metabolic and psychosocial needs of the client and family.

005.05 COSMETIC AND RECONSTRUCTIVE SURGERY. Cosmetic and reconstructive surgical procedures and medical services, are covered when medically necessary, for the purpose of correcting the following conditions:

(1) Limitations in movement of a body part caused by trauma or congenital conditions;

(2) Disfiguring or painful scars in areas which are visible;

(3) Congenital birth anomalies that result in functional impairment or are severely disfiguring;

(4) Post-mastectomy breast reconstruction; and

(5) Other procedures determined to be restorative or necessary to correct a medical condition.

005.05(A) EXCEPTIONS. To determine the medical necessity of the condition, prior authorization is required for cosmetic and reconstructive surgical procedures except for the following conditions:

(i) Cleft lip and cleft palate;

(ii) Post-mastectomy breast reconstruction;

(iii) Congenital hemangiomas of the face; and

(iv) Nevus removals.

005.06 STERILIZATIONS.

005.06(A) COVERAGE RESTRICTIONS. Sterilization of beneficiaries is not covered when the beneficiary is:

(i) Under the age of 21 on the date the beneficiary signs the appropriate Nebraska Medicaid approved consent form ; or

(ii) Legally incapable of consenting to sterilization.

005.06(B) COVERAGE CONDITIONS. Sterilizations are only covered when:

(i) The sterilization is performed because the beneficiary receiving the service made a voluntary request for services;

(ii) The beneficiary is advised at the outset and before the request or receipt of their consent to the sterilization that benefits provided by programs or projects will not be withdrawn or withheld because of a decision not to be sterilized;

(iii) Beneficiaries whose primary language is other than English are provided with the required elements for informed consent in their primary language; and

(iv) Suitable arrangements are made to communicate the required elements of informed consent to a beneficiary who is blind, deaf, hard of hearing, or is otherwise disabled .

005.06(C) PROCEDURE FOR OBTAINING SERVICES. Non-therapeutic sterilizations are covered by Nebraska Medicaid only when:

(i) Legally effective informed consent is obtained on the appropriate Nebraska Medicaid approved consent form from the beneficiary on whom the sterilization is to be performed. The surgeon must submit a completed form to Nebraska Medicaid before payment of claims can be considered; and

(ii) The sterilization is performed at least 30 days following the date informed consent was given. To calculate this time period, day one is the first day following the date on which the form is signed by the beneficiary. Day 31 in this period is the first day on which the procedure may be covered. The consent is effective for 180 days from the beneficiary’s signature.

005.06(D) EXCEPTION. A beneficiary may consent to be sterilized at the time of a premature delivery or emergency abdominal surgery if at least 72 hours have passed since the beneficiary signed the informed consent for the sterilization. For a premature delivery, the beneficiary must have signed the informed consent at least 72 hours before the surgery is performed and at least 30 days before the expected date of delivery. The expected delivery date must be entered on the appropriate Nebraska Medicaid approved consent form .

005.06(E) INFORMED CONSENT. Informed consent means the voluntary, knowing assent of the beneficiary who is to be sterilized after they have been given the following information and completed the appropriate Nebraska Medicaid consent form :

(i) A clear explanation of the procedures to be followed;

(ii) A full description of the discomforts and risks which may follow the procedure, including an explanation of the type and possible effects of any anesthetic to be used;

(iii) A description of the benefits to be expected;

(iv) Counseling concerning appropriate alternative methods, and the effect and impact of the proposed sterilization including the fact that it must be considered an irreversible procedure;

(v) An offer to answer any questions concerning the procedures;

(vi) An instruction that the beneficiary is free to withhold or withdraw consent to the sterilization at any time before the sterilization without prejudicing future care and without loss of other project or program benefits to which the beneficiary might otherwise be entitled;

(vii) Advice that the sterilization will not be performed for at least 30 days, except under the circumstances previously specified; and

(viii) The beneficiary to be sterilized must be permitted to have a witness of his or her choice present when informed consent was obtained.

005.06(F) STERILIZATION CONSENT FORMS. The surgeon will submit a completed Nebraska Medicaid approved consent form to Nebraska Medicaid before payment of claims can be considered. The consent form must be signed and dated by the beneficiary to be sterilized, the person obtaining consent, the physician who will perform the procedure, and the interpreter if one was provided.

005.07 HYSTERECTOMIES. Medically necessary hysterectomies are covered if the following conditions have been met, and a completed form is submitted to Nebraska Medicaid by the surgeon before claims for the hysterectomy can be considered for payment:

(1) The provider who secured authorization to perform the hysterectomy has informed the woman and her representative, if any, orally and in writing, that the hysterectomy will make the woman permanently incapable of reproducing; and

(2) The woman or her representative, if any, has signed the appropriate Nebraska Medicaid approved consent form , acknowledging receipt of the above information.

005.07(A) EXCEPTION. Informed consent is not required in the following situations and a copy of the surgeon’s certification of the following exceptions must be submitted to Nebraska Medicaid prior to consideration of payment for claims associated with the hysterectomy:

(i) The woman was sterile before the hysterectomy, and the physician performing the hysterectomy certifies in writing that the woman was sterile before the hysterectomy and states the cause of the sterility;

(ii) Post-menopausal women are considered to be sterile. All claims related to the procedure must indicate the woman is post-menopausal; or

(iii) The woman requires a hysterectomy due to a life-threatening emergency situation and the physician determines informed consent is not possible. The physician performing the hysterectomy must certify, in writing, that the hysterectomy was performed under a life-threatening emergency situation in which informed consent was not possible. The physician must also include a certification of the emergency.

005.07(B) NON-COVERED HYSTERECTOMIES. Hysterectomies are not covered if they are performed solely to make the woman sterile or, if there was more than one purpose for the procedure, it would not have been performed except to make the woman sterile.

005.08 INFERTILITY. Coverage for infertility is limited to diagnosis and treatment of medical conditions when infertility is a symptom of a suspected medical condition. Reimbursement or coverage is not available when the sole purpose of the service is achieving a pregnancy.

005.09 ALCOHOL AND CHEMICAL DETOXIFICATION. Alcohol and chemical detoxification is limited to medically necessary treatment, subject to Nebraska Medicaid utilization review.

005.10 OSTEOGENIC STIMULATION. Electrical stimulation to augment bone repair, also known as osteogenic stimulation, can be performed either invasively or noninvasively.

005.10(A) INVASIVE OSTEOGENIC STIMULATION. The use of the invasive device is covered only for non-union of long bone fractures. Non-union is considered to exist only after six months or more have elapsed without the fracture healing.

005.10(B) NON-INVASIVE OSTEOGENIC STIMULATION. The use of the non-invasive device is covered only for non-union of long bone fractures, failed fusion, or congenital pseudoarthroses.

005.11 BIOFEEDBACK THERAPY. Biofeedback therapy is covered only when it is reasonable and necessary for the beneficiary for muscle re-education of specific muscle groups or for treating pathological muscle abnormalities of spasticity, incapacitating muscle spasm, or weakness, and more conventional treatments have not been successful. This therapy is not covered for treatment of ordinary muscle tension states, for psychosomatic conditions, or for psychiatric conditions.

005.12 SLEEP DISORDER CLINICS. Sleep disorder clinics are facilities in which certain conditions are diagnosed through the study of sleep. Diagnostic and therapeutic services of a sleep disorder clinic are covered under the following conditions.

005.12(A) DIAGNOSTIC SERVICES. Diagnostic testing which is duplicative of previous testing done by the attending physician to the extent the results are still pertinent is not covered. Beneficiaries who undergo diagnostic testing are not considered inpatients; however, if required as part of the diagnostic testing, the overnight stay is considered an integral part of these tests. All reasonable and necessary diagnostic tests given for narcolepsy and sleep apnea are covered when the following criteria are met:

(i) The clinic is affiliated with a hospital;

(ii) The beneficiary is referred to the sleep disorder clinic by a physician. The clinic must maintain a record of the attending physician’s orders with the physician’s signature; and

(iii) The need for diagnostic testing is confirmed by medical evidence, such as physician examinations and laboratory tests.

005.12(B) THERAPEUTIC SERVICES. Therapeutic services may be covered provided they are standard and accepted services and are reasonable and medically necessary for the beneficiary . Sleep disorder clinics must provide therapeutic services in the hospital outpatient setting. Therapeutic services may be provided for:

(i) Insomnia which is not associated with psychiatric disorders;

(ii) Nocturnal myoclonus, also known as muscle jerks;

(iii) Sleep apnea;

(iv) Drug dependency;

(v) Shift work and schedule disturbances;

(vi) Restless leg syndrome;

(vii) Hypersomnia, also known as excessive daytime sleepiness;

(viii) Somnambulism;

(ix) Night terrors or dream anxiety attacks;

(x) Enuresis; and

(xi) Bruxism.

005.13 SURGERY. Surgical procedures are covered, including 14 days of post-operative care. When multiple procedures are performed at the same time, the primary procedure and any secondary procedures are covered and reimbursed in accordance with this chapter. Incidental procedures through the same incision are not considered separate secondary procedures for reimbursement.

005.13(A) ASSISTANT SURGEON. The services of an assistant surgeon are covered when reasonable and medically necessary.

005.13(B) SECOND SURGICAL OPINION. Beneficiaries who desire a second physician's opinion concerning proposed surgery have coverage to receive a second physician’s opinion.

005.13(C) SERVICES PERFORMED IN AN AMBULATORY SURGICAL CENTER (ASC). In addition to the federally identified ambulatory surgical center (ASC) services, the certain state-defined services provided in an ambulatory surgical center (ASC) are covered.

005.14 HOSPITAL VISITS. Only one visit per day by the same physician, or physicians of the same specialty from the same group practice is covered, unless the primary physician states on the appropriate Nebraska Medicaid approved claim form , or electronically, more than one visit was necessary because of serious illness or change in condition, and approval is given by Nebraska Medicaid .

005.14(A) SURVEILLANCE AND UTILIZATION REVIEW CRITERIA. A medical review organization may be utilized to review inpatient hospital services. The physician must comply with all medical review requirements. For hospitalizations not subject to medical review, Nebraska Medicaid’s in-house utilization review will prevail. If a hospitalization is denied or reduced based on utilization review, the physician's claim may also be denied or reduced accordingly.

005.15 EMERGENCY ROOM SERVICES. At least one of the following conditions must be met before payment is approved for use of an emergency room:

(1) The beneficiary is evaluated or treated for an emergency medical condition. The facility must review emergency room services and determine whether services provided in the emergency room constitute an emergency and bill accordingly;

(2) If the beneficiary’s evaluation or treatment in the emergency room results in an approved inpatient hospital admission, the emergency room charges must be displayed on the inpatient claim as ancillary charges and included in the inpatient per diem; or

(3) The beneficiary is referred by his or her physician for treatment in an emergency room.

005.15(A) NON-EMERGENT SERVICES. When the facility or Nebraska Medicaid determines services are non-emergent, the room fee for non-emergent services provided in an emergency room will be disallowed to 50 percent of what would otherwise be allowed. When these conditions are met, the physician's fee will be disallowed to the rate of a comparable office service.

005.16 PRENATAL, DELIVERY, AND POSTPARTUM CARE. Physicians' services related to pregnancy are covered. Routine prenatal care, delivery, six weeks' postpartum care, and routine urinalysis are reimbursed as a package service. The physician may claim, as independent procedures, those laboratory and medical services which are not related to the pregnancy, or which are not included as part of the global fee package service. Postpartum services are covered through the applicable postpartum period for beneficiaries who were eligible for, applied for, and received medical assistance on the day the pregnancy ends. After the infant is delivered, the infant is treated as a separate patient for reimbursement purposes.

005.16(A) CERTIFIED NURSE MIDWIFE (CNM) SERVICES. Certified nurse midwife (CNM) services which are medically necessary and provided in accordance with the practice as defined by law are covered. Routine office visits to a physician are not covered when a certified nurse midwife (CNM) is providing complete obstetrical care, unless documentation of medical necessity for the physician's office visit is submitted. Prenatal care, delivery, and postpartum care is covered as a global service. Auxiliary services, such as prenatal classes and home visits, are not paid separately.

005.17 PRENATAL PLUS PROGRAM (PPP). Prenatal Plus Program (PPP) services are covered when a Nebraska Medicaid-eligible pregnant mother has been determined by their prenatal health care provider to be at risk of having a negative maternal or infant health outcome.

005.17(A) NUTRITION COUNSELING. Nutrition counseling is provided by the prenatal clinician as part of routine prenatal care and is not reimbursed separately. If the beneficiary is referred to a licensed medical nutrition therapist (LMNT), the Prenatal Plus Program (PPP) covers up to six sessions of nutrition counseling. These sessions can be provided in-person or via audiovisual telehealth.

005.17(B) PSYCHOSOCIAL COUNSELING AND SUPPORT. If the beneficiary has mental health or substance use disorder needs, the beneficiary can be referred to a Nebraska Medicaid enrolled licensed independent practitioner to receive psychosocial counseling and support services.

005.17(C) BREASTFEEDING SUPPORT. Breastfeeding education is provided by the prenatal clinician as part of routine prenatal care and is not reimbursed separately. If the beneficiary is referred for a breastfeeding instruction session, it must be provided by a licensed medical nutrition therapist (LMNT) or an international board-certified lactation consultant (IBCLC). The session can be provided in-person or via audiovisual telehealth and in an individual or group setting. Beneficiaries are limited to one session per pregnancy.

005.17(D) GENERAL PATIENT EDUCATION AND HEALTH PROMOTION. The prenatal clinician provides beneficiary education as part of routine care and is not reimbursed separately. The beneficiary can be referred to an appropriate resource to receive the education.

005.17(E) TARGETED CASE MANAGEMENT (TCM). Targeted case management (TCM) services are provided to assist beneficiaries in gaining access to needed services. This includes a comprehensive assessment, periodic reassessment of the beneficiary’s needs, development and revision of a specific care plan that specifies goals and actions, referral to help the beneficiary obtain needed services, and monitoring and follow-up activities to ensure the care plan is implemented. Targeted case management (TCM) can be provided in-person, via audiovisual telehealth, or by telephone. A minimum of one targeted case management (TCM) interaction per month is required for reimbursement.

005.17(F) PRENATAL PLUS PROGRAM (PPP) DOCUMENTATION. All documentation for the Prenatal Plus Program (PPP) must be completed and maintained in the beneficiary’s medical records. All activities performed must be documented on the appropriate Nebraska Medicaid approved checklist form or directly in the beneficiary’s medical record. The documents must be made available to Nebraska Medicaid upon request.

005.18 ANTIGEN THERAPY. Payment for a reasonable supply of antigens which have been prepared for and administered to a particular beneficiary even though the antigens have not been administered to the beneficiary by the same physician who prepared them may be made if:

(A) The antigens are prepared by a physician who is a doctor of medicine or osteopathy; and

(B) The physician who prepared the antigens has examined the beneficiary and determined a plan of treatment and a dosage regimen.

005.19 DIALYSIS. Nebraska Medicaid follows Medicare’s requirements for coverage of dialysis are followed.

005.20 FAMILY PLANNING SERVICES. Family planning services, including consultation and procedures, provided upon the request of the beneficiary are covered. The beneficiary must be allowed to exercise freedom of choice in choosing a method of family planning. Family planning services performed in family planning clinics must be prescribed by a physician, and must be and furnished, directed, or supervised by a physician or registered nurse (RN). Family planning services must:

(A) Be provided without regard to age, sex, or marital status. There can be no discrimination in the provision of services and information; and

(B) Include available services and information relating to medical, social, and educational services and information, including initial physical examination and health history, annual and follow-up visits, laboratory services, prescribing and supplying contraceptive supplies and devices, counseling services, and prescribing medication for specific treatment.

005.21 FRACTURE CARE. Coverage of initial fracture care includes the application and removal of the first cast or traction device.

005.22 COVERED DRUGS. Outpatient prescription drugs are covered in accordance with federal law including legend drugs, compounded prescriptions, and over the counter (OTC) drugs indicated as covered on the Nebraska point of sale system or listed on Nebraska Medicaid’s website.

005.22(A) PREFERRED DRUG LIST (PDL). Prescribed drugs which are found to be therapeutically equivalent to or superior to other drugs within a therapeutic class and whose net cost is equal to or less than other drugs within a therapeutic class after consideration of applicable rebates or discounts negotiated by the Department or its designated contractor will be included on the preferred drug list (PDL) . Medications designated as non-preferred on the preferred drug list (PDL) will be subject to prior authorization.

005.22(B) COMPOUNDED PRESCRIPTIONS. Any mixture of drugs which results in a commercially available over the counter (OTC) preparation is not considered a compounded prescription.

005.22(C) OVER THE COUNTER (OTC) DRUGS. Only over the counter (OTC) drugs indicated as covered on the Nebraska point of sale system or listed on Nebraska Medicaid’s website are covered. Over the counter (OTC) drugs must be prescribed by a licensed practitioner.

005.22(D) BRAND NECESSARY CERTIFICATION OF DRUGS. The Federal Upper Limit (FUL) or State Maximum Allowable Cost (SMAC) limitations will not apply in any case where the prescribing physician certifies a specific brand is medically necessary. In these cases, the usual and customary charge, or National Average Drug Acquisition Cost (NADAC) will be the maximum allowable cost. The prescriber must certify on the appropriate Nebraska Medicaid approved physician’s certification form that a brand name is medically necessary.

005.22(E) INJECTIONS. Injections administered by the physician in the clinical setting are not reimbursable through the outpatient drug program. Medications used in this manner are considered medical services and are to be purchased, used, and billed to Nebraska Medicaid by the physician or clinic.

005.23 PRACTITIONER-ADMINISTERED MEDICATIONS. Practitioner administered injectable medications will be reimbursed at average sales prices (ASP) plus 6%, consistent with the Medicare Drug Fee Schedule. Injectable medications not available on the Medicare Drug Fee Schedule will be reimbursed at whole acquisition cost (WAC) plus 6.8%, or manual pricing based on the provider’s actual acquisition cost. Practitioner administered injectable medications, including specialty drugs, purchased through the Federal Public Health Service’s 340B Drug Pricing Program will be reimbursed at the 340B actual acquisition cost and no more than the 340B ceiling price. When billing for medications administered during the course of a clinic visit, the physician must use the appropriate Health Care Common Procedure Coding System (HCPCS) procedure code for the medication, the correct number of units per the Health Care Common Procedure Coding System (HCPCS) description, the National Drug Code (NDC) of the drug administered, the National Drug Code (NDC) unit of measure, and the number of National Drug Code (NDC) units. A Current Procedural Terminology (CPT) code for the administration must also be submitted. When billing for medication which does not have a specific level I or II code, the physician must use a miscellaneous Health Care Common Procedure Coding System (HCPCS) code with the name and National Drug Code (NDC) number identifying the drug and include the dosage given. If this information is not with the claim, the claim may be returned to the physician for completion or the claim may be paid at the lowest dosage manufactured for the specific drug. Payment for service is as described in this chapter.

005.23(A) ALLERGY INJECTIONS. Allergy injections must be administered under the supervision of a physician who can recognize early symptoms and signs of anaphylaxis and administer emergency medications where necessary. Allergy injections should be administered only in facilities equipped to treat anaphylaxis.

005.23(B) VITAMIN B-12 INJECTIONS. Vitamin B-12 injections are covered as specific or effective treatment for:

(i) Gastrectomy;

(ii) Idiopathic steatorrhea;

(iii) Ileostomy;

(iv) Internal cancers;

(v) Macrocytic anemia;

(vi) Megaloblastic anemia;

(vii) During or after radiation therapy;

(viii) Certain neuropathies;

(ix) Pernicious anemia; and

(x) Post-surgical and mechanical disorders.

005.24 CHEMOTHERAPY. Chemotherapy agents may be covered if all of the following criteria are met:

(i) The agents are reasonable and medically necessary;

(ii) The drug is approved by the Federal Drug Administration (FDA); and

(iii) Nationally accepted oncology clinical guidelines have listings with the specific International Classifications of Diseases (ICD-10) diagnosis that is being treated for the drug or agent.

005.25 IMMUNIZATIONS. Routine immunizations are covered for children, adolescents, and adults that are medically necessary according to the Advisory Committee on Immunization Practices’ requirements that are effective the date the service is provided. Immunizations are available to children and adolescents from birth through age 20 under the Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) program. Vaccines for those beneficiaries age 18 and younger are available through the Vaccine for Children (VFC) program. When the vaccine is available through the Vaccine for Children (VFC) program and is a physician’s private stock vaccine, it will not be reimbursed.

005.26 LABORATORY SERVICES. Laboratory services may be provided in a physician’s or group of physicians’ private office, in a licensed and certified independent clinical laboratory, or in a hospital whose certification covers services performed in the laboratory.

005.26(A) PHYSICIAN’S OFFICE LABORATORY. A laboratory which a physician or a group of physicians maintains for performing diagnostic tests in connection with their own or the group practice is not considered an independent clinical laboratory.

005.26(B) LICENSED AND CERTIFIED INDEPENDENT CLINICAL LABORATORIES. A laboratory which is operated by or under the supervision of a hospital or the organized medical staff of the hospital which does not meet the definition of a hospital is considered to be an independent laboratory. A laboratory serving hospital inpatients and outpatients and operated on the premises of a hospital which meets the definition of a hospital is presumed to be subject to the supervision of the hospital or its organized medical staff and is not classified as an independent clinical laboratory. The hospital's certification covers the services performed in this laboratory. Laboratory tests which have been referred by one independent laboratory to another may be covered. Handling services for tests referred to a second laboratory are not covered. A specimen collection fee is not covered for samples where the cost of collecting the specimen is minimal, such as a throat culture, a routine capillary puncture, or a pap smear.

005.27 RADIOLOGY SERVICES. Claims for radiology procedures must have at least a provisional diagnosis or statement of symptoms. Claims with a diagnosis of routine radiology are not accepted. These services may be provided in a physician’s or group of physicians’ private office or a hospital whose certification covers the radiological services provided.

005.27(A) PHYSICIAN’S PRIVATE OFFICE. The total radiology procedure is covered when both the technical and professional components of medically necessary radiological procedures are performed in a physician's private office.

005.27(B) HOSPITAL RADIOLOGY SERVICES. Medically necessary radiological services that are referenced in this title are covered when ordered by a physician and performed in a hospital. The ordering physician is not reimbursed for interpreting radiology procedures performed outside their office.

005.27(C) MAMMOGRAMS. Mammograms are covered when provided based on a medically necessary diagnosis. In the absence of a diagnosis, mammograms provided according to the American Cancer Society's periodicity schedule are also covered.

005.27(D) ULTRASOUND DIAGNOSTIC PROCEDURES. Ultrasound diagnostic procedures listed by Medicare under Category I are covered. Claims for these procedures may be reviewed to ensure the techniques are medically appropriate and the general indications of Medicare's categories are met. Claims for uses other than those listed under Medicare's Category I will be reviewed before payment. Ultrasound procedures listed by Medicare under Category II are not covered.

005.27(E) COMPUTERIZED TOMOGRAPHY (CT) SCANS. Diagnostic examinations of the head and of certain other parts of the body performed by computerized tomography (CT) scanners are covered when medical and scientific literature and opinion support the use of a scan for the condition, the scan is reasonable and necessary for the beneficiary , and the scan is performed on a model of computerized tomography (CT) equipment which meets Medicare’s criteria for coverage.

005.27(E)(i) REASONABLE AND NECESSARY. To be determined reasonable and necessary for the beneficiary , the use of the computerized tomography (CT) scan must be medically appropriate considering the beneficiary’s symptoms and preliminary diagnosis. It may be determined the use of a computerized tomography (CT) scan as the initial diagnostic test was not reasonable and necessary because it was not supported by the beneficiary’s symptoms and complaints stated on the claim form or electronic format. Claims for computerized tomography (CT) scans are reviewed for evidence of abuse, such as the absence of reasonable indications for the scans, an excessive number of scans, or unnecessarily expensive types of scans.

005.27(F) PORTABLE X-RAY SERVICES. Diagnostic x-ray services provided by a certified portable x-ray provider are covered when provided in a place of residence used as the beneficiary’s home and in nonparticipating institutions. These services must be performed under the prescription of a physician and conditions relating to health and safety must be met. Diagnostic portable x-ray services are also covered when provided in participating nursing facilities (NF) under circumstances in which they cannot be covered as nursing facility (NF) services, such as those services not provided by the participating institution either directly or under arrangements which allow the institution to bill for the services. If portable x-ray services are provided in a participating hospital under arrangement, the hospital will bill for the service.

005.27(F)(i) COVERED PORTABLE X-RAY SERVICES. The following portable x-ray services are covered:

(1) Skeletal films involving arms, legs, pelvis, vertebral column, and skull;

(2) Chest films which do not involve the use of contrast media and are not used for routine screening or physical examinations; and

(3) Abdominal films which do not involve the use of contrast media.

005.27(F)(ii) ELECTROCARDIOGRAMS. The taking of an electrocardiogram tracing by an approved provider of portable x-ray services may be covered as an other diagnostic test.

005.28 HOSPITAL DIAGNOSTIC AND THERAPEUTIC SERVICES. Hospital diagnostic and therapeutic services are procedures performed to determine the nature and severity of an illness or injury, or procedures used to treat disease or disorders. Hospital diagnostic and therapeutic services include both inpatient and outpatient hospital services. Hospital diagnostic and therapeutic services are comprised of two distinct elements: the professional component and the technical component. Other services may be designated as having professional and technical components when the services are identified.

005.28(A) PROFESSIONAL COMPONENT. The professional component of hospital diagnostic and therapeutic services includes those physician's services directly related to the medical care of the beneficiary . A physician includes not only a specialist but also a physician who normally performs or supervises these services for all inpatients and outpatients of a hospital, even though the physician does not otherwise specialize in this field.

005.28(A)(i) COVERAGE CONDITIONS. To be covered as a professional component, the physician’s services must:

(1) Be personally provided to a beneficiary by a physician;

(2) Contribute directly to the diagnosis or treatment of a beneficiary;

(3) Ordinarily require performance by a physician;

(4) Be medically necessary; and

(5) For anesthesiology, laboratory, or radiology services, meet the requirements previously set forth in this chapter.

005.28(B) TECHNICAL COMPONENT. The technical component of hospital diagnostic and therapeutic services is comprised of two distinct elements:

(i) Physicians’ professional services not directly related to the medical care of the beneficiary; and

(ii) Hospital services.

005.28(C) PRE-ADMISSION TESTING. Pre-admission testing performed in a physician’s office which is performed solely to satisfy hospital pre-admission requirements is not covered.

005.287(D) RADIOLOGY AND PATHOLOGY. Medically necessary radiological and pathological services provided to inpatients and outpatients are covered. Only those services which are directly related to the beneficiary’s diagnosis are covered.

005.287(D)(i) OUTPATIENT DIAGNOSTIC SERVICES PROVIDED BY ARRANGEMENT. Medically necessary diagnostic services provided to an outpatient by arrangement are covered.

005.287(D)(ii) LABORATORY AND PATHOLOGY.

005.287(D)(ii)(1) PROFESSIONAL COMPONENT. The professional component of laboratory services provided by a physician to a beneficiary is covered as a physician’s service only if the services meet the conditions of coverage previously outlined and are:

(a) Anatomical pathology services; or

(b) Consultative pathology services, which must:

(i) Be requested by the beneficiary’s attending physician;

(ii) Relate to a test result which lies outside the clinically significant normal or expected range in view of the beneficiary’s condition;

(iii) Result in a written narrative report included in the beneficiary’s medical record; and

(iv) Require the exercise of medical judgment by the consulting physician; or

(v) Be performed by a physician in personal administration of test devices, isotopes, or other materials to a beneficiary.

005.287(D)(ii)(2) TECHNICAL COMPONENT. Clinical laboratory services do not require performance by a physician and are considered the technical component. There is no professional component for these services.

005.28(D)(ii)(3) ANATOMICAL PATHOLOGY SERVICES. Anatomical pathology services are services which ordinarily require a physician's interpretation. If these services are provided to hospital inpatients or outpatients, the professional and technical components must be separately identified for billing and payment.

005.28(D)(ii)(4) CLINICAL LABORATORY CONSULTATION. A physician clinical laboratory consultation is covered if the consultation:

(a) Is requested by the beneficiary’s attending physician;

(b) Relates to a test result which lies outside the clinically significant normal or expected range for the beneficiary’s condition;

(c) Results in a written narrative report which is included in the beneficiary’s record; and

(d) Requires the exercise of medical judgement by the consulting physician.

005.28(D)(iii) RADIOLOGY. All radiology services have a technical component and a professional component. The professional and technical component of hospital services must be separately identified for billing and payment.

005.28(D)(iii)(1) PROFESSIONAL COMPONENT. The professional component of radiology services provided by a physician to a beneficiary is covered as a physician's service when the services meet the previously outlined conditions of coverage and the services are identifiable, direct, and discrete diagnostic or therapeutic services to a beneficiary.

005.28(D)(iii)(2) TECHNICAL COMPONENT. The technical component of hospital diagnostic and therapeutic services are services needed to produce the x-ray films or other items that are interpreted by the radiologist .

005.29 NON-PHYSICIAN CARE PROVIDERS. Services provided by non-physician care providers who have fulfilled all state and federal licensing, certification, and training requirements are covered, under the following conditions:

(A) The non-physician care provider must meet the following definition: An individual trained to assist or act in the place of a physician;

(B) The service provided by the non-physician care provider must be within the scope of practice as defined by state law; and

(C) The non-physician care provider must provide the services under a practice agreement between the non-physician care provider and their supervising physician and must be approved by the Nebraska Board of Medicine and Surgery or the appropriate licensing agency in the state in which they provide the services.

005.30 PHYSICIAN SERVICES IN NURSING FACILITIES (NF), INTERMEDIATE CARE FACILITIES (ICF) AND INTERMEDIATE CARE FACILITIES FOR INDIVIDUALS WITH DEVELOPMENTAL DISABILITIES (ICF/DD). Initial certifications for admission into nursing facilities (NF), intermediate care facilities (ICF), or intermediate care facilities for individuals with developmental disabilities (ICF/DD) are required. The physician must examine the beneficiary before completing the certification, within the following time frames:

(1) NURSING FACILITIES (NF). The beneficiary must have a physical examination no later than two business days after admission unless an examination was performed within five days before admission; and

(2) INTERMEDIATE CARE FACILITIES (ICF). The beneficiary must have a recent physical examination within 30 days before admission or the date eligibility was determined, or no later than two business days after admission or the date eligibility was determined.

005.30(A) ANNUAL PHYSICAL EXAMINATION. All long-term care (LTC) facility residents are required to have an annual physical examination. The physician, based on their authority to prescribe continued treatment, determines the extent of the examination for beneficiaries based on medical necessity. Routine laboratory and radiology services which are not directly related to the beneficiary’s diagnosis and treatment are not covered; however, for the annual physical exam, a complete blood count (CBC), and urinalysis are not considered routine and are reimbursed based on the physician's orders when noted on the claim that these services were performed for an annual physical exam for a long-term care facility (LTC) resident. The results of the examination must be recorded in the beneficiary’s medical record.

005.30(B) PHYSICIANS’ SERVICES FOR NURSING FACILITY (NF) RESIDENTS.

005.30(B)(i) PHYSICIANS’ VISITS. The physician must see the nursing facility (NF) resident whenever necessary, but at least once every 30 days for the first 90 days following admission. After the 90th day following admission, an alternate schedule for physician's visits not to exceed 60 days may be adopted if the attending physician determines, and justifies in the beneficiary’s medical record, the beneficiary’s condition does not require visits at 30-day intervals. The facility's Utilization Review Committee will approve the alternate schedule. At the time of each visit, the physician must document the visit in the beneficiary’s medical record and write and sign a progress note on the beneficiary’s condition.

005.30(B)(ii) REVIEW OF PLAN OF CARE. The physician and facility staff involved in the nursing facility (NF) resident’s care will review each plan of care every 60 days. This should be done in conjunction with a physician's visit or recertification.

005.30(B)(iii) RECERTIFICATION. For nursing facility (NF) residents, the physician, the physician's assistant (PA), or nurse practitioner (NP) will recertify in writing the beneficiary’s continued need for the current level of care (LOC) every 30 days for the first 90 days, every 60 days thereafter, and at any time the beneficiary requires a different level of care (LOC). The nurse practitioner (NP) or physician’s assistant (PA), under the general supervision of a physician, may recertify the individual’s beneficiary’s need . The physician, the physician's assistant (PA), or nurse practitioner (NP) must sign, or stamp and initial, the recertification clearly identifying themselves. The recertification must also be dated at the time it is signed. Facility staff must maintain the recertification in the beneficiary’s medical record in the facility or building where the beneficiary resides.

005.30(B)(iii)(1) ON-SITE RECERTIFICATION. The recertifying practitioner must record recertification accomplished by on-site visits to the facility in the beneficiary’s record.

005.30(C) PHYSICIANS’ SERVICES FOR RESIDENTS OF INTERMEDIATE CARE FACILITIES (ICF’S) AND INTERMEDIATE CARE FACILITIES FOR THE DEVELOPMENTALLY DISABLED (ICF/DD’S).

005.30(C)(i) PHYSICIAN’S VISITS. The physician must actually see the beneficiary to claim the service. At the time of each visit, the physician must document the visit in the beneficiary’s medical record and write and sign a progress note on the beneficiary’s condition.

005.30(C)(ii) REVIEW PLAN OF CARE. The interdisciplinary team, which includes the physician, must review each intermediate care facility (ICF) plan of care every 90 days. This should be done in conjunction with recertification and is not reimbursed separately.

005.30(C)(iii) RECERTIFICATION. The physician, physician’s assistant (PA), or nurse practitioner (NP) must recertify in writing the beneficiary’s continued need for the intermediate care facility for the developmentally disabled (ICF/DD) level of care (LOC) at least once every 365 days, and at any time the beneficiary requires a different level of care. The extended recertification period in no way indicates one year is the appropriate length of stay for a beneficiary in an intermediate care facility (ICF) for the developmentally disabled (ICF/DD). The interagency team responsible for the beneficiary’s care determines the beneficiary’s length of stay. The physician's assistant (PA) or nurse practitioner (NP) may recertify the beneficiary’s need under the general supervision of a physician when the physician formally delegates this function to the physician's assistant (PA) or nurse practitioner (NP). The physician, the physician's assistant (PA), or nurse practitioner (NP) must sign, or stamp and initial, the recertification clearly identifying themselves. The physician, physician's assistant (PA), or nurse practitioner (NP) must date the recertification at the same time it is signed. Facility staff must maintain the recertification in the beneficiary’s medical record in the facility or building where the beneficiary resides.

005.30(C)(iii)(1) ON-SITE RECERTIFICATION. The recertifying practitioner must record recertification accomplished by on-site visits to the facility in the beneficiary’s record.

005.31 TELEPHONE CONSULTATIONS. Telephone calls to or from a beneficiary, pharmacy, nursing facility (NF) , or hospital are not covered. Telephone consultations with another physician may be covered if the name of the consulting physician is indicated on or in the claim.

005.32 MEDICAL TRANSPLANTS. Transplants are covered, including donor services which are medically necessary and defined as non-experimental by Medicare. Transplantation services may be covered when performed in a facility approved by Centers for Medicaid & Medicare (CMS) as meeting coverage criteria. Nebraska Medicaid is the payor of last resort.. Prior authorization of all transplant services is required before the services are provided. An exception may be made for emergency situations, in which case verbal approval is obtained and the notification of authorization is sent later.

005.32(A) SERVICES FOR A NEBRASKA MEDICAID-ELIGIBLE DONOR. Medically necessary services are covered, including laboratory tests directly related to the transplant, for the Nebraska Medicaid-eligible donor to a Nebraska Medicaid-eligible beneficiary. The services must be directly related to the transplant.

005.32(B) SERVICES FOR A NEBRASKA MEDICAID-INELIGIBLE DONOR. Medically necessary services are covered, including laboratory tests directly related to the transplant, for a Nebraska Medicaid-ineligible donor to a Nebraska Medicaid-eligible beneficiary. The services must be directly related to the transplant and must directly benefit the Nebraska Medicaid transplant beneficiary . Coverage of treatment for complications related to the donor is limited to those which are reasonably medically foreseeable.

005.32(C) AMBULATORY ROOM AND BOARD. Ambulatory room and board services may be covered for transplant patients for the beneficiary and an attendant, if necessary.

005.33 ITINERANT PHYSICIAN VISITS. Non-emergency physician visits provided in a hospital outpatient setting are covered if the services are:

(A) Provided by an out-of-town specialist who has a contractual agreement with the hospital. General practitioners or family practitioners are not considered to be specialists; and

(B) Determined to have been provided in the most appropriate place of service .

005.34 NURSE PRACTITIONER SERVICES (NP). Nurse practitioner (NP) services are covered in accordance with the scope of practice applicable to their specific licensure designation.

005.35 DURABLE MEDICAL EQUIPMENT AND SUPPLIES. With certain exceptions, hospitals, hospital pharmacies, long-term care (LTC) facilities, rehabilitation services or centers, or physicians are not enrolled as providers of durable medical equipment and medical supplies.

005.36 ANESTHESIOLOGY.

005.36(A) PROFESSIONAL COMPONENT. The professional component of anesthesiology services provided by a physician to a beneficiary is covered as a physician’s service if the conditions in this chapter are met.

005.36(B) MEDICAL DIRECTION OF FOUR OR FEWER CONCURRENT PROCEDURES. The professional component for the physician's medical direction of concurrent anesthesiology services provided by qualified anesthetists is covered as a physician's service when the services meet the requirements previously designated as conditions of coverage and the following additional requirements:

(1) For each beneficiary, the physician:

(a) Performs and documents a pre-anesthetic examination and evaluation;

(b) Prescribes the anesthesia plan;

(c) Personally participates in the most demanding procedures in the anesthesia plan, including induction and emergence;

(d) Ensures any procedures in the anesthesia plan that he or she does not perform are performed by a qualified individual;

(e) Monitors the course of anesthesia administration at frequent intervals;

(f) Remains physically present and available for immediate diagnosis and treatment of emergencies; and

(g) Provides indicated post-anesthesia care; and

(2) The physician directs no more than four anesthesia procedures concurrently and does not provide any other services while directing the concurrent procedures.

005.36(B)(i) OTHER SERVICES PROVIDED WHILE DIRECTING CONCURRENT PROCEDURES. A physician who is directing concurrent anesthesia services for four or fewer surgical patients must not ordinarily be involved in providing additional services to other patients.

005.36(B)(i)(1) SERVICES CONSIDERED A TECHNICAL COMPONENT. If the physician leaves the immediate area of the operating suite for longer than short durations, devotes extensive time to an emergency case, or is otherwise not available to respond to the immediate needs of surgical beneficiaries , the physician's services to the surgical beneficiary are supervisory in nature and are considered a technical component; therefore, these services must be billed as the technical component by the hospital.

005.36(C) MEDICAL DIRECTION OF MORE THAN FOUR CONCURRENT PROCEDURES. If the physician is involved in providing supervision for more than four concurrent procedures or is performing other services while directing concurrent procedures, the concurrent anesthesia services are covered as the technical component of the hospital services. The physician must ensure that a qualified individual performs any procedure in which the physician does not personally participate. The physician's personal services up to and including induction are considered the professional component.

005.36(D) STANDBY ANESTHESIA SERVICES. A physician's standby anesthesia services are covered when the physician is physically present in the operating suite, monitoring the beneficiary’s condition, making medical judgments regarding the beneficiary’s anesthesia needs, and is ready to furnish anesthesia services to a specific beneficiary who is known to be in potential need of services.

005.36(E) SERVICES OF CERTIFIED REGISTERED NURSE ANESTHETISTS (CRNA). When anesthesia services are provided by an anesthesiologist and a certified registered nurse anesthetist (CRNA) at the same time, only those services provided by the anesthesiologist are covered. In the event multiple surgical procedures are performed at the same time, only services provided by the certified registered nurse anesthetist (CRNA) for the major procedure are covered. Certified registered nurse anesthetist (CRNA) services for secondary procedures are not covered.

005.37 FEEDING AND SWALLOWING CLINIC SERVICES. This service is covered for those beneficiaries with dysphagia. The service is covered when the beneficiary is referred by a physician for a medical evaluation. The purpose of the evaluation is to assess the beneficiary’s current status and potential for improvement and to develop a plan of care for the beneficiary.

005.37(A) DEFINITIONS. For the purposes of feeding and swallowing clinic services, the following definitions will apply:

005.37(A)(i) SWALLOWING DISORDERS ASSESSMENT, COMPREHENSIVE. This includes, at a minimum, comprehensive evaluation by the occupational therapist (OT), speech-language pathologist, nurse, and nutritionist. The need for a psychological evaluation is determined by intake information; if necessary, the psychological evaluation is billed separately.

005.37(A)(ii) SWALLOWING DISORDER ASSESSMENT, EXTENDED. This includes, at a minimum, a comprehensive evaluation by the occupational therapist (OT) and extended evaluations by the speech-language pathologist, nurse, and nutritionist. The need for a psychological evaluation is determined by intake information; if necessary, the psychological evaluation is billed separately.

005.37(A)(iii) SWALLOWING DISORDER ASSESSMENT, BRIEF. The brief assessment includes approximately two hours of time for the occupational therapist (OT), speech-language pathologist, and nutritionist.

005.37(A)(iv) FOLLOW-UP VISIT, BRIEF. This includes a visit with two or more team members.

005.37(A)(v) FOLLOW-UP VISIT, EXTENDED. This includes a visit which involves four or more team members.

005.37(B) INITIAL EVALUATION. An initial evaluation must be performed by an interdisciplinary team, which, at a minimum, must include a nurse, occupational therapist (OT), speech-language pathologist, nutritionist, psychologist, and radiologist. The interdisciplinary team must be under the direction of a physician. After the initial visit, the interdisciplinary team formulates a formal written report and sends copies to the individual or family, the referring physician, and others designated by the beneficiary or family and by Nebraska Medicaid. The team contacts the referring physician and, if appropriate, other medical professionals, to provide immediate feedback to the team on primary findings and recommendations.

005.37(C) FOLLOW-UP VISITS. Follow-up visits must be available in a frequency adequate to meet beneficiary needs and program objectives.

005.37(D) FOLLOW-UP CALLS. Follow-up telephone calls are made after the initial evaluation and are included in the cost of the evaluation, as follows:

(i) Within 48 hours after the evaluation, a team member calls the beneficiary or family to answer questions and provide clarification, if needed, for any information presented during the initial visit;

(ii) Two to four weeks after the initial visit, a follow-up call is made to ask about progress and problems in following the plan of care; and

(iii) Ongoing telephone communication is maintained with the beneficiary or family and referring physician to facilitate implementation of the plan of care.

005.38 COMPREHENSIVE INTERDISCIPLINARY TREATMENT FOR A SEVERE FEEDING DISORDER. Comprehensive interdisciplinary treatment for an infant or child with a severe feeding disorder is covered when it impacts the infant’s or child’s ability to consume sufficient oral nutrition to maintain adequate growth or weight.

005.38(A) DEFINITIONS. For the purposes of comprehensive interdisciplinary treatment for a severe feeding disorder service, the following definitions will apply:

005.38(A)(i) DAY TREATMENT. Daily therapy, which occurs Monday through Friday, from approximately 8:30 am to 5:00 pm.

005.38(A)(ii) OUTPATIENT. Therapy one to two times per week for one to three hours per day.

005.39 TOBACCO CESSATION. Tobacco cessation services are covered as practitioner and pharmacy services, for beneficiaries 18 years of age or older, under the following conditions:

(A) Tobacco cessation services must be ordered by a physician or mid-level practitioner;

(B) Up to two tobacco cessation sessions may be covered in a 12-month period. A session is defined as medical encounters and drug products as listed below. Beneficiary access to the Nebraska Tobacco Free Quitline will be unlimited;

(C) Practitioner office visits:

(i) Beneficiaries must see their medical care provider for evaluation particularly for any contraindications for drug products and to obtain prescriptions if tobacco cessation products are needed; and

(ii) In addition to the evaluation, a total of four tobacco cessation counseling visits with a medical care provider or tobacco cessation counselor are covered for each tobacco cessation session. This may be a combination of intermediate or intensive tobacco cessation counseling visits;

(D) Tobacco cessation products are covered as a pharmacy service for those 18 years of age or older who require this particular assistance;

(i) Coverage of products used for tobacco cessation is limited to a maximum 90 days' supply in one tobacco cessation session. Up to two 90-day supplies may be covered in a 12-month period, beginning with the date the first prescription for the products is dispensed; and

(ii) Tobacco cessation products will only be covered when beneficiaries are currently enrolled with, and actively participating in, the Nebraska Tobacco Free Quitline. Disenrollment or lack of active participation in the Nebraska Tobacco Free Quitline will result in discontinuation of Nebraska Medicaid coverage of tobacco cessation drug products; and

(E) Referral to the Nebraska Tobacco Free Quitline may be made by a medical professional or a self-referral.

005.40 ENDOMETRIAL ASPIRATION. Vacutage type or other endometrial aspiration or curettage is covered. The provider must submit the pathologist's report on the tissue with all claims for this service. For diagnoses of absent, delayed, or late menstruation, the physician must administer a pregnancy test to verify the beneficiary is not pregnant. When requested, the provider must submit copies of beneficiaries’ medical records to Nebraska Medicaid .

005.41 MEDICAL NUTRITION THERAPY FOR BENEFICIARIES AGE 21 AND OLDER. Medical nutrition therapy is available to beneficiaries with medical needs which require nutritional assessment, intervention, and continued monitoring. One-on-one medical nutrition therapy provided by a licensed medical nutritional therapist (LMNT) is covered for beneficiaries age 21 and older under the following requirements:

(A) The service is covered when the beneficiary is referred by a physician or nurse practitioner (NP). A nutritional assessment is done by the beneficiary’s primary care provider. The diagnostic finding from the exam must indicate a nutritional problem or condition of such severity that nutritional counseling beyond that normally expected as part of the standard medical management is warranted;

(B) Beneficiaries must meet at least one of the following medical conditions:

(i) Type I or Type II diabetes;

(ii) Current kidney disease; or

(iii) A kidney transplant in the last 36 months;

(C) For beneficiaries who receive medical nutrition therapy as part of their overall dialysis care in a dialysis facility, medical nutrition therapy is not separately billable; and

(D) Medical nutrition therapy includes the assessment, intervention, and counseling provided to prevent, improve, or resolve identified nutritional problems. Coverage of medical nutrition therapy allows for:

(i) Three hours in the first year;

(ii) Two hours in subsequent years; and

(iii) Additional hours are considered to be medically necessary and covered if the treating physician determines there is a change in medical condition, diagnosis, or treatment regimen which requires a change in medical nutrition therapy and orders additional hours during that episode of care. Nebraska Medicaid may request periodic review of the services.

006. NON-COVERED SERVICES. Non-covered services will not be covered by Nebraska Medicaid. Services are reviewed on a case-by-case basis to determine if they are covered.

006.01 SERVICES REQUIRED TO TREAT COMPLICATIONS OR CONDITIONS RESULTING FROM NON-COVERED SERVICES. If medically necessary services which are required to treat complications or conditions resulting from non-covered services are determined to be part of a previous non-covered service, such as an extension or a periodic segment of a non-covered service or follow-up care associated with it, the subsequent services will be denied.

006.02 SERVICES NOT REASONABLE AND NECESSARY. Items and services which are not reasonable and necessary for the diagnosis and treatment of illness or injury, or to improve the function of a malformed body member are not covered.

006.03 SURGICAL ASSISTANT FEES. Surgical assistance fees for the following procedures are not covered. Additional assistant fees may be determined to be noncovered during the utilization review process.

(A) Laparoscopy, including laparoscopic tubal ligation;

(B) Tonsillectomy, adenoidectomy, myringotomy;

(C) Conservative or closed fracture care; and

(D) Uncomplicated procedures of the integument.

006.04 EXPERIMENTAL AND INVESTIGATIONAL SERVICES. Medical services which are considered investigational or experimental or which are not generally employed by the medical profession are not covered. While the circumstances leading to participation in an experimental or investigational program may meet the definition of medical necessity, payment for these services is prohibited.

006.04(A) RELATED SERVICES. Associated or adjunctive services which are directly related to non-covered experimental or investigational services are not covered. All medically necessary expenses incurred which are not directly related to the non-covered experimental or investigative services will be paid. Complications of non-covered services may be covered once the non-covered service is completed.

006.04(B) INVESTIGATIONAL AND EXPERIMENTAL CRITERIA. Services may be deemed investigational or experimental by Nebraska Medicaid, which may convene ad hoc advisory groups of experts to review requests for coverage. A service is deemed investigational or experimental if it meets any one of the following criteria:

(1) The Food and Drug Administration (FDA), or other governmental or regulatory authority, has not approved the service or treatment for general marketing to the public for the proposed use;

(2) Reliable evidence does not lead to the conclusion that there is a consensus within the medical community that the service is a generally accepted standard of care employed by the medical profession as a safe and effective service for treating or diagnosing the condition or illness for which its use is proposed. Reliable evidence includes peer reviewed literature with statistically significant data regarding the service for the specific disease or proposed use and age group. Also, facility specific data, including short and long term outcomes, must be submitted to Nebraska Medicaid;

(3) The service is available only through an institutional review board (IRB) research protocol for the proposed use or subject to such an institutional review board (IRB) process; or

(4) The service is the subject of an ongoing clinical trial which meets the definition of a phase I, phase II, or phase III clinical trial, regardless of whether the trial is actually subject to Food and Drug Administration (FDA) oversight and regardless of whether an institutional review board (IRB) process or protocol is required at any one particular institution.

006.04(C) DEFINITION OF CLINICAL TRIALS. For services not subject to Food and Drug Administration (FDA) approval, the following definitions apply:

(i) PHASE I. Initial introduction of an investigational service into humans.

(ii) PHASE II. Controlled clinical studies conducted to evaluate the effectiveness of the service for a particular indication or medical condition of the beneficiary; these studies are also designed to determine the short-term side effects and risks associated with the clinical trial.

(iii) PHASE III. Clinical studies to further evaluate the effectiveness and safety of a service which is needed to evaluate the overall risk and benefit and to provide an adequate basis for determining patient selection criteria for the service as the recommended standard of care. These studies usually compare the clinical trial to the current recommended standard of care.

006.05 NON-COVERED PORTABLE X-RAY SERVICES. The following portable x-ray services are not covered:

(A) Procedures involving fluoroscopy;

(B) Procedures involving the use of contrast media;

(C) Procedures requiring the administration of a substance to the beneficiary or injection of a substance into the beneficiary or special manipulation of the beneficiary ;

(D) Procedures which require special medical skill or knowledge possessed by a doctor of medicine or doctor of osteopathy or which require medical judgment be exercised;

(E) Procedures requiring special technical competency or special equipment or materials;

(F) Routine screening procedures; and

(G) Procedures which are not of a diagnostic nature.

006.06 INFLUENZA INJECTIONS IN LONG-TERM CARE (LTC) FACILITIES. No payment is made to a physician giving influenza injections in long-term care (LTC) facilities.

006.07 INJECTABLE ESTROGENS. Injectable estrogens for depression or osteoporosis associated with menopause are not covered.

006.08 LIVER AND VITAMIN INJECTIONS. Liver and vitamin injections are not covered.

006.09 AUTOPSIES. Autopsies are a non-covered service .

006.10 REQUESTS FOR NEBRASKA MEDICAID COVERAGE. Requests for Nebraska Medicaid coverage for new or currently non-covered services or those which may be considered experimental or investigational must be submitted in writing before providing the services, or in the case of medical emergencies, before submitting a claim. The request for coverage must include sufficient information to document the new service is not considered investigational or experimental for Nebraska Medicaid payment purposes. Reliable evidence must be submitted identifying the status on the new service with regard to cost-benefit data, short- and long-term outcome data, patient selection criteria which is both disease or condition specific and age specific, information outlining the circumstances under which the service is considered the accepted standard of care, and any other information which would be helpful to Nebraska Medicaid in deciding coverage determination. Requests must be submitted to Nebraska Medicaid, and additional information may be requested. Nebraska Medicaid will make the final determination of coverage. The decision is final and is not appealable.

007. BILLING FOR PHYSICIAN SERVICES.

007.01 SPECIFIC BILLING REQUIREMENTS. Physicians’ services must be billed on the appropriate Nebraska Medicaid approved claim form or the standard electronic transaction form . Physicians’ services must not be billed by a hospital. The physician or the physician's authorized agent must approve and date each paper claim. Approval of paper claims is indicated by the handwritten signature, signature stamp, or computer-generated signature of the physician or authorized agent. When a computer-encoded document or electronic transaction is used, the provider’s source input documentation may be requested from the provider for input verification and signature requirements. The physician or the physician's authorized agent must enter the physician's usual and customary charge for each procedure code on the claim.

007.01(A) PROCEDURE CODES. Physicians must use Healthcare Common Procedure Coding System (HCPCS) procedure codes when submitting claims to Nebraska Medicaid .

007.01(B) PORTABLE X-RAY SERVICES. Claims for portable x-ray services must contain the name of the physician who ordered the service and a diagnosis of medical necessity.

007.01(C) SECOND SURGICAL OPINION. The second physician must bill Nebraska Medicaid with a Healthcare Common Procedure Coding System (HCPCS) consultation procedure code indicating the level of the consultation and identifying the service as a second surgical opinion.

007.01(D) PRENATAL, DELIVERY, AND POSTPARTUM CARE. When billing Nebraska Medicaid for prenatal, delivery, and postpartum care, the provider must submit a claim at the time of delivery. When the primary physician does not participate in the total obstetrical care, the partial care may be billed separately from the delivery using the appropriate procedure codes. An explanation for the partial care must be submitted. Providers must use one procedure code but must provide individual dates of service on the claim. One charge is submitted covering all:

(i) Routine prenatal care, vaginal delivery, and postpartum care; or

(ii) Routine prenatal care, cesarean delivery, and postpartum care.

007.01(D)(i) EXCEPTION. Prenatal Plus Program (PPP) services outside of routine prenatal visits can be billed as they occur and are not submitted as a claim at the time of delivery.

007.01(E) FRACTURE CARE. Providers may claim subsequent replacement of cast or traction devices used during or after the period of follow-up care as an independent service using the appropriate Healthcare Common Procedure Coding System (HCPCS) procedure code.

007.01(F) PRACTITIONER ADMINISTERED MEDICATIONS. When billing for medications administered during the course of a clinic visit, the physician must use the appropriate Healthcare Common Procedure Coding System (HCPCS) procedure code for the medication, the correct number of units per the Healthcare Common Procedure Coding System (HCPCS) description, the National Drug Code (NDC) of the drug administered, the National Drug Code (NDC) unit of measure and the National Drug Code (NDC) number of units. A Current Procedural Terminology (CPT) code for the administration must also be submitted. When billing for medication which does not have a specific Level I or II code, the physician must use a miscellaneous Healthcare Common Procedure Coding System (HCPCS) code with the name and National Drug Code (NDC) number identifying the drug and include the dosage given. If this information is not with the claim, the claim may be returned to the physician for completion or pay the claim at the lowest dosage manufactured for the specific drug.

007.01(F)(i) CHEMOTHERAPY. Providers must bill for chemotherapy using Healthcare Common Procedure Coding System (HCPCS) procedure codes for chemotherapy administration. The drug used must be identified and claimed separately on the claim using the appropriate Healthcare Common Procedure Coding System (HCPCS) procedure code, the number of units per the Healthcare Common Procedure Coding System (HCPCS) description, the National Drug Code (NDC) of the drug administered, the National Drug Code (NDC) unit of measure, and the number of National Drug Code (NDC) units. For drugs which do not have a specific Healthcare Common Procedure Coding System (HCPCS) code, the provider must use a miscellaneous chemotherapy code. The provider must indicate on or in the claim the name of medication, the dosage administered, and the National Drug Code (NDC) number, unit of measure, and number of units.

007.01(F)(ii) IMMUNIZATIONS. When using Vaccine for Children (VFC) vaccines, only the administration is billed to Nebraska Medicaid by adding the appropriate modifier to the vaccine code. The billed charge for the administration must not exceed the Vaccine for Children (VFC) federally determined state maximum for Nebraska.

007.01(G) PHYSICIAN’S OFFICE LABORATORY. If the services are provided in a physician's or group of physician's private office, payment may be claimed for the medically necessary services provided or supervised by the physician, using the appropriate Healthcare Common Procedure Coding System (HCPCS) procedure code.

007.01(H) LICENSED AND CERTIFIED INDEPENDENT CLINICAL LABORATORY. The physician must indicate on or with the appropriate claim form or electronic format the fee for obtaining the specimen by venipuncture or catheterization is for tests performed outside his or her office and submit the name of the facility performing the tests on the claim.

007.01(I) BILLING FOR THE PROFESSIONAL AND TECHNICAL COMPONENTS OF HOSPITAL INPATIENT AND OUTPATIENT DIAGNOSTIC AND THERAPEUTIC SERVICES. The professional component of hospital diagnostic and therapeutic services must be billed as previously described except for facilities paid under an all-inclusive rate. The technical component of hospital diagnostic and therapeutic services must be billed by the hospital. A hospital may act as the billing agent for the physician's professional component. A separate Nebraska Medicaid provider number is required for each specialty for the hospital professional component. A separate provider agreement is required for each separate provider number. The professional component must be billed on the claim, using the appropriate provider number for the professional component of the appropriate specialty. Only one specialty and one provider number, may be billed on each claim.

007.01(J) ANESTHESIOLOGY. The professional component must be claimed and must indicate actual time in one-minute increments. The physician's medical direction of four or fewer concurrent anesthesia procedures is considered a professional component.

007.01(J)(i) CLAIMS FOR PAYMENT. When a physician bills for anesthesia services, the physician must certify with the claim, as appropriate, that:

(1) The services were personally provided by the physician to the beneficiary; or

(2) When the physician provided medical direction for certified registered nurse anesthetist (CRNA) services, the number of concurrent services directed is indicated by the appropriate modifier.

007.01(J)(ii) STERILIZATION OR HYSTERECTOMY. To make payment for anesthesia services for sterilizations, a completed copy of the appropriate Nebraska Medicaid approved consent form must be on file with Nebraska Medicaid . For a hysterectomy, a completed copy of the appropriate Nebraska Medicaid approved consent form , signed and dated by the beneficiary stating she was made aware before the surgery that the surgery would result in sterility, must be on file with Nebraska Medicaid before payment can be made. Claims for these services must indicate actual time in one-minute increments.

007.01(J)(iii) CLAIMS FOR CERTIFIED REGISTERED NURSE ANESTHETIST (CRNA) SERVICES. Claims for certified registered nurse anesthetist (CRNA) services must be billed accordingly, except rural hospitals which have been exempted by their Medicare fiscal intermediary for certified registered nurse anesthetist (CRNA) billing must follow the Medicare billing requirements. Additional reimbursement is not provided for emergency and risk factors. When multiple surgical procedures are performed at the same time, the certified registered nurse anesthetist (CRNA) must bill only for the major procedure. Payment is not made for certified registered nurse anesthetist (CRNA) services for secondary procedures.

007.01(K) LABORATORY AND PATHOLOGY.

007.01(K)(i) INPATIENT HOSPITAL ANATOMICAL PATHOLOGY SERVICES. Payment for the technical component of anatomical pathology is included in the hospital’s payment . The pathologist must claim the professional component of anatomical pathology using the appropriate Healthcare Common Procedure Coding System (HCPCS) procedure code and modifier.

007.01(K)(ii)(1) EXCEPTION. If an anatomical pathology specimen is obtained from a hospital inpatient but is referred to an independent laboratory or the pathologist of a second hospital's laboratory, the independent laboratory, or the pathologist of the second hospital's laboratory to which the specimen has been referred may claim payment for the total service.

007.01(K)(ii) OUTPATIENT HOSPITAL ANATOMICAL PATHOLOGY SERVICES. The hospital must claim the technical component according to this title . The pathologist must claim the professional component.

007.01(K)(ii)(1) EXCEPTION. If an anatomical pathology specimen is obtained from a hospital outpatient and is referred to an independent laboratory or the pathologist of a second hospital's laboratory, the independent laboratory, or the pathologist of a second hospital's laboratory to which the specimen was referred may claim payment for the total service.

007.01(K)(iii) NON-PATIENT ANATOMICAL PATHOLOGY SERVICES. A non-patient is a beneficiary receiving services who is neither an inpatient nor an outpatient. For specimens from non-patients referred to the hospital, the hospital must bill the total service.

007.01(K)(iv) LEASED DEPARTMENTS. If the pathology department is leased and an anatomical pathology service is provided to a hospital non-patient, the pathologist must claim the total service. Leased department status has no bearing on billing for or payment of inpatient or outpatient anatomical pathology services.

007.01(K)(v) CLINICAL LABORATORY SERVICES. The professional and technical components of clinical laboratory services are not separately identified for billing and payment.

007.01(K)(vi) PHYSICIAN’S OFFICE OR INDEPENDENT LABORATORY. Clinical laboratory services performed in a physician's office or independent laboratory must be billed appropriately.

007.01(K)(vi)(1) CLINICAL LABORATORY CONSULTATION. The physician must claim a clinical laboratory consultation using the appropriate Healthcare Common Procedure Coding System (HCPCS) procedure codes.

007.01(L) RADIOLOGY. The professional component must be billed appropriately.

007.01(L)(i) INPATIENT RADIOLOGY SERVICES. Payment for the technical component of inpatient radiology services is included in the hospital's payment . Physicians must bill the professional component of inpatient radiology services appropriately.

007.01(L)(ii) OUTPATIENT RADIOLOGY SERVICES. The hospital must claim the technical component of outpatient radiology services on the appropriate Nebraska Medicaid approved claim form or electronic format. The physician must bill the professional component using the appropriate Healthcare Common Procedure Coding System (HCPCS) procedure code with the modifier.

007.01(M) SERVICES PROVIDED BY PHYSICIAN ASSISTANTS (PA). Claims for services provided by physician assistants (PA) must be submitted on the appropriate Nebraska Medicaid approved claim form or the standard electronic : transaction form under the physician assistant’s (PA) provider group number.

007.01(N) PHYSICIAN SERVICES IN NURSING FACILITY (NF), INTERMEDIATE CARE FACILITY (ICF), AND INTERMEDIATE CARE FACILITY FOR INDIVIDUALS WITH DEVELOPMENTAL DISABILITIES (ICF/DD). The physician may bill Nebraska Medicaid for an annual nursing facility (NF) physical exam service, regardless of the extent of the exam. Additionally, the physician may bill Nebraska Medicaid for the certification service.

007.01(N)(i) ANNUAL PHYSICAL EXAMINATION. If the annual physical examination is performed solely to meet the requirement of Nebraska Medicaid , the physician must submit the claim to Nebraska Medicaid on the appropriate Nebraska Medicaid approved claim form or the standard electronic transaction format . .

007.01(N)(ii) MEDICARE COVERAGE. If a physical examination is performed for diagnosis or treatment of a specific symptom, illness, or injury and the beneficiary has Medicare coverage, the physician must submit the claim through the usual Medicare process. This applies to all physicians' visits in a long-term care (LTC) facility.

007.01(N)(iii) PHYSICIANS’ VISITS TO NURSING FACILITY (NF) RESIDENTS. When billing for a physician's visit, the physician must use the appropriate Healthcare Common Procedure Coding System (HCPCS) procedure code for a nursing facility (NF) visit.

007.01(N)(iv) ON-SITE RECERTIFICATION. The physician must use the appropriate Healthcare Common Procedure Coding System (HCPCS) procedure code for nursing facility (NF) visits when billing Nebraska Medicaid for this service.

007.01(N)(v) PHYSICIANS’ VISITS TO INTERMEDIATE CARE FACILITY (ICF) AND INTERMEDIATE CARE FACILITY FOR INDIVIDUALS WITH DEVELOPMENTAL DISABILITIES (ICF/DD) RESIDENTS. When billing for a physician's visit, the physician must use the appropriate Healthcare Common Procedure Coding System (HCPCS) procedure code. The physician must submit the following statements on or with the claim: 60-day or alternate schedule intermediate examination.

007.01(O) TRANSPLANT SERVICES. Physician services must be billed accordingly.

007.01(O)(i) BILLING FOR TRANSPLANT SERVICES PROVIDED TO A MEDICAID-INELIGIBLE DONOR. Claims for services provided to a Nebraska Medicaid-ineligible donor must be submitted under the Nebraska Medicaid-eligible beneficiary’s case number. There must be a notation with the claim indicating these services were provided to the Nebraska Medicaid-ineligible donor on the beneficiary’s behalf.

007.01(P) ITINERANT PHYSICIAN VISITS. The hospital room charge must be billed on the appropriate Nebraska Medicaid approved claim form or electronic format. The physician's service must be coded as an office visit and billed on the appropriate Nebraska Medicaid approved claim form or electronic format.

007.01(Q) CERTIFIED NURSE MIDWIFE (CNM) OR NURSE PRACTITIONER (NP) SERVICES. Claims for certified nurse midwife (CNM) services and nurse practitioner (NP) services must be submitted on the appropriate Nebraska Medicaid approved claim form according to instructions or on the appropriate electronic format transaction.

007.01(R) FEEDING AND SWALLOWING CLINIC SERVICES. The interdisciplinary team (IDT) services must be billed under the physician's provider number accordingly. The physician services are billed under appropriate Current Procedural Terminology (CPT) codes.

008. PAYMENT.

008.01 GENERAL PAYMENT REQUIREMENTS. The provider will be reimbursed for services rendered in accordance with the applicable Nebraska regulations .

008.02 REIMBURSEMENT. Covered physician services, except clinical laboratory services, are paid at the lower of the provider’s submitted charge or the allowable amount for the procedure code in the Nebraska Medicaid Practitioner Fee Schedule in effect for the date of service.

008.02(A) EXCEPTION. An out-of-state provider may enter into an agreement for a rate which exceeds the rate according to the Nebraska Medicaid Practitioner Fee Schedule only when Nebraska Medicaid has determined the beneficiary requires specialized services which are not available in Nebraska and no other source of the specialized service can be found.

008.03 SITE OF SERVICE ADJUSTMENT. A site of service differential is applied which reduces the fee schedule amount for specific Current Procedural Terminology (CPT) and Healthcare Common Procedure Coding System (HCPCS) codes when the service is provided in a facility setting. Based on the Medicare differential, specific Current Procedural Terminology (CPT), and Healthcare Common Procedure Coding System (HCPCS) codes will be reimbursed with adjusted rates based on the site of service.

008.04 NON-PAYMENT OF OTHER PROVIDER PREVENTABLE CONDITIONS (OPPC). For physician and non-physician provider claims, payment will be denied for the following other provider preventable conditions (OPPCs):

(i) Wrong surgical or other invasive procedure performed on a beneficiary;

(ii) Wrong surgical or other invasive procedure performed on the wrong body part; and

(iii) Wrong surgical or other invasive procedure performed on the wrong beneficiary.

008.05 SURGERY. The surgical procedure, including 14 days post-operative care, is reimbursed under a Healthcare Common Procedure Coding System (HCPCS) surgery procedure code. When multiple surgical procedures are done at one time, Nebraska Medicaid reimburses the primary procedure according to the Nebraska Medicaid Practitioner Fee Schedule. Any secondary procedures which add significant time and complexity to patient care is reimbursed at one-half of the amount which would be paid if the procedure were the primary procedure.

008.052(A) ASSISTANT SURGEON. When an assistant surgeon is required, reimbursement is made according to the Nebraska Medicaid Practitioner Fee Schedule. Medicare’s assistant surgery policy designation is followed.

008.06 PRACTITIONER ADMINISTERED MEDICATIONS. Practitioner administered injectable medications are reimbursed at 100 percent of the Medicare Drug Fee Schedule plus an administration fee as listed. Injectable medications approved by Nebraska Medicaid but not included on the Medicare Drug Fee Schedule will be reimbursed at the wholesale acquisition cost (WAC) plus 6.8 percent.

008.062(A) ALLERGY INJECTIONS. When the cost of the medication is not listed in either the Drug Topics Red Book or The Blue Book, allergy injections are paid at the provider's submitted charge up to the maximum allowable dollar amount under the Nebraska Medicaid Practitioner Fee Schedule per injection which includes medication and injection fee. If the allergy medication is not prepared in the office of the physician administering the allergen and the administering physician incurs no expense for the supply or the supplier bills Nebraska Medicaid separately, the administering physician is reimbursed according to the Nebraska Medicaid Practitioner Fee Schedule for the injection fee. If the administering physician purchases the supply for administration in the office, the administering physician must not bill Nebraska Medicaid for more than the cost of the supply. The maximum allowable dollar amount under the Nebraska Medicaid Practitioner Fee Schedule must not be exceeded in reimbursement per allergy injection, which includes the cost of the medication and the injection fee.

008.06(B) IMMUNIZATIONS. Reimbursement is available for the provider’s private stock vaccine and the administration fee for immunizations of adolescents age 19 and 20.

008.07 LABORATORY AND PATHOLOGY.

008.07(A) PHYSICIAN’S OFFICE OR INDEPENDENT LABORATORY. Payment is based on the Nebraska Medicaid fee schedule for clinical laboratory services to cover the total service, both professional and technical components.

008.07(A)(i) PHYSICIAN’S OFFICE LABORATORY. Payment for tests obtained in the physician's office but sent to an independent clinical laboratory or hospital for processing must be claimed by the facility performing the tests, using the appropriate Healthcare Common Procedure Coding System (HCPCS) procedure code. The private physician's office may be reimbursed for the collection by venipuncture or catheterization for these procedures by using the appropriate Healthcare Common Procedure Coding System (HCPCS) procedure code at the providers' submitted charge up to 100 percent of the Medicare clinical laboratory fee schedule. The private physician is not reimbursed for processing or interpreting tests performed outside their office.

008.07(B) CLINICAL LABORATORY SERVICES. Payment for clinical laboratory services including collection of laboratory specimens by venipuncture or catheterization is made at the amount allowed for each procedure code in the national fee schedule for clinical laboratory services as established by Medicare.

008.07(B)(i) LICENSED AND CERTIFIED INDEPENDENT CLINICAL LABORATORY. When a physician's private office sends the specimen to an independent clinical laboratory for processing, the procedure is paid directly to the independent clinical laboratory. The laboratory is not reimbursed for collecting, handling, or drawing the specimen sent in by a physician's office. Specimens collected by venipuncture or catheterization obtained by the hospital or independent laboratory for hospital or independent laboratory patients are paid for. The private physician is not reimbursed for processing or interpreting tests performed outside their office. Reimbursement is not allowed for collection of specimens in a nursing facility (NF) or long-term care (LTC) facility. If a physician performs some tests on a specimen and then sends the same specimen to an outside facility for additional procedures, the private physician may be reimbursed for the medically necessary procedures performed in their office plus a fee for drawing the specimen by venipuncture or obtaining urine by catheterization sent to a hospital or independent laboratory.

008.07(B)(ii) HOSPITAL CLINICAL LABORATORY SERVICES. There is no separate payment made to the pathologist for routine clinical laboratory services. To be paid, the pathologist must negotiate with the hospital to arrange a salary or compensation agreement.

(a) INPATIENT SERVICES. Payment is included in the hospital’s prospective payment rate ;

(b) OUTPATIENT SERVICES. Payment is made according to the fee schedule determined by Nebraska Medicaid; and

(c) NON-PATIENT SERVICES. Payment is made according to the fee schedule determined by Nebraska Medicaid.

008.08 PROFESSIONAL COMPONENT OF HOSPITAL DIAGNOSTIC AND THERAPEUTIC SERVICES. The professional component of a physician's hospital diagnostic or therapeutic service is paid . In the absence of available payment data the professional component is paid for at a percentage of the allowable fee for the total procedure. The percentage is established by Nebraska Medicaid .

008.09 ANESTHESIOLOGY SERVICES. Covered anesthesiology services are paid for in accordance with the reimbursement rates previously described. Additional reimbursement is not made for emergency and risk factors.

008.10 PAYMENT FOR SERVICES PROVIDED BY PHYSICIAN ASSISTANTS (PA). Payment to physician assistants (PA) is made to the physician provider group number with whom the physician assistant (PA) is enrolled. When payment is made to the physician group, the physician is responsible for payment to the physician assistant (PA). Payments will not be made to physician’s assistants (PA) who are employed by a hospital.

008.11 PAYMENT FOR TRANSPLANT SERVICES. The provider must submit, at the request of Nebraska Medicaid, any medical documentation from the beneficiary’s record to support and substantiate claims submitted to Nebraska Medicaid for payment.

008.11(A) TRANSPLANT SURGEON SERVICES. This fee will include two weeks' routine post-operative care by the designated primary surgeon. Payment for routine post-operative care will not be made to other members of the surgical team. Services provided after the two-week post-operative period may be billed on a fee-for-service basis.

008.12 ITINERANT PHYSICIAN VISITS. The physician will be paid at the rate for the appropriate level of office visit.

008.13 CERTIFIED NURSE MIDWIFE (CNM) SERVICES . Payment for certified nurse midwife (CNM) services is made to the certified nurse midwife (CNM) or the physician group with whom the certified nursemidwife (CNM) has a practice agreement.

008.14 COMPREHENSIVE INTERDISCIPLINARY TREATMENT FOR A SEVERE FEEDING DISORDER.

008.14(A) PEDIATRIC FEEDING DISORDER CLINIC INTENSIVE DAY TREATMENT. Reimbursement for pediatric feeding disorder clinic intensive day treatment for medically necessary services will be a bundled rate based on the sum of the fee scheduled amounts for covered services provided by Nebraska Medicaid enrolled licensed practitioners.

008.14(B) PEDIATRIC FEEDING DISORDER CLINIC OUTPATIENT TREATMENT. Pediatric feeding disorder clinic outpatient treatment for medically necessary services is reimbursed at the appropriate fee schedule amount for a physician consultation for covered services provided by Nebraska Medicaid enrolled licensed practitioners.

009. PRESCRIPTION DRUG MONITORING PROGRAM (PDMP).

009.01 GENERAL REQUIREMENT. Each provider prescribing a controlled substance in Nebraska to a Nebraska Medicaid beneficiary must check the prescription drug monitoring program (PDMP) established under Nebraska statutes before prescribing a schedule II medication and at dosage adjustment. The provider may delegate checking of the prescription drug monitoring program (PDMP) to a delegate as defined in Nebraska statutes .

009.02 EXCEPTION. Good faith exceptions must be documented in the beneficiary’s medical record and provided upon request to Nebraska Medicaid. These requirements do not include a prescription to a beneficiary as set forth under federal statutes and to a resident of a facility where schedule II medications are dispensed to a beneficiary through a single pharmacy.

History

• Effective 2026-07-19

Chapter 19 Podiatry Services

Neb. Admin. Code tit. 471, ch. 19 Podiatry Services {#sec-471-nac-19 omnilex-key=us-ne-regs-official--title-471--471 NAC 19}

001. SCOPE AND AUTHORITY . The regulations govern the services provided under Nebraska’s Medicaid program as defined by Nebraska Revised Statute (Neb. Rev. Stat.) §§ 68-901 et seq.

002. DEFINITIONS .

002.01 PODIATRIST. A physician of the foot, ankle, and related governing structures.

003. PROVIDER REQUIREMENTS .

003.01 GENERAL PROVIDER REQUIREMENTS. To participate in Nebraska Medicaid, providers of podiatry services must comply with all applicable participation requirements codified in 471 Nebraska Administrative Code (NAC) 1, 2 and 3. In the event that provider participation requirements in 471 NAC 1, 2 or 3 conflict with requirements outlined in 471 NAC 19, the individual provider participation requirements in 471 NAC 19 will govern.

003.02 SERVICE SPECIFIC PROVIDER REQUIREMENTS. Podiatrists must be licensed by the Nebraska Department of Health and Human Services, Division of Public Health. If podiatry services are provided outside Nebraska, the podiatrist must be licensed in that state.

003.03(A) PROVIDER AGREEMENT. The podiatrist will complete and sign a Medical Assistance Provider Agreement, and submit the completed form to the Department for approval to participate in Nebraska Medicaid.

004. SERVICE REQUIREMENTS .

004.01 GENERAL REQUIREMENTS.

004.01(A) MEDICAL NECESSITY. Nebraska Medicaid incorporates the definition of medical necessity from 471 NAC 1. Services and supplies that do not meet the 471 NAC 1 definition of medical necessity are not covered.

004.01(B) SERVICES PROVIDED FOR RECIPIENTS ENROLLED IN THE NEBRASKA MEDICAID MANAGED CARE PROGRAM. See 471 NAC 1.

004.01(C) EARLY AND PERIODIC, SCREENING, DIAGNOSIS, AND TREATMENT (EPSDT) SERVICES. See 471 NAC 33.

004.02 COVERED SERVICES. Nebraska Medicaid covers medically necessary podiatry services within the scope of the podiatrist's licensure and within program guidelines.

004.02(A) ROUTINE FOOT CARE. Routine foot care includes:

(1) Cutting or removal of corns or calluses;

(2) Trimming of nails;

(3) Other hygienic and preventive maintenance care or debridement; and

(4) Any services performed in the absence of localized illness, injury, or symptoms involving the foot.

004.02(A)(i) FREQUENCY LIMITATIONS. Coverage of routine foot care is limited to:

(a) One treatment every 90 days for non-ambulatory recipients; or

(b) One treatment every 30 days for ambulatory recipients.

004.02(A)(ii) EVALUATION AND MANAGEMENT (E&M) SERVICES. (E&M) services are not covered in addition to routine foot care on the same date of service, except:

(a) New patient visits; or

(b) When another separately identifiable service or procedure provided on the same date is documented in the medical record.

004.02(B) SURGERY. Surgical procedures performed by podiatrists must be in accordance with the provisions of Neb. Rev. Stat. § 38-3011.

004.02(B)(i) SITE OF SERVICE LIMITATIONS. Nebraska Medicaid accepts Medicare's determination of surgical procedures that are primarily performed in office settings.

004.02(B)(ii) STERILE SURGICAL TRAYS. Nebraska Medicaid covers one sterile surgical tray for each surgical procedure the podiatrist performs on an individual, in their office.

004.02(B)(iii) ASSISTANT SURGERY. Nebraska Medicaid covers an assistant surgeon only for surgical procedures that are identified as warranting an assistant surgeon.

004.02(C) SUPPORTIVE DEVICES OF THE FEET. Nebraska Medicaid covers orthopedic footwear, shoe corrections, orthotic devices and similar supportive devices for the feet if medically necessary for the recipient's condition. In addition to coverage as outlined herein, please see 471 NAC 7.

004.02(D) CLINICAL LABORATORY SERVICES. Nebraska Medicaid covers clinical laboratory services that are:

(i) Medically necessary;

(ii) Provided in a podiatrist's, or group of podiatrists', private office; and

(iii) Provided or supervised by the podiatrist(s).

004.02(E) INJECTIONS. Nebraska Medicaid covers intramuscular and subcutaneous injections at the cost of the medication plus an injection fee.

004.02(F) SUPPLIES. Nebraska Medicaid may cover medically necessary supplies that are used during the course of treatment and require application by the podiatrist. Routine supplies, and supplies that are considered incidental to the professional service are not covered.

005. BILLING AND PAYMENT FOR SERVICES .

005.01 BILLING.

005.01(A) GENERAL BILLING REQUIREMENTS. Providers must comply with all applicable billing requirements codified in 471 NAC 3. In the event that billing requirements in 471 NAC 3 conflict with billing requirements outlined in 471 NAC 19, the billing requirements in 471 NAC 19 will govern.

005.01(B) SPECIFIC BILLING REQUIREMENTS.

005.01(B)(i) BILLING INSTRUCTIONS. Providers must bill Nebraska Medicaid using the appropriate claim form or electronic format.

005.02 PAYMENT.

005.02(A) GENERAL PAYMENT REQUIREMENTS. The department will reimburse the provider for services rendered in accordance with the applicable payment regulations codified in 471 NAC 3. In the event that payment regulations in 471 NAC 3 conflict with payment regulations outlined in 471 NAC 19, the payment regulations in 471 NAC 19 will govern.

005.02(B) SPECIFIC PAYMENT REQUIREMENTS.

005.02(B)(i) REIMBURSEMENT. Nebraska Medicaid pays for covered podiatry services in an amount equal to the lesser of:

(1) The provider's submitted charge; and

(2) The allowable amount for that procedure code in the Nebraska Medicaid Practitioner Fee Schedule in effect for that date of service.

005.02(B)(ii) MEDICARE AND NEBRASKA MEDICAID CROSSOVER CLAIMS. For information on the payment of Medicare and Nebraska Medicaid crossover claims, see 471 NAC 3.

005.02(B)(iii) COPAYMENT. For Nebraska Medicaid copayment requirements, see 471 NAC 3.

005.02(B)(iv) PAYMENT FOR SURGERY. Payment for surgeries is as follows:

(1) Surgical procedures are arranged in descending order according to the Department’s allowable charges. The major procedure is paid at 100 percent of the allowable charge; and

(2) Subsequent procedures are paid at 50 percent of the allowable charge.

(3) Except for the initial office visit, payment for major surgical procedures includes office visits on the day of surgery and 14 days of post-operative care. The department follows the surgery guidelines in the American Medical Association’s Current Procedural Terminology (CPT).

(4) Payment for surgical procedures that are primarily performed in office settings is reduced by 12 percent when performed in hospital outpatient settings, including emergency departments.

005.02(B)(v) STERILE SURGICAL TRAYS. Payment for a sterile surgical tray includes routine or special surgical instruments, office operating room cost, sutures, supplies, items used to prepare a sterile field for the surgical procedure, and the sterilization and maintenance of these items.

005.02(B)(vi) SUPPORTIVE DEVICES FOR THE FEET. Payment for custom orthotic devices which require impression casting by the podiatrist includes:

(1) Fitting;

(2) Cost of parts and labor;

(3) Repairs due to normal wear and tear within 90 days of the date dispensed; and

(4) Adjustments made when fitting and for 90 days from the date dispensed; and

(a) Adjustments necessitated by changes in the recipient’s medical condition, or the recipient's functional abilities, are reimbursed separately.

005.02(B)(vii) CLINICAL LABORATORY SERVICES. Payment for specimens obtained in the podiatrist's office and sent to an independent clinical lab or hospital for processing must be claimed by the facility performing the tests. The Department does not reimburse the podiatrist for handling specimens or processing or interpreting tests performed outside the podiatrist’s office.

History

• Effective 2021-12-26

Chapter 20 Psychiatric Services for Individuals Age 21 and Older

Neb. Admin. Code tit. 471, ch. 20 Psychiatric Services for Individuals Age 21 and Older {#sec-471-nac-20 omnilex-key=us-ne-regs-official--title-471--471 NAC 20}

TITLE 471 NEBRASKA MEDICAL ASSISTANCE PROGRAM SERVICES

CHAPTER 20 PSYCHIATRIC SERVICES FOR BENEFICIARIES AGE 21 AND OLDER

001. SCOPE AND AUTHORITY. These regulations govern services provided under the Medical Assistance Act, Nebraska Revised Statute (Neb. Rev. Stat.) §§ 68-901 et seq.

002. DEFINITIONS. The following definitions apply:

002.01 ADULT DAY TREATMENT PSYCHIATRIC SERVICES. Psychiatric day treatment is a service in a continuum of care designed to prevent hospitalization or to facilitate the movement of the acute psychiatric beneficiary to a status in which the beneficiary is capable of functioning within the community with less frequent contact with the psychiatric health care provider.

002.02 ADULT INPATIENT HOSPITAL PSYCHIATRIC SERVICES. Inpatient hospital psychiatric services for beneficiaries 21 and over are medically necessary psychiatric services provided to an inpatient.

002.03 ADULT SUBACUTE INPATIENT HOSPITAL PSYCHIATRIC SERVICES. Subacute inpatient hospital psychiatric services for beneficiaries 21 and over are medically necessary short-term psychiatric services provided to a beneficiary.

002.04 ANNUAL SUPERVISION OF NEBRASKA MEDICAID ELIGIBLE BENEFICIARIES. Annual supervision includes a review of a beneficiary’s treatment plan and progress notes, specific case discussion, and assessment of the beneficiary. This review should be completed annually or as often as is medically necessary.

002.05 BEHAVIORAL HEALTH OUTCOMES. Behavioral health outcomes mean improving adaptive ability, preventing relapse or decompensation, stabilization in an emergency situation, or resolving symptoms.

002.06 Family Assessment. A comprehensive family assessment must be completed during the initiation of services. This must be completed by a mental health professional with training and experience in family systems.

002.07 Family Psychotherapy. A treatment session requiring professional expertise between the beneficiary, the nuclear family, the extended family, or both, and the appropriate mental health professional. These services must focus on the family as a system and include a comprehensive family assessment. The specific objective of treatment must be to alter the family system to increase the functional level of the identified beneficiary. This therapy must be provided with the appropriate family members and the identified beneficiary. The focus of the services must be on systems within the family unit. Therapists of families with more than one provider must communicate with and coordinate services with any other provider for the family or individual family members. Coordination of services is required as part of the overall treatment plan and is not billable as a separate service. Duplicate or co-therapist services will not be reimbursed. The beneficiary must be eligible for Nebraska Medicaid and have an acceptable primary psychiatric diagnosis. Crisis outpatient family therapy is an immediate, short-term treatment service provided to a family with urgent psychotherapy needs.

002.08 FUNCTIONAL FAMILY THERAPY (FFT). Functional family therapy (FFT) is family therapy targeted at youth. Functional family therapy (FFT) provides clinical assessment and treatment for the beneficiary and their family to improve communication, problem solving, and conflict management in order to reduce problematic behavior of the beneficiary.

002.09 GEOGRAPHICALLY DEPRIVED AREAS. A geographically deprived area is an area where a psychiatrist is not available in the community, or within a reasonable driving distance of the community, to provide services.

002.10 Group Psychotherapy. A treatment session, requiring professional expertise, between the beneficiary and the appropriate mental health professional in the context of a group setting of at least three and not more than 12 beneficiaries. Group psychotherapy must provide active treatment for a primary psychiatric diagnosis. Nebraska Medicaid does not cover groups that are primarily supportive or educational in nature or the services of a co-therapist.

002.11 Individual Psychotherapy. A treatment session between the beneficiary and the appropriate mental health professional for an acceptable primary psychiatric diagnosis. No additional reimbursement is made for medication checks performed by a physician in the course of individual psychotherapy. Crisis outpatient individual therapy is an immediate, short-term treatment service provided to a beneficiary with urgent psychotherapy needs.

002.12 Inpatient Hospital Services for BENEFICIARIES Age 65 or Older in AN Institution for Mental Disease (IMD). Services provided under the direction of a psychiatrist for the care and treatment of beneficiaries age 65 and older in an institution for mental disease that meets the requirements of federal regulations.

002.13 Inspection of Care Team. The Department's inspection of care team, consisting of a psychiatrist knowledgeable about mental institutions, a qualified registered nurse (RN), and other appropriate personnel as necessary who conduct inspection of care reviews under federal regulations and this chapter.

002.14 Institution for Mental Disease (IMD). An institution for mental disease (IMD) is defined as an entity that primarily provides inpatient treatment for beneficiaries with mental diseases and is credentialed according to federal regulations.

002.15 Interdisciplinary Team. The interdisciplinary team is responsible for developing each beneficiary's individual plan of care. The team must include a board-eligible or board-certified psychiatrist. The team must also include at least two of the following:

(A) A licensed mental health practitioner (LMHP);

(B) A registered nurse (RN) with specialized training or one year's experience in treating individuals with mental illness;

(C) An occupational therapist (OT) who is licensed, if required by state law, and who has specialized training or one year's experience in treating mentally ill individuals; or

(D) A licensed psychologist.

002.16 MEDICAL NECESSITY. Medically necessary services are services provided at an appropriate level of care which are based on documented clinical evaluations including a comprehensive diagnostic workup and supervising practitioner-ordered treatment.

002.17 Medical Review Organization. A review body contracted by Nebraska Medicaid, responsible for pre-admission certification and concurrent and retrospective reviews of care.

002.18 OPIOID TREATMENT PROGRAM (OTP). An opioid treatment program (OTP) offers community-based outpatient addiction treatment for beneficiaries diagnosed with an opioid use disorder (OUD) and meeting level of care criteria. Opioid treatment programs (OTP) administer medications approved by the Food and Drug Administration (FDA) to treat opioid use disorder (OUD) and the alleviation of the adverse medical, psychological, or physical effects of opioid addiction.

002.19 OUTPATIENT. An outpatient is defined as a person who has not been admitted as an inpatient but is registered on the hospital records as an outpatient and receives services, rather than supplies alone.

002.20 Services of Psychiatric Resident Physicians. Psychiatric resident physicians may only provide psychotherapy services and medication checks when these services are directly supervised by the attending psychiatrist. The resident's supervising psychiatrist must sign Nebraska Medicaid approved treatment planning document for services provided by the resident physician. The resident physician will not supervise services of allied health therapists, licensed mental health practitioners (LMHP), or qualified registered nurses (RNs). Resident physician services must be billed using the appropriate Current Procedural Terminology (CPT) and Healthcare Common Procedure Coding System (HCPCS) procedure codes.

002.21 SUPERVISION. Supervision by the supervising practitioner is defined as the critical oversight of a treatment activity or course of action.

003. PHILOSOPHY OF CARE. Nebraska Medicaid's philosophy is that all care provided to beneficiaries must be provided at the least restrictive and most appropriate level of care. More restrictive levels of care will be used only when all other resources have been explored and deemed to be inappropriate.

004. NON-DISCRIMINATION. Nebraska Medicaid providers must comply with applicable federal civil rights laws and must not discriminate on the basis of race, color, national origin, age, sex or disability.

005. FAMILY OF ORIGIN COMPONENT. Care must address family concerns and, whenever possible, involve the family in treatment planning, therapy, and transition and discharge planning. Family may include biological, step, foster, or adoptive parents; siblings or half siblings; and extended family members, as appropriate. Family involvement, or lack thereof, must be documented in the clinical record. For adults who choose not to have family members involved or for whom the treating professional deems family involvement inappropriate or harmful, that information must be documented in the medical record.

005.01 FAMILY INVOLVEMENT. Providers must encourage family members to be involved in the assessment of the beneficiary, the development of the treatment plan, and all aspects of the beneficiary's treatment unless prohibited by the beneficiary through legal action, or because of federal confidentiality laws.

005.02 FLEXIBLE SCHEDULING. Providers must be available to schedule meetings and sessions in a flexible manner to accommodate and work with a family's schedule. This includes the ability to schedule sessions at a variety of times including weekends or evenings.

005.03 TREATMENT PLAN. The provider must document their attempts to involve the family in treatment plan development and treatment plan reviews.

006. COMMUNITY BASED CARE. Care must be community-based and, when appropriate, must involve a representative from the beneficiary's community support system. Community involvement must be documented in the clinical record. This documentation must include any lack of cooperation or resistance from the community support system.

007. DEVELOPMENTALLY APPROPRIATE CARE. Care must address the beneficiary's biological, psychological, and social development. Therapeutic interventions must be congruent with the findings of the developmental level of the beneficiary, based on comprehensive psychiatric and psychological assessments.

008. CULTURALLY COMPETENT CARE. Providers of psychiatric services for beneficiaries age 20 and over must be culturally competent. This includes awareness, acceptance, and respect of differences and continuing self-assessment regarding culture. Cultural competence also includes careful attention to the dynamics of differences and how they affect interactions, assumptions, and the delivery of services. Providers also demonstrate cultural competence through continuous expansion of cultural knowledge and resources through training, readings, and by providing a variety of adaptations to service models in order to meet the needs of different cultural populations.

008.01 CULTURALLY COMPETENT PROVIDERS. Culturally competent providers hire unbiased employees, seek advice and consultation from the minority community, and actively decide whether or not they are capable of providing services to beneficiaries from other cultures. They provide support for staff to become comfortable working in cross-cultural situations, understand the interplay between policy and practice, and are committed to policies that enhance services to diverse beneficiaries.

009. Dually Diagnosed BENEFICIARIES. The treatment provider must incorporate the needs of the dually diagnosed beneficiary and provide active treatment for beneficiaries with concurrent or secondary complicating problems. Dual diagnosis treatment is the simultaneous and integrated treatment of coexisting disorders.

010. Coordinated Services. If a beneficiary is receiving services from more than one psychiatric provider, the providers must assure coordination of all services. That coordination must be documented in the beneficiary's medical record. Coordination of services is required as part of the overall treatment plan, must be covered in one unified treatment plan, and is not billable as a separate service.

011. Provider Enrollment.

011.01 PROVIDER AGREEMENT. A provider of psychiatric services for beneficiaries age 21 and over must complete the appropriate Nebraska Medicaid approved provider agreement form , and submit the completed form to Nebraska Medicaid for approval. Specific requirements for each type of care are listed in the respective subpart. The provider must meet all of these standards in order to be enrolled with Nebraska Medicaid. Nebraska Medicaid is the sole determiner of which providers are approved for participation in this program. The provider will be advised in writing when their participation is approved. A separate application must be submitted for each particular service and each service will be approved separately. The provider must meet the standards for participation as outlined in each subpart of the provider agreement.

011.02 Provider Enrollment Status. The provider enrollment process allows for three types of provider enrollment status based on information from the provider and other sources. Nebraska Medicaid must notify the provider of the status assigned.

011.02(A) PROVISIONAL STATUS. A provider who has recently established services within this chapter or who is new to Nebraska Medicaid will be enrolled with a provisional status. After a minimum of one year of services, Nebraska Medicaid may choose to grant ongoing status to the provider.

011.02(A)(i) APPEAL OF TERMINATION OF PROVIDER ENROLLMENT. Providers can appeal the decision to terminate a provider enrollment.

011.02(B) ONGOING STATUS. A provider must establish ongoing status after a minimum of one year of service within the Nebraska Medicaid requirements.

011.02(C) PROBATIONARY STATUS. A provider can be placed on probationary status when there are deficiencies in meeting Nebraska Medicaid requirements or there are other concerns about the provider's program or practices. While on probationary status, a provider can be required to work with Nebraska Medicaid to develop a corrective action plan. This plan must be submitted to Nebraska Medicaid for approval.

011.02(C)(i) APPEAL OF PROBATIONARY STATUS. Providers can appeal the decision to place a provider on probationary status.

011.02(C)(ii) PROBATIONARY STATUS EVALUATION. The probationary status will be evaluated by Nebraska Medicaid on a frequency based on the situation. At these evaluations, a provider's enrollment may be terminated, placed on further probation, or returned to ongoing status. Providers can appeal these decisions.

011.02(C)(iii) CONTINUED PARTICIPATION. If the deficiencies are not causing immediate jeopardy or compromising the safety of the beneficiaries, then the facility can continue to participate in Nebraska Medicaid. A prohibition of new admissions may occur if there are allegation of abuse or neglect under investigation in relation to the program or staff, the quality of treatment is significantly compromised by the deficiencies, or the provider is violating any laws, regulations, or code of ethics governing their program.

011.02(D) UPDATES. The provider will send to Nebraska Medicaid an update of the services provided in its facility and the current list of staff each year during the anniversary quarter of the provider's enrollment in Nebraska Medicaid as a provider of psychiatric services for beneficiaries 21 and over. This information will also be sent to Nebraska Medicaid if a provider makes changes in how they provide a service. These changes and updates must be indicated on the appropriate Nebraska Medicaid approved provider agreement form.

012. Out-of-State Services. Potential out-of-state providers of services in this chapter must have a specific plan of how they will meet the family and community requirements. This plan will be approved by Nebraska Medicaid to become a provider of Nebraska Medicaid services.

013. Quality Assurance and Utilization Review. All Nebraska Medicaid providers have agreed to provide services under the requirements of this title regarding , provider agreements. If there is any question or concern about the quality of service being provided by an enrolled provider, Nebraska Medicaid may perform quality assurance and utilization review activities to verify the quality of service. If the provider or the services do not meet the standards of this chapter and the specific level of care, the provider may be subject to administrative sanctions or denial of provider agreement for good cause . Nebraska Medicaid may request a refund for all services not meeting the requirements. If beneficiaries are in immediate jeopardy, the sanctions will be imposed without a hearing.

014. OBSERVATION ROOM SERVICES (23:59). When appropriate for brief crisis stabilization, Nebraska Medicaid covers outpatient hospital observation room services up to 23 hours 59 minutes in an emergency room or acute hospital with the following qualifiers:

(A)If a beneficiary receives 24 or more hours of continuous outpatient care, that beneficiary is defined as an inpatient regardless of the hour of admission, whether they used a bed, and whether they remained in the hospital past midnight or the census-taking hour;

(B)When the beneficiary reaches 24 hours of continuous outpatient care, all inpatient medical review prior-authorization requirements noted in this chapter apply; and

(C)The services must be billed as an outpatient hospital psychiatric service on the appropriate Nebraska Medicaid approved health care claim form .

015. PSYCHIATRIC Therapeutic Staff Standards. Psychiatric therapeutic staff for adult services will meet the following requirements:

015.01 Supervising Practitioners. All psychiatric services must be provided under the supervision and direction of a supervising practitioner. The following are the professional designations of those who qualify as a supervising practitioner:

(A) Must be licensed as a physician by the Nebraska Department of Health and Human Services, Division of Public Health or the appropriate licensing agency in the state in which they practice and must be enrolled with Nebraska Medicaid with a primary specialty of psychiatry;

(B) Must be a licensed psychologist by the Nebraska Department of Health and Human Services, Division of Public Health or the appropriate licensing agency of the state in which they practice and must be enrolled with Nebraska Medicaid with a primary specialty of clinical psychology;

(C) Must be a licensed advanced practice registered nurse (APRN) by the Nebraska Department of Health and Human Services, Division of Public Health or the appropriate licensing agency of the state in which they practice, must be enrolled with Nebraska Medicaid, and have proof of a current certification from an approved certification program in a psychiatric or mental health specialty; or

(D) Licensed independent mental health practitioners (LIMP).

015.02 PRACTICE OF SUPERVISION. The critical involvement of the supervising practitioner must be reflected in the initial diagnostic interview, the treatment plan, and the interventions provided.

015.02(A) SUPERVISING PRACTITIONER. The supervising practitioner or their designated and qualified substitute must be available, in person or by telephone, to provide assistance and direction as needed during the time the services are being provided.

015.02(B) SUPERVISORY CONTACT. Supervisory contact may occur in a group setting.

015.02(C) SUPERVISION NOT BILLABLE. Supervision is not billable by either the therapist or the supervising practitioner as it is considered a mandatory component of the care.

015.02(D) SUPERVISOR LIMITATIONS. Psychiatric resident physicians may not supervise allied health therapists for Nebraska Medicaid services.

015.02(E) PERIODIC EVALUATION. The supervising practitioner must periodically evaluate the therapeutic program and determine if treatment goals are being met and if changes in direction or emphasis are needed.

015.03 LICENSED INDEPENDENT MENTAL HEALTH PRACTITIONERS (LIMHP). Licensed independent mental health practitioners (LIMHP) may provide direct care as allowed by the scope of practice requirements set by Nebraska Department of Health and Human Services, Division of Public Health.

015.04 ALLIED HEALTH THERAPISTS. All psychotherapy services provided by allied health therapists must be prescribed by the supervising practitioner and provided under their supervision. All allied health therapists must have knowledge of the interactional systems within families. Allied health therapists include:

(A) SPECIALLY LICENSED PSYCHOLOGISTS. Persons who are specially licensed as psychologists through the Nebraska Department of Health and Human Services, Division of Public Health or the appropriate licensing agency of the state in which they practice;

(B) LICENSED MENTAL HEALTH PRACTITIONERS (LMHP). Persons who are licensed as mental health practitioners (LMHP) by the Nebraska Department of Health and Human Services, Division of Public Health or the appropriate licensing agency of the state in which they practice;

(C) PROVISIONALLY LICENSED MENTAL HEALTH PRACTITIONERS (LMHP). Practitioners who are licensed as a provisional mental health practitioner by the Nebraska Department of Health and Human Services, Division of Public Health or the appropriate licensing agency of the state in which they practice;

(D) QUALIFIED REGISTERED NURSES (RN). A registered nurse (RN) with a bachelor's, master’s, or Doctor of Philosophy (Ph.D.), or certification as a psychiatric clinical specialist or nurse practitioner (NP) by the American Nurse Association who is licensed by the Nebraska Department of Health and Human Services, Division of Public Health or the appropriate licensing agency of the state in which they practice; and

(E) QUALIFIED MENTAL HEALTH PROFESSIONAL OR MASTER’S EQUIVALENT. A holder of a master's degree in a closely related field that is applicable to the bio, psycho, or social sciences or to treatment for persons who are mentally ill and is actively pursuing licensure as a mental health practitioner as allowed by the Nebraska Department of Health and Human Services, Division of Public Health; or a Doctor of Philosophy (Ph.D.) candidate who has bypassed the master's degree but has sufficient hours to satisfy a master's degree requirement.

015.05 SUBSTANTIATED DISCIPLINARY ACTION. Any Nebraska Medicaid provider who is licensed by the Nebraska Department of Health and Human Services, Division of Public Health, and has a substantiated disciplinary action filed against the license that limits the provision of services will not be allowed to provide Nebraska Medicaid services. If a provider is licensed by another state, substantiated disciplinary action filed against that license that limits the provision of services will be cause for termination as a Nebraska Medicaid provider.

016. PAYMENT LIMITATIONS. Payment for psychiatric services for beneficiaries age 21 and older under Nebraska Medicaid is limited to payment for medically necessary psychiatric services for medically necessary primary psychiatric diagnoses.

016.01 CHRONIC OR CUSTODIAL. Nebraska Medicaid does not pay for psychiatric services that are chronic or custodial. Psychiatric services may be covered when treating an acute exacerbation of a long-term or chronic condition. The provider must document medical necessity and active treatment for each beneficiary . Documentation is kept in the beneficiary’s medical record. Nebraska Medicaid does not reimburse for services for diagnoses of developmental disabilities, or V codes as part of this chapter.

017. MEDICAL NECESSITY.

017.01 NECESSARY TREATMENT INTERVENTIONS AND SUPPLIES. Biopsychosocially necessary treatment interventions and supplies are those which are:

(A)Consistent with the behavioral health condition and conducted with the treatment of the beneficiary as the primary concern;

(B)Supported by sufficient evidence to draw conclusions about the treatment intervention's effects of behavioral health outcomes;

(C)Supported by evidence demonstrating the treatment intervention can be expected to produce its intended effects on behavioral health outcomes;

(D)Supported by evidence demonstrating the intervention's intended beneficial effects on behavioral health outcomes outweigh its expected harmful effects;

(E)Cost effective in addressing the behavioral health outcome;

(F)Determined by the presentation of behavioral health conditions, not necessarily by the credentials of the service provider;

(G)Not primarily for the convenience of the beneficiary or the provider; and

(H)Delivered in the least restrictive setting that will produce the desired results in accordance with the needs of the beneficiary.

017.02 BEHAVIORAL HEALTH CONDITIONS. Behavioral health conditions are the diagnoses identified in diagnostic manuals commonly recognized in this field.

018. active treatment. Active treatment is provided under an individualized treatment plan developed by the professional staff as required for each level of care. The plan must be based on a comprehensive evaluation of the beneficiary’s restorative needs and potentialities for a primary psychiatric diagnosis. An isolated service not furnished under a planned program of therapy or diagnosis is not active treatment even when the service is therapeutic or diagnostic in nature.

018.01 SERVICES REQUIRED TO IMPROVE CONDITION OR DIAGNOSE. The services must be reasonably expected to improve the beneficiary's condition or to determine a psychiatric diagnosis. The treatment must, at a minimum, be designed to reduce or control the beneficiary's psychiatric symptoms to facilitate the beneficiary's movement to a less restrictive environment within a reasonable period of time.

018.02 ACTIVE TREATMENT. The administration of a drug or drugs does not by itself necessarily constitute active treatment .

018.03 ACTIVE TREATMENT REQUIREMENT. The active treatment services must be supervised, directed, and evaluated by a supervising practitioner. The services of other qualified professionals must be prescribed by a supervising practitioner to meet the specific needs of the beneficiary. The supervising practitioner must evaluate the therapeutic program and determine if treatment goals are being met and if changes in direction or emphasis are needed on a regular basis , as defined for the level of care being provided. The evaluation must be based on periodic consultations and conferences with all current treatment staff, reviews of the beneficiary’s clinical record, and regularly scheduled beneficiary interviews as required for the level of care being provided.

019. TREATMENT PLANS. A treatment plan must be established for each beneficiary. The treatment plan is a comprehensive plan of care formulated by the clinical staff under the direction of a supervising practitioner and is based on the individual needs of the beneficiary. The treatment plan validates the necessity and appropriateness of services and outlines the service delivery needed to meet the identified needs, reduce problem behaviors, and improve overall functioning.

019.01 TREATMENT PLAN. The treatment plan must be based upon an assessment of the beneficiary’s problems and needs in the areas of emotional, behavioral, and skills development. The treatment plan must be individualized to the beneficiary and must include the specific problems, behaviors, or skills to be addressed; clear and realistic goals and objectives; services, strategies, and methods of intervention to be implemented; criteria for achievement; target dates; methods for evaluating the beneficiary’s progress; and the responsible professional.

019.02 GOALS AND OBJECTIVES. The goals and objectives documented on the treatment plan must reflect the recommendations from the initial diagnostic interview, the supervising practitioner, and the therapist. The treatment interventions provided must reflect these recommendations, goals, and objectives. Evaluation of the treatment plan by the therapist and the supervising practitioner should reflect the beneficiary’s response to the treatment interventions based on the recommendations, goals and objectives.

019.02(A) SUFFICIENT NEED. The beneficiary must have sufficient need for active psychiatric treatment at the time the psychiatric service provider accepts the beneficiary.

019.02(B) BEST CHOICE. The treatment must be the best choice for expecting reasonable improvement in the beneficiary’s psychiatric condition.

019.03 TREATMENT PLAN TIME FRAMES. A treatment plan must be developed for every beneficiary within the time frames specified for each type of service and must be placed in the beneficiary’s clinical record. If a treatment plan is not developed within the specified time frames, services rendered may not be reimbursable by Nebraska Medicaid.

019.04 TREATMENT PLAN REVIEW. The treatment plan must be reviewed and updated by the treatment team according to the beneficiary’s level of functioning. Minimum time frames for treatment plan reviews are dependent on the type of service. Refer to each individual service description for the review requirements. The purpose of this review is to ensure that services and treatment goals continue to be appropriate to the beneficiary’s current needs, and to assess the beneficiary’s progress and continued need for psychiatric services. The supervising practitioner and treatment team members must sign and date the treatment plan at each treatment plan review.

019.05 COORDINATION OF SERVICES. If the beneficiary is receiving services from more than one psychiatric provider, these agencies must coordinate their services and develop one overall treatment plan for the beneficiary or family. This treatment plan is used by all providers working with the beneficiary or family.

019.06 BENEFICIARY AND FAMILY INVOLVEMENT. The provider must work with the beneficiary and family, at the beneficiary’s discretion, to develop the treatment plan.

019.07 DOCUMENTATION. The provider must document their attempts to involve the family in treatment plan development and treatment plan reviews. A variety of communication means should be considered. Providers must be available to schedule meetings and sessions in a flexible manner to accommodate and work with a family's schedule. This includes the ability to schedule sessions at a variety of times including weekends or evenings. Providers must encourage family members to be involved in the assessment of the beneficiary, the development of the treatment plan, and all aspects of the beneficiary’s treatment unless prohibited by the beneficiary, through legal action, or because of federal confidentiality laws.

019.08 TREATMENT PLANNING DOCUMENT UPDATE. The treatment plan must be reviewed and updated every 90 days, or more frequently if indicated. The beneficiary’s clinical record must include the supervising practitioner's comments on the beneficiary’s response to treatment and changes in the treatment plan. The supervising practitioner must review and sign off on the updated treatment plan prior to its initiation. Changes in the treatment plan must be noted on the current treatment planning document. In addition, the psychiatric service provider must complete an updated treatment planning document annually, or more frequently, if necessary, to reflect changes in treatment needs. A copy of the current treatment planning document must be maintained in the beneficiary’s medical record.

019.08(A) SIGNATURE. For services provided under the supervision of a supervising practitioner, the signature of the supervising practitioner on the treatment planning document indicates their agreement that the scheduled treatment interventions are appropriate.

020. TRANSITION AND DISCHARGE PLANNING. When a beneficiary is transferred from one level of care to another, transition and discharge planning must be performed and documented by the treating providers, beginning at the time of admission.

020.01 STANDARDS FOR TRANSITION AND DISCHARGE PLANNING. Providers must meet the following standards regarding transition and discharge planning:

(A)Transition and discharge planning must begin on admission;

(B)Discharge planning must be based on the treatment plan to achieve the beneficiary’s discharge from the current treatment status and transition into a different level of care;

(C)Transition and discharge planning must address the beneficiary’s need for ongoing treatment to maintain treatment gains and to continue normal physical and mental development following discharge;

(D)Discharge planning must include identification of and clear transition into developmentally appropriate services needed following discharge;

(E)Treatment providers must make or facilitate referrals and applications to the next level of care or treatment provider;

(F)The current provider must arrange for prompt transfer of appropriate records and information to ensure continuity of care during transition into the next level of care; and

(G)A written transition and discharge summary must be provided as part of the medical record.

021. clinical records. Clinical records must be arranged in a logical order such that the clinical information can be easily reviewed, audited, and copied. Each provider must maintain accurate, complete, and timely records and must always adhere to procedures that ensure the confidentiality of clinical data.

021.01 RECORDS REQUIREMENTS. Treatment provided to the beneficiary must be written legibly or typed in the clinical record in a manner and with a frequency to provide a full picture of the therapies provided, as well as an assessment of the beneficiary’s reaction to it. If three separate individuals cannot understand the information written in a record because of handwriting which is difficult to read, the program must provide a readable format. Reimbursement for services may be denied if claims or medical records are not legible. Recoupment of previous payments for services may result if appropriate, legible, and complete records are not maintained for the beneficiary .

021.02 INSPECTION. Providers of psychiatric services to beneficiaries age 21 and older must comply with Nebraska Medicaid requests to review clinical records. This review may be of photocopies or on-site at the discretion of Nebraska Medicaid .

022. INSPECTIONS OF CARE. Inspections of care will be conducted as outlined in federal regulations .

023. PROCEDURE CODES. Providers must use Current Procedural Terminology (CPT) and Healthcare Common Procedure Coding System (HCPCS) procedure codes when submitting claims to Nebraska Medicaid for services.

024. INITIAL DIAGNOSTIC INTERVIEW. For services in this chapter to be covered by Nebraska Medicaid, the necessity of the service for the beneficiary must be established through an Iinitial Ddiagnostic Iinterview. The beneficiary must have a diagnosable mental health disorder of sufficient duration to meet diagnostic criteria that results in functional impairment which substantially interferes with or limits the beneficiary’s role or functioning within the family, job, school, or community. The initial diagnostic interview is used to determine the presence or absence of a mental health disorder, identify the problems and needs, develop goals and objectives, and determine appropriate strategies and methods of intervention for the beneficiary. This comprehensive plan of care will be outlined in the individualized treatment plan and should reflect an understanding of how the beneficiary’s particular issues will be addressed with the service. The initial diagnostic interview must occur prior to the initiation of treatment interventions and must include a baseline of the beneficiary’s current functioning and treatment needs. Except for beneficiaries receiving acute inpatient hospital services, crisis services, or substance use disorder services are not required to receive an initial diagnostic interview before services are initiated. Initial diagnostic interviews that are incomplete will not be reimbursable.

024.01 COVERED SERVICES. Initial diagnostic interviews must contain:

(A) A mental health evaluation with relevant beneficiary information, mental status exam, and diagnosis; and

(B) Recommendations:

(i) Treatment needs and recommended interventions for beneficiary and family;

(ii) Identification of who needs to be involved in the beneficiary's treatment;

(iii) Overall plan to meet the treatment needs of the beneficiary including transitioning to lower levels of care and discharge planning;

(iv) A means to evaluate the beneficiary's progress throughout their treatment and outcome measures at discharge;

(v) Recommended linkages with other community resources; and

(vi) Other areas that may need further evaluation.

024.02 PROVIDER AGREEMENT. Providers of the acute services must facilitate or perform the initial diagnostic interview. Providers of crisis intervention services must facilitate the referral to or provide the initial diagnostic interview if it has not already occurred. For providers of substance use disorder services, if a co-occurring mental health condition is known or suspected, the clinician will refer the beneficiary for an initial diagnostic interview, if the clinician is unable to also do an initial diagnostic interview by scope of practice.

024.03 involvement of the supervising practitioner. The supervising practitioner must complete the initial diagnostic interview. The supervising practitioner must work with the staff person to develop the recommendations. The supervising practitioner must sign the assessment document.

024.04 PAYMENT FOR INITIAL DIAGNOSTIC INTERVIEW. Practitioners must use the national code sets to bill for the initial diagnostic interview. The reimbursement for these codes includes interview time, documentation review, and the writing of the report and recommendations.

024.04(A) PROVIDERS OF the INITiAL DIAGNOSTIC INTERVIEW. Providers of the initial diagnostic interview must bill on the appropriate Nebraska Medicaid approved health care claim form or electronic claim. The completed initial diagnostic interview must be included in the beneficiary file and available for review upon request. Failure to produce documentation of an initial diagnostic interview upon request, or lack of inclusion in the beneficiary file determined during review, must be cause for claim denial or refund.

024.04(B) REIMBURSEMENT. Nebraska Medicaid will provide reimbursement for one initial diagnostic interview per treatment episode. Addendums may be included if additional information becomes available. If the beneficiary remains involved continuously in treatment for more than one year, reimbursement for an initial diagnostic interview may be available annually. If the beneficiary leaves treatment prior to a successful discharge and returns for further treatment, the provider must assess the need for an addendum or a new initial diagnostic interview. A second initial diagnostic interview within a year must be prior authorized. Practitioners must use national code sets to bill for this activity.

024.05 DISTRIBUTION OF THE INITIAL DIAGNOSTIC INTERVIEW. Providers must distribute complete copies of the initial diagnostic interview to other treatment providers in a timely manner when the information is necessary for a referral and the appropriate releases of information are secured.

025. OUTPATIENT PSYCHIATRIC SERVICES. All requirements in this chapter apply to outpatient psychiatric services.

025.01 COVERED OUTPATIENT PSYCHIATRIC THERAPEUTIC SERVICES. Nebraska Medicaid covers the following outpatient psychiatric therapeutic services for beneficiaries age 21 and older as defined in this chapter:

(A)Psychiatric evaluation;

(B)Psychological evaluation;

(C)Psychological testing;

(D)Individual psychotherapy;

(E)Group psychotherapy overview must be approved by Nebraska Medicaid prior to billing for this service;

(F)Family psychotherapy services;

(G)Family assessment;

(H)Medication checks by a physician, physician assistant (PA), or advanced practice registered nurse (APRN) ;

(I)Electroconvulsive therapy;

(J) Annual supervision of eligible beneficiaries by a psychologist or a licensed independent mental health practitioner (LIMHP);

(K) Functional family therapy (FFT); and

(L) Opioid treatment program (OTP).

025.02 RESTRICTIONS. Nebraska Medicaid does not reimburse for services for diagnoses of developmental disabilities, or V codes as part of this chapter.

025.03 SKILLED NURSING. Skilled nursing services for the monitoring of medications is available through home health agencies .

025.04. PSYCHIATRIC THERAPEUTIC STAFF STANDARDS. The following psychiatric therapeutic staff may provide services and must meet the requirements as defined in this chapter:

(A)Physician;

(B)Licensed psychologist;

(C) Physician assistant (PA);

(D) Advanced practice registered nurse (APRN);

(E)Licensed independent mental health practitioner (LIMHP); and

(F)Allied health therapists.

025.04(i) LOCATION OF SERVICES. Outpatient psychiatric services by qualified staff may be provided in:

(1)A licensed community mental health program which meets the criteria for approval by the Joint Commission , the Commission on Accreditation of Rehabilitation Facilities (CARF), the Council on Accreditation (COA), or the American Osteopathic Association (AOA) ;

(2)A licensed and certified hospital which provides psychiatric services and which:

(a)Is maintained for the care and treatment of patients with primary psychiatric disorders;

(b)Is licensed or formally approved as a hospital by the Nebraska Department of Health and Human Services, Division of Public Health, or if the hospital is located in another state, the officially designated authority for standard - setting in that state;

(c)Is accredited by the Joint Commission or the American Osteopathic Association (AOA);

(d)Has licensed and certified psychiatric beds;

(e)Meets the requirements for participation in Medicare for psychiatric hospitals; and

(f)Has in effect a utilization review plan applicable to all Nebraska Medicaid clients;

(3)A licensed and certified hospital which provides acute medical services and which:-

(a)Is maintained for the care and treatment of patients with acute medical disorders;

(b)Is licensed or formally approved as a hospital by the Nebraska Department of Health and Human Services, Division of Public Health, or if the hospital is located in another state, the officially designated authority for standard - setting in that state;

(c)Is accredited by the Joint Commission or the American Osteopathic Association (AOA);

(d)Meets the requirements for participation in Medicare for acute medical hospitals; and

(e)Has in effect a utilization review plan applicable to all Nebraska Medicaid beneficiaries;

(4)A physician's private office;

(5)A licensed psychologist's private office;

(6)An allied health therapist's private office;

(7)The beneficiary's home;

(8)Nursing homes; or

(9)Rural mental health clinics or federally qualified health centers.

025.05 PROVIDER AGREEMENT. A provider of psychiatric outpatient services must complete a provider agreement, and submit the form to Nebraska Medicaid for approval.

025.05(A) INDEPENDENT PSYCHIATRIC SERVICE PROVIDERS. Independent psychiatric service providers must complete the appropriate form . The provider agreement issued to the supervising practitioner or clinic is used to claim services provided by allied health therapists who are in the practitioner’s or clinic’s employ or supervision. For outpatient psychiatric services provided through a group practice, the provider agreement must be kept current by providing Nebraska Medicaid with:

(i)The termination date of any therapist leaving the group practice;

(ii)The initial employment date of any therapist joining the group practice; and

(iii)A current resume detailing education and clinical experience for each application for allied health therapists.

025.05(B) HOSPITALS. Hospitals as defined in this chapter providing outpatient psychiatric services must complete the appropriate Nebraska Medicaid approved provider agreement orm .

025.05(C) VERIFICATION. Providers are responsible for verifying that allied health therapists, physicians, physician assistants (PA), advanced practice registered nurses (APRN), and licensed psychologists are appropriately licensed for the correct scope of practice.

025.05(D) GEOGRAPHICALLY DEPRIVED AREAS. A physician who is qualified, skilled, and experienced in the diagnosis and treatment of psychiatric disorders may serve as an alternative to a psychiatrist for outpatient services in a geographically-deprived area. A resume detailing the physician's mental health education and experience must accompany the provider agreement. When outpatient psychiatric services are provided under these conditions, the physician is subject to all policy requirements outlined for psychiatrists. Psychiatric services provided by the attending physician, other than a psychiatrist, are limited to psychotherapy services provided in a physician's office which do not exceed six months without documented consultation between the physician providing the service and a psychiatrist.

025.06 COVERAGE CRITERIA FOR OUTPATIENT PSYCHIATRIC SERVICES. Nebraska Medicaid covers outpatient psychiatric therapeutic services listed in this chapter when the services are medically necessary and provide active treatment as defined in this chapter.

025.06(A) DOCUMENTATION OF MEDICAL NECESSITY AND ACTIVE TREATMENT. Medical necessity and active treatment for outpatient services is documented through the use of Nebraska Medicaid’s approved treatment planning document, in accordance with this chapter which must be developed by a licensed practitioner and supervising practitioner based on a thorough evaluation of the beneficiary's restorative needs and potentialities for a primary psychiatric diagnosis.

025.06(B) SERVICES PROVIDED BY ALLIED HEALTH THERAPISTS. Services provided by allied health therapists, as defined in this chapter must be prescribed and provided under the direction of a supervising practitioner. Supervision must meet the active treatment criteria in this chapter .

025.06(B)(i) RE-EVALUATION. The supervising practitioner must personally re-evaluate the beneficiary through a face-to-face contact annually or more often, if necessary.

psychiatric service provider accepts the client; and

025.07 DOCUMENTATION IN BENEFICIARY’S CLINICAL RECORDS. : All documents submitted to Nebraska Medicaid must contain sufficient information for identification . . The beneficiary's medical record must also include:

(A)The initial diagnostic interview;

(B)The treatment plan, including the initial document, updates, and current treatment plan;

(C)The beneficiary's diagnosis. A provisional or interim psychiatric diagnosis must be established by the supervising practitioner at the time the beneficiary is accepted for treatment. This diagnosis must be reviewed and revised as a part of the treatment plan;

(D)A chronological record of all psychiatric services provided to the beneficiary, the date performed, the duration of the session, and the staff member who conducted the session;

(E)A chronological account of all medications prescribed, the name, dosage, and frequency to be administered and beneficiary's response;

(F)6A comprehensive family assessment;

(G)A clear record of family and community involvement;

(H)Documentation verifying coordination with other therapists when more than one provider is involved with the beneficiary and family; and

(I)Transition and discharge planning.

025.08 UTILIZATION REVIEW. Payment for outpatient psychiatric services is based on adequate legible documentation of medical necessity and active treatment. All outpatient claims are subject to utilization review before payment.

025.08(A) ADDITIONAL DOCUMENTATION. Additional documentation from the beneficiary's clinical record may be requested prior to considering authorization of payment when the treatment plan does not adequately document medical necessity or active treatment.

025.09 PSYCHOLOGICAL TESTING AND EVALUATION SERVICES. Testing and evaluation services must reasonably be expected to contribute to the diagnosis and plan of care established for the individual beneficiary.

025.09(A) PROVIDER. Testing and evaluation services may be performed by a licensed psychologist, or by a specially licensed psychologist or a master's level person approved to administer psychological testing under the supervision of a licensed psychologist.

025.09(A)(i) SUPERVISING PRACTITIONER. If testing and evaluation services are provided by a licensed, non-certified psychologist, the services must be ordered by a supervising practitioner.

025.09(A)(ii) COPY OF TESTING NARRATIVE SUMMARY. A copy of the testing narrative summary must be kept in the beneficiary’s clinical record. If the evaluation is court ordered, the provider must note this on the treatment plan and include documentation of medical need for the service.

025.09(B) GRAND-PARENTED MASTERS PSYCHOLOGISTS. Services provided by master's level clinical psychologists whose certification has been grand-parented by the Department of Health and Human Services, Division of Public Health may be covered under this chapter. Documentation of the grand-parented status may be required.

025.09(C) MEDICATION CHECKS. Medication checks may only be done when medically necessary. When a physician, physician assistant (PA) or advanced practice registered nurse (APRN) provides psychotherapy services, medication checks are considered a part of the psychotherapy service.

025.09(C)(i) MEDICATION CHECK. The supervising physician may provide a medication check when a licensed psychologist or an allied health therapist provides the psychotherapy service. Only physicians and psychiatrically trained physician assistants (PA) or advanced practice registered nurses (APRN) may provide medication checks.

025.09(D) TRAVEL TO THE HOME OF BENEFICIARIES WHO HAVE HAVE HANDICAPS. If a beneficiary has a handicapping physical condition that prevents them from traveling to a mental health clinic or office, the provider may request prior authorization to bill for mileage to the beneficiary's home. The information requested must be provided, in writing, to Nebraska Medicaid or their designee for consideration. The following requirements must be met:

(i)The provider requests prior authorization before the initiation of services;

(ii)The treatment must meet the criteria for active treatment and medical necessity;

(iii)The beneficiary's handicapping physical condition prevents their travel to the mental health clinic or office; and

(iv)The beneficiary's home is more than 30 miles from the clinic or office.

025.09(E) FAMILY ASSESSMENT. Nebraska Medicaid covers family assessments used to identify the functional level of the family unit and the system changes that would influence this functional level. This includes interviews with the beneficiary and collateral parties.

025.09(F) ANNUAL SUPERVISION OF NEBRASKA MEDICAID ELIGIBLE BENEFICIARIES BY A PSYCHOLOGIST OR A LICENSED INDEPENDENT MENTAL HEALTH PRACTITIONER (LIMHP). The supervising practitioner must be available in person or by telephone to provide assistance as needed during the time services are being provided. The critical involvement of the supervising practitioner is to be reflected in the initial diagnostic interview, the treatment plan, and the interventions provided.

025.09(G) FUNCTIONAL FAMILY THERAPY (FFT). Functional family therapy (FFT) is family therapy targeted at youth.

025.09(G)(i) INITIAL DIAGNOSTIC INTERVIEW. An initial diagnostic interview must be completed prior to the beginning of treatment and will serve as the initial treatment plan until a comprehensive treatment plan is completed.

025.09(G)(ii) STAFFING. All staffing must be adequate to meet the individualized treatment needs of the beneficiary and meet the responsibilities of each staff position as outlined in the functional family therapy (FFT) model.

025.09(G)(iii) TREATMENT PLAN REQUIREMENTS. Assessments and treatment must address mental health and substance use disorder needs, and mental health and emotional issues related to medical conditions. The treatment plan must be individualized and include the specific problems, behaviors, or skills to be addressed; clear and realistic goals and objectives; services, strategies, and methods of intervention to be implemented; criteria for achievement; target dates; methods for evaluating the beneficiary’s progress; and the responsible professional. The treatment plan must be developed with the beneficiary and the identified, appropriate family members as part of the outpatient family therapy treatment planning process. The treatment plan must meet the following requirements:

(1) The treating provider must consult with or refer to other providers for general

medical, psychiatric, and psychological needs as indicated;

(2) It is the treating provider’s responsibility to coordinate with other treating professionals as needed;

(3) The treatment plan will be reviewed every 90 days or more often if clinically indicated;

(4) After hours crisis assistance must be available; and

(5) Services must be trauma informed, culturally sensitive, age and developmentally appropriate, and incorporate evidence-based practices when appropriate.

025.09(G)(iv) FUNCTIONAL FAMILY THERAPY (FFT). A functional family therapy (FFT) treatment provider must have a master’s degree or greater and be a member of an active team. An active functional family therapy (FFT) team requires a functional family therapy (FFT) certified clinical supervisor and at least three functional family therapy (FFT) certified treatment providers working collaboratively with one another using the functional family therapy (FFT) model.

025.09(G)(v) TREATMENT PROVIDERS. Treatment providers may be any of the following: physician, physician assistant (PA), advanced practice registered nurse (APRN), nurse practitioner (NP), licensed psychologist, provisionally licensed psychologist, licensed independent mental health practitioner (LIMHP), licensed mental health professional, and a provisionally licensed mental health practitioner (LMHP) acting within their scope of practice.

025.09(G)(v)(1) TREATMENT CLINICAL SUPERVISORS. Treatment clinical supervisors must be physicians, physician assistants (PA), licensed psychologists, or licensed independent mental health practitioners (LIMHP) certified in functional family therapy (FFT) model and with experience in the practice of psychotherapy. All psychiatric and psychotherapy services will be prescribed and provided under the supervision and direction of a supervising practitioner. Supervision is not a billable service.

025.09(G)(v)(2) TREATMENT ASSESSMENT PROVIDERS. Treatment assessment providers may be any of the following: physicians, physician assistants (PA), psychiatric advanced practice registered nurse practitioners (APRN), psychologists, provisionally licensed psychologists, or licensed independent mental health practitioners (LIMHP), all acting within their scope of practice.

025.09(H) OPIOID TREATMENT PROGRAM (OTP). An opioid treatment program (OTP) treatment must be compliant with federal regulations.

025.09(H)(i) CERTIFICATION. Treatment must be provided by Substance Abuse and Mental Health Services Administration (SAMHSA) certified treatment centers that meet federal regulatory requirements.

025.09(H)(ii) COORDINATION. Opioid treatment must be coordinated through a collaborative process that implements, monitors, and evaluates the options and services required to meet the beneficiary’s needs and includes referrals to outside resources when the needed services are not offered by the opioid treatment program (OTP). Providers must establish a plan of care with a clinically appropriate maintenance period that is based on assessments of withdrawal symptoms using standardized scales and evidence-based practice.

025.09(H)(iii) ASSESSMENTS. Ongoing assessments must meet the following requirements:

(1) A substance use assessment must be completed prior to initiation of services and must be updated annually;

(2) A substance use addendum should be completed if determined to be medically necessary; and

(3) Assessments and addendums must be completed by one of the following licensed medical professionals:

(a) Licensed or provisionally licensed psychologist;

(b) Licensed independent mental health practitioner (LIMHP);

(c) Licensed or provisionally licensed mental health practitioner (LMHP); and

(d) Licensed or provisionally licensed alcohol and drug counselor (LADC).

025.09(H)(iv) OPIOID AGONIST. Opioid agonist medications must be administered and dispensed by licensed professionals authorized by law. A physician, physician assistant (PA) or advance practice registered nurse(APRN)must determine and document, in writing, the initial dose of opioid agonist medications and schedule to be followed for each beneficiary. This information is to be communicated to the licensed medical staff supervising the dispensing of any opioid replacement treatment medication. Opioid agonist medications are provided in conjunction with rehabilitative and medical services.

025.10 PAYMENT FOR OUTPATIENT BEHAVIORAL HEALTH SERVICES IN A HOSPITAL. Nebraska Medicaid pays for covered outpatient mental health services, except for laboratory services, at the lower of:

(i)The provider's submitted charge; or

(ii)The allowable amount for that procedure code in the Medicaid Practitioner Fee Schedule for that date of service. The allowable amount is indicated in the fee schedule as:

(1)The unit value multiplied by the conversion factor;

(2)The maximum allowable dollar amount; or

(3)The reasonable charge for the procedure as determined by Nebraska Medicaid , indicated as BR - by report or RNE - rate not established in the fee schedule.

025.10(B) REVISIONS OF THE FEE SCHEDULE. Nebraska Medicaid reserves the right to adjust the fee schedule to:

(i)Comply with changes in state or federal requirements;

(ii)Comply with changes in national standard code sets ;

(iii)Establish an initial allowable amount for a new procedure based on information that was not available when the fee schedule was established for the current year; and

(iv)Adjust the allowable amount when Nebraska Medicaid determines that the current allowable amount is:

(1)Not appropriate for the service provided; or

(2)Based on errors in data or calculation.

025.10(C) UPDATES TO FEE SCHEDULE. Nebraska Medicaid may issue revisions of the Nebraska Medicaid Practitioner Fee Schedule during the year that it is effective. Providers will be notified of the revisions and their effective dates.

025.11 BILLING REQUIREMENTS. For outpatient psychiatric service providers, the following requirements must be met:

(A)Community mental health programs providing outpatient psychiatric services must submit all claims for outpatient services on the appropriate Nebraska Medicaid approved health care claim form or electronic claim;

(i) Payment for approved outpatient psychiatric services provided by employees of a community mental health program is made to the facility;

(B)Hospitals providing outpatient psychiatric services must submit all claims for non-physician services on the appropriate Nebraska Medicaid approved health care claim form or electronic claim;

(i) All physician services must be submitted on the appropriate Nebraska Medicaid approved health care claim form ; and

(ii) Payment for approved outpatient psychiatric services provided by employees of a hospital is made to the facility;

(C)Independent providers of outpatient psychiatric services must submit all claims for outpatient psychiatric services provided in their private office on the appropriate Nebraska Medicaid approved health care claim form or electronic claim; and

(i) Payment for approved outpatient psychiatric services provided in an independent provider's private office is made to the provider as identified on the provider agreement.

025.12 DOCUMENTATION FOR CLAIMS. For outpatient psychiatric services, unless otherwise instructed by Nebraska Medicaid or their designee, the following documentation must be kept in the beneficiary’s file for each claim:

(A)The initial treatment plan; or

(B)An updated version of the treatment plan completed every 90 days.

025.13 PSYCHOLOGICAL TESTING AND EVALUATION. For psychological testing and evaluation services, unless otherwise instructed by Nebraska Medicaid, the following information must be kept in the beneficiary’s file:

(A)The treatment plan;

(B)Medical necessity for the service documented on the treatment plan;

(C)The documentation that the evaluation services will reasonably be expected to contribute to the diagnosis and plan of care established for the individual beneficiary; and

(D)A narrative of the testing results.

025.14 PROCEDURE CODES AND DESCRIPTIONS. Current Procedural Terminology (CPT) and Healthcare Common Procedure Coding System (HCPCS) procedure codes used by Nebraska Medicaid are listed in the Nebraska Medicaid Practitioner Fee Schedule .

026. ADULT DAY TREATMENT PSYCHIATRIC SERVICES.

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026.01 COVERED DAY TREATMENT SERVICES. Psychiatric day treatment programs must provide the following mandatory services and at least two of the following optional services. Payment for both mandatory services and optional services is included in the rate for day treatment. Providers must not make any additional charges to Nebraska Medicaid or to the beneficiary.

026.01(A) MANDATORY SERVICES. The following services must be included in a program for psychiatric day treatment to be approved for participation in the Nebraska Medical Assistance Program.

026.01(A)(i) MEDICALLY NECESSARY PSYCHOTHERAPY SERVICES. These services must demonstrate active treatment of a beneficiary with a psychiatric condition. These services are subject to program limitations and must be provided by professionals operating within the appropriate scope of practice, including individual psychotherapy, group psychotherapy, family psychotherapy, and family assessment if appropriate.

026.01(A)(ii) MEDICALLY NECESSARY NURSING SERVICES. Services directed by a registered nurse (RN) who evaluates the particular medical nursing needs of each beneficiary and provides for the care and treatment that is indicated by Nebraska Medicaid approved treatment planning document approved by the supervising practitioner.

026.01(A)(iii) MEDICALLY NECESSARY PSYCHOLOGICAL DIAGNOSTIC SERVICES. Testing and evaluation services must reasonably be expected to contribute to the diagnosis and plan of care established for the individual beneficiary. Testing and evaluation services may be performed by a licensed psychologist. If testing and evaluation services are provided by a specially licensed psychologist or approved Master's level person, the services must be ordered by a supervising practitioner. Medical necessity must be documented by the supervising practitioner. Reimbursement for psychological diagnostic services is included in the per diem and will not be reimbursed for separately.

026.01(A)(iv) MEDICALLY NECESSARY PHARMACEUTICAL SERVICES. If medications are dispensed by the program, pharmacy services must be provided under the supervision of a registered pharmacy consultant; or the program may contract for these services through an outside facility that meets applicable provider participation requirements. All medications must be stored in a special locked storage space and administered only by a physician, physician assistant (PA), advanced practice registered nurse (APRN), registered nurse (RN), or licensed practical nurse (LPN).

026.01(A)(v) MEDICALLY NECESSARY DIETARY SERVICES. If meals are provided by a day treatment program, services must be supervised by a registered dietitian, based on the beneficiary's individualized medical diet needs. The program may contract for these services through an outside licensed certified facility.

026.01(A)(vi) TRANSITION AND DISCHARGE. Transition and discharge planning must meet the requirements of this chapter .

026.01(B) OPTIONAL SERVICES. The program must provide two of the following optional services. The beneficiary must have a need for the services, a supervising practitioner must order the services, and the services must be a part of the beneficiary's treatment plan. The therapies must be restorative in nature, not prescribed for conditions that have plateaued or cannot be significantly improved by the therapy, or which would be considered maintenance therapy. In appropriate circumstances, occupational therapy (OT) may be covered if prescribed as an activities therapy in a psychiatric program:

(i)Services provided or supervised by a licensed or certified therapist may be provided under the supervision of a qualified consultant or the program may contract for these services from a professional that meets applicable provider participation requirements, as listed below:

(1)Recreational therapy;

(2)Speech therapy;

(3)Occupational therapy (OT);

(4)Vocational skills therapy; and

(5)Self-care services: services supervised by a registered nurse (RN) or occupational therapist (OT) who is oriented toward activities of daily living and personal hygiene;

(ii)Social work provided by a bachelor's level social worker: social services to assist with personal, family, and adjustment problems which may interfere with effective use of treatment ;

(iii)Social skills building; and

(iv)Life survival skills.

026.01(C) SPECIAL TREATMENT PROCEDURES IN DAY TREATMENT. If a beneficiary needs behavior management and containment beyond unlocked time outs or redirection, special treatment procedures may be utilized. Special treatment procedures in day treatment are limited to physical restraint, and locked time out (LTO). Mechanical restraints and pressure point tactics are not allowed. Facilities must meet the following standards regarding special treatment procedures:

(i)De-escalation techniques must be taught to staff and used appropriately before the initiation of special treatment procedures;

(ii)Special treatment procedures may be used only when a beneficiary's behavior presents a danger to self or others, or to prevent serious disruption to the therapeutic environment; and

(iii)The beneficiary's treatment plan must address the use of special treatment procedures and have a clear plan to decrease the behavior requiring locked time out (LTO) or physical restraints.

026.01(D) STANDARDS DOCUMENTED. These standards must be reflected in all aspects of the treatment program. Attempts to de-escalate, the special treatment procedure and subsequent processing must be documented in the clinical record and reviewed by the supervising practitioner.

026.02 PROVIDER STANDARDS. Providers of day treatment services must meet the following standards:

026.02(A) NON-HOSPITAL BASED DAY TREATMENT. A center providing day treatment must be:

(1)Appropriately licensed by the Nebraska Department of Health and Human Services, Division of Public Health; and

(2)Accredited by the Joint Commission , the Commission on Accreditation of Rehabilitation Facilities (CARF), the Council on Accreditation (COA), or the American Osteopathic Association (AOA).

026.02(A)(i) HOSPITAL BASED DAY TREATMENT. A hospital providing on-site day treatment must:

(1)Be licensed or formally approved as a hospital by the Nebraska Department of Health and Human Services, Division of Public Health;

(2)Be accredited by the Joint Commission or the American Osteopathic Association (AOA);

(3)Meet the requirements for participation in Medicare; and

(4)Have in effect a utilization review plan applicable to all Nebraska Medicaid beneficiaries.

026.02(A)(ii) FREESTANDING FACILITIES. When hospitals provide services in freestanding facilities, the freestanding facility must be appropriately licensed by the Nebraska Department of Health and Human Services, Division of Public Health.

026.02(B) HOURS. The program must provide a minimum of three hours of services five days a week, which is considered a half day for billing purposes. A minimum of six hours a day is considered a full day of service. Services may not be prorated for under three hours of services for half day of service or six hours of services for full day of service.

026.02(B)(i) SUPERVISING PRACTITIONER. A designated supervising practitioner must be responsible for the psychiatric care in a day treatment program. The supervising practitioner must be present on a regularly-scheduled basis and must assume clinical responsibility for all patients. If the supervising practitioner is present on a part-time basis, one of the following must assume delegated professional responsibility for the program and must be present at all times when the program is providing services:

(1)A licensed physician;

(2)A licensed psychologist;

(3)Licensed independent mental health practitioner (LIMHP); or

(4)An allied health therapist.

026.02(B)(ii) REFERRAL. Any supervising practitioner may refer a beneficiary to a day treatment program, but all treatment must be prescribed and directed by the program supervising practitioner.

026.02(B)(iii) SUPERVISION. All treatment must be conducted under the supervision of the supervising practitioner in charge of the program.

026.02(B)(iv) PSYCHOTHERAPY STAFF. Psychotherapy staff as outlined in this chapter include the following:

(1)Physician;

(2)Licensed psychologist;

(3)Licensed independent mental health practitioner (LIMHP); and

(4)Allied health therapists. All psychotherapy services provided by allied health therapists must be prescribed by the supervising practitioner and provided under their supervision. The supervising practitioner's personal involvement in all aspects of the beneficiary's psychiatric care must be documented in the beneficiary's medical record through physician's orders, progress notes, and nurse’s notes.

026.02(B)(v) ADMISSION CRITERIA. The following criteria must be met for a beneficiary's admission to a psychiatric day treatment program:

(1)The beneficiary must have sufficient medical need for active psychiatric treatment at the time of admission to justify the expenditure of the beneficiary's and program's time, energy, and resources; and

(2)Of all reasonable options for active psychiatric treatment available to the beneficiary, treatment in this program must be the best choice for expecting a reasonable improvement in the beneficiary's psychiatric condition.

026.02(B)(vi) PRE-ADMISSION EVALUATION. Before the beneficiary is admitted to the program, the supervising practitioner must complete an initial diagnostic interview to validate the appropriateness of care. When a beneficiary is transferred from inpatient hospital care to day treatment, the inpatient evaluation and discharge summary documenting the rationale of transfer as part of the treatment plan serves the same purpose as the initial diagnostic interview. The evaluation must be filed in the beneficiary's medical record. The pre-admission evaluation must include:

(1)A clinical assessment of the health status and related psychological, medical, social, and educational needs of the beneficiary; and

(2)A determination of the range and kind of services required.

026.02(B)(vii) TREATMENT PLAN. The program supervising practitioner must determine the psychiatric diagnosis and prescribe the treatment, including the modalities and the professional staff to be used. The program supervising practitioner must be responsible and accountable for all evaluations and treatment provided to the beneficiary. The treatment plan must be completed upon the beneficiary's admission to the program.

026.02(B)(xiii) TREATMENT PLAN REVIEW. At least every 30 days thereafter, a treatment plan review must be conducted by the multi-disciplinary team, including the supervising practitioner. The treatment plan reviews must be documented. The treatment plan must be signed by the program supervising practitioner for day treatment services.

026.02(B)(ix) PERSONAL EVALUATION BY SUPERVISING PRACTITIONER. The supervising practitioner must personally evaluate the beneficiary every 30 days, or more often, as medically necessary. This evaluation must occur in a one-to-one, face-to-face session separate from the treatment plan review.

026.02(B)(x) UTILIZATION REVIEW. Every 30 days a utilization review must be conducted in accordance with this chapter. This review must be documented on the treatment plan. Utilization review is not required for the calendar month in which the beneficiary was admitted.

026.02(B)(xi) DESCRIPTIONS OF TREATMENTS AND SERVICES. The program must have a description of each of the services and treatment modalities available. This includes psychotherapy services, nursing services, psychological diagnostic services, pharmaceutical services, dietary services, and other psychiatric day treatment services:

(1)The program must have a description of how the family-centered requirement in this chapter will be met, including a complete description of any family assessment and family psychotherapy services:

(a) Providers must encourage family members to be involved in the assessment of the beneficiary, the development of the treatment plan, and all aspects of the beneficiary's treatment unless prohibited by the beneficiary, through legal action, or because of federal confidentiality laws;

(b) Providers must be available to schedule meetings and sessions in a flexible manner to accommodate and work with a family's schedule. This includes the ability to schedule sessions at a variety of times including weekends or evenings; and

(c) The provider must document their attempts to involve the family in treatment plan development and treatment plan reviews. A variety of communication means should be considered. These may include, but should not be limited to, including the family via conference telephone calls, using registered letters to notify the family of meetings, and scheduling meetings in the evening and on weekends;

(2)The program must have a description of how the community-based requirement in this chapter will be met;

(3)The program must state the qualifications, education, and experience of each staff member and the therapy services each provides; and

(4)The program must have a daily schedule covering the total number of hours the program operates per day. The schedule must be submitted to Nebraska Medicaid for approval. The program must be fully staffed and supervised during the time the program is available for services and must provide at least three hours of approved treatment for each day services are provided. This schedule must be updated annually, or more frequently if appropriate.

026.02(B)(xii) OUTPATIENT OBSERVATION. When appropriate for brief crisis stabilization, outpatient observation up to 23 hours 59 minutes in an emergency room or acute hospital may be used. If a beneficiary receives 24 or more hours of continuous outpatient care, that beneficiary is defined as an inpatient regardless of the hour of admission, whether they used a bed and whether they remained in the hospital past midnight or the census-taking hour, and all inpatient medical review prior-authorization requirements apply.

026.02(B)(xiii) INPATIENT SERVICES PLAN. The program must have a written plan for immediate admission or readmission for appropriate inpatient psychiatric services, if necessary. The written plan must include a cooperative agreement with a psychiatric hospital or distinct part of a hospital, as outlined in this chapter . A copy of this agreement must accompany the provider application and agreement.

026.03 PROVIDER AGREEMENT. The provider must attach to the provider application and agreement a written overview of the program including philosophy, objectives, policies and procedures, confirmation that the requirements in this chapter are met, and any other information requested by Nebraska Medicaid . Staff must meet the standards outlined in this chapter; and:

(A)Community mental health programs and licensed mental health clinics must complete the appropriate Nebraska Medicaid approved provider agreement form , and submit the completed form to Nebraska Medicaid for approval. The provider application and agreement must be renewed annually to coincide with the submittal of the cost report. Satellites of community mental health programs must bill Nebraska Medicaid through their main community mental health program, unless the satellite has a separate provider number under Medicare. A satellite of a community mental health program that has a separate provider number under Medicare must complete a separate provider agreement. All claims submitted to Nebraska Medicaid by these satellites must be filed under the satellite's Nebraska Medicaid provider number. The facility must have in effect a utilization review plan applicable to all Nebraska Medicaid beneficiaries; and

(B)Hospitals must complete the appropriate Nebraska Medicaid approved provider agreement form and submit the completed form to Nebraska Medicaid for approval.

026.03(i) ANNUAL UPDATE. The program must update the provider agreement, program overview, and cost report annually and whenever requested by Nebraska Medicaid .

026.04 COVERAGE CRITERIA FOR DAY TREATMENT PSYCHIATRIC SERVICES. Nebraska Medicaid covers psychiatric day treatment services for beneficiaries age 21 and over when the services meet the requirements in this chapter.

026.04(A) OBSERVATION AND INTERVIEW. The beneficiary must be observed and interviewed by the program supervising practitioner at least every 30 days or more frequently if medically necessary and the interaction must be documented in the beneficiary's medical record.

026.04(B) SERVICES NOT COVERED UNDER NEBRASKA MEDICAID. Payment is not available for psychiatric day treatment services for beneficiaries :-

(i)Receiving services in an out-of-state facility, except as outlined in this title ;

(ii)Living in long-term care facilities or institutes for mental disease (IMD);

(iii)Whose needs are social or educational and may be met through a less structured program;

(iv)Whose primary diagnosis and functional impairment is psychiatric in nature but is not stable enough to allow them to participate in and benefit from the program; or

(v)Whose behavior may be very disruptive or harmful to other program participants or staff members.

026.05 DOCUMENTATION IN THE BENEFICIARY’S RECORD. All documents submitted to Nebraska Medicaid must contain sufficient information for identification . Each beneficiary's clinical record must contain the following documentation:

(A)The supervising practitioner's orders;

(B)The initial diagnostic interview and referral documented by the supervising practitioner;

(C)The treatment plan;

(D)The team progress notes, recorded chronologically. The frequency is determined by the beneficiary's condition, but the team's progress notes must be recorded at least weekly. The progress notes must contain a concise assessment of the beneficiary's progress and recommendations for revising the treatment plan, as indicated by the beneficiary's condition, and discharge planning;

(E)Documentation indicating compliance with all requirements in this chapter;

(F)The program's utilization review committee's abstract or summary; and

(G)The discharge summary.

026.06 TRANSITION AND DISCHARGE PLANNING. Each provider must meet the requirements in this chapter for transition and discharge planning.

026.07 UTILIZATION REVIEW. Each program is responsible for establishing a utilization review plan and procedure which meets the following requirements. A site visit by Nebraska Medicaid for purposes of utilization review may be required for further clarification.

026.07(A) COMPONENTS OF UTILIZATION REVIEW. Utilization review must provide:

(i)Timely review, at least every 30 days, of the medical necessity of admissions and continued treatment;

(ii)Utilization of professional services provided;

(iii)High quality patient care; and

(iv)Effective and efficient utilization of available health facilities and services.

026.07(B) UTILIZATION REVIEW OVERVIEW. An overview of the program's utilization review process must be submitted with the provider application and agreement before the program is enrolled as a Nebraska Medicaid provider. The overview must include:

(i)The organization and composition of the utilization review committee which is responsible for the utilization review function;

(ii)The frequency of meetings, which must occur at least once every 30 days ;

(iii)The type of records to be kept; and

(iv)The arrangement for committee reports and their dissemination, including how the supervising practitioner is informed of the findings.

026.07(C) UTILIZATION REVIEW COMMITTEE. The utilization review committee must consist of a supervising practitioner and at least two mental health practitioners as defined in this chapter. A licensed psychologist may replace one of the allied health staff members. The committee's reviews may not be conducted by any person whose primary interest in or responsibility to the program is financial or who is professionally involved in the care of the client whose case is being reviewed. At Nebraska Medicaid's discretion, an alternative plan for facilities that do not have these resources readily available may be approved.

026.07(D) BASIS OF REVIEW. The review must be based on:

(i)The identification of the individual beneficiary by appropriate means to ensure confidentiality;

(ii)The identification of the supervising practitioner;

(iii)The date of admission;

(iv)The diagnosis and symptoms;

(v)The supervising practitioner plan of treatment; and

(vi)Other supporting materials the group may deem appropriate.

026.07(E) CONTENTS OF REPORT. A copy of the admission review and the extended stay review must be attached to all claims for psychiatric services submitted to Nebraska Medicaid for payment. In addition, the written report must contain:

(i)An evaluation of treatment, progress, and prognosis based on:

(1)Appropriateness of the current level of care and treatment;

(2)Alternate levels of care and treatment available; and

(3)The effective and efficient utilization of services provided;

(ii)Verification that:

(1)Treatment provided is documented in the beneficiary's record;

(2)All entries in the beneficiary's record are signed by the person responsible for entry. The supervising practitioner must sign all orders; and

(3)All entries in the beneficiary's record are dated;

(iii)Recommendations for:

(1)Continued treatment;

(2)Alternate treatment or level of care; and

(3)Disapproval of continued treatment;

(iv)The date of the review;

(v)The names of the program utilization review committee members; and

(vi)The date of the next review if continued treatment is recommended.

026.08 PAYMENT FOR PSYCHIATRIC DAY TREATMENT SERVICES. Payment for psychiatric day treatment services will be based upon rate setting by Nebraska Medicaid .

026.08(A) PAYMENT RATES. Payment rates for psychiatric day treatment services for beneficiaries age 21 and older will be on a unit basis. Rates are set annually, for the period July 1 through June 30. Rates are set prospectively for this period, and are not adjusted during the rate period.

026.08(B) COST REPORTS. Providers are required to report their costs on an annual basis. Providers may choose any fiscal year end that they desire. Providers desiring to enter the program who have not previously reported their costs, or that are newly operated, are to submit a budgeted cost report, estimating their anticipated annual costs.

026.08(C) COST AND STATISTICAL DATA REQUIREMENTS. Providers must submit cost and statistical data on the appropriate Nebraska Medicaid approved cost reporting document . The provider must submit one original Nebraska Medicaid approved cost reporting document to Nebraska Medicaid within 90 days of the close of fiscal year, or change in ownership or management. One 15-day extension may be granted under extenuating circumstances if requested, in writing, prior to the date. Providers must compile data based on generally accepted accounting principles and the accrual method of accounting based on the provider's fiscal year. Financial and statistical records for the period covered by the cost report must be accurate and sufficiently detailed to substantiate the data reported. All records must be readily available upon request by Nebraska Medicaid for verification. If the provider fails to file a cost report as due, Nebraska Medicaid will suspend payment. At the time the suspension is imposed, Nebraska Medicaid will send a letter informing the provider that no further payment will be made until a proper cost report is filed.

026.08(D) COSTS CONSIDERED. In setting payment rates, Nebraska Medicaid will consider those costs which are reasonable and necessary for the active treatment of the beneficiaries being served. Such costs will include those necessary for licensure and accreditation, meeting all staffing standards for participation, meeting all service standards for participation, meeting all requirements for active treatment, maintaining medical records, conducting utilization review, meeting inspection of care requirements and discharge planning.

026.08(E) NOT ALL COSTS REIMBURSED. Nebraska Medicaid does not guarantee that all costs will be reimbursed. The cost reporting document is used by Nebraska Medicaid only as a guide in the rate setting process. Actual costs incurred by the providers may not be entirely reimbursed.

026.08(F) PAYMENT RATES FOR PSYCHIATRIC DAY TREATMENT SERVICES PROVIDED BY THE STATE. Psychiatric day treatment centers operated by the State of Nebraska will be reimbursed for all reasonable and necessary costs of operation, excluding educational services. State-operated centers will receive an interim payment rate, with an adjustment to actual costs following the cost reporting period.

026.08(G) UNALLOWABLE COSTS. The following costs are not allowable:

(i)Provisions for income tax;

(ii)Fees paid board of directors;

(iii)Non-working officers' salaries;

(iv)Promotion expense, except for promotion and advertising as allowed in HIM-15. Yellow Page display advertising is not allowable; one Yellow Page informational listing is allowable;

(v)Travel and entertainment, other than for professional meetings and direct operations of the day treatment program ;

(vi)Donations;

(vii)Expenses of non-related facilities and operations included in expense;

(viii)Insurance and annuity premiums on the life of officer or owner;

(ix)Bad debts, charity, and courtesy allowances;

(x)Cost and portions of costs which are determined by Nebraska Medicaid not to be reasonably related to the efficient production of service because of either the nature or amount of the particular expenditure;

(xi)Education costs;

(xii)Services provided by the beneficiaries' physicians or dentists, drugs, laboratory services, radiology services, or services provided by similar independent licensed providers, except services provided by state operated facilities. These exclusions are paid separately;

(xiii)Return on equity;

(xiv)Costs for services which occurred in a prior or subsequent fiscal year ;

(xv)Expenses for equipment, facilities, and programs provided to beneficiaries which are determined by Nebraska Medicaid not to be reasonably related to the efficient production of service because of either the nature or amount of the particular service;

(xvi)Costs of amusements, social activities, and related expenses for employees and governing body members , except when part of an authorized beneficiary treatment program;

(xvii)Costs of alcoholic beverages ;

(xviii)Costs resulting from violations of, or failure to comply with federal, state, and local laws and regulations ;

(xix)Costs relating to lobbying or attempts to influence or promote legislative action by local, state, or federal government ; and

(xx)Costs of lawsuits or other legal or court proceedings against Nebraska Medicaid , or its employees, or State of Nebraska .

026.08(H) SUSPENSION OR TERMINATION OF LICENSE. Nebraska Medicaid does not make payment for care provided after 30 days following the date of expiration or termination of the provider's license or certificate to operate under Title XIX. Nebraska Medicaid does not make payment for care provided to beneficiaries who were admitted after the date of expiration or termination of the provider's license or certificate to operate under Title XIX.

026.08(I) APPEAL PROCESS. Final administrative decision or inaction in the rate setting process is subject to administrative appeal. The provider may request an appeal, in writing, from the Director for a hearing within 90 days of the decision or inaction.

026.08(J) ADMINISTRATIVE FINALITY. An administrative decision or inaction in the allowable cost determination process, which is otherwise final, may be reopened by Nebraska Medicaid within three years of the date of notice of the decision or inaction.

026.08(K) REOPENING. Reopening is an action taken by the Medicaid and Long-Term Care Director to re-examine or question the correctness of a determination or decision which is otherwise final. The Director of Medicaid and Long-Term Care is the sole authority for deciding whether to reopen an administrative decision or inaction. The action may be taken:

(i) On the initiative of Nebraska Medicaid within the three-year period;

(ii) In response to a written request of a provider or other entity within the three-year period. Whether the Director of Medicaid and Long-Term Care will reopen a determination, which is otherwise final, depends on whether new and material evidence has been submitted, a clear and obvious error has been made, or the determination is found to be inconsistent with any law, regulations , or general instructions; or

(iii) Any time fraud or abuse is suspected.

025.08(K)(1) NO APPEAL RIGHT. A provider has no right to appeal a finding by the Director of Medicaid and Long-Term Care that a reopening or correction of a determination or decision is not warranted.

026.09 RECORD RETENTION. The provider must retain financial records, supporting documents, statistical records, and all other pertinent records related to the cost report for a minimum of five years after the end of the report period.

026.10 BILLING REQUIREMENTS. For day treatment services, the following requirements must be met:

(A) Providers of non-hospital based day treatment services must submit claims for day treatment services on the appropriate Nebraska Medicaid approved health care claim form or electronic claim. Payment for approved day treatment services is made to the facility; and

(B) Providers of hospital-based day treatment services must submit claims for services on the appropriate Nebraska Medicaid approved health care claim form or electronic claim. Payment for approved hospital based day treatment services is made to the hospital.

026.10(i) DOCUMENTATION FOR CLAIMS. The following documentation, kept in the beneficiary’s file, is required for all claims for day treatment services:

(1)Initial diagnostic interview;

(2)Supervising practitioner orders;

(3)Nurses' notes; and

(4)Progress notes for all disciplines.

026.10(i)(a) UTILIZATION REVIEW. All claims are subject to utilization review by Nebraska Medicaid prior to payment.

026.10(ii) EXCEPTION. Additional documentation from the beneficiary's medical record may be requested by Nebraska Medicaid prior to considering authorization of payment. Progress notes for other Nebraska Medicaid beneficiaries may be requested when the treatment report does not adequately explain family psychotherapy or medical necessity cannot be determined.

026.11 PROCEDURE CODES AND DESCRIPTIONS FOR PSYCHIATRIC DAY TREATMENT. Current Procedural Terminology (CPT) and Healthcare Common Procedure Coding System (HCPCS) procedure codes used by Nebraska Medicaid are listed in the Nebraska Medicaid Practitioner Fee Schedule .

026.12 COSTS NOT INCLUDED IN THE DAY TREATMENT FEE. The mandatory and optional services are considered to be part of the fee for day treatment services. The following charges can be reimbursed separately from the day treatment fee when the services are necessary, part of the beneficiary's overall treatment plan, and in compliance with Nebraska Medicaid requirements:

(A)Direct beneficiary services performed by the supervising practitioner;

(B)Prescription medications including injectable medications;

(C)Direct beneficiary services performed by a physician or advanced practice registered nurse (APRN) other than the supervising practitioner; and

(D)Treatment services for a physical injury or illness provided by other professionals.

026.12(i) SECOND MANAGED CARE VENDOR. If the beneficiary is enrolled with another managed care vendor for medical-surgical services, it may be necessary to pursue prior authorization or referral with that entity.

027. ADULT SUBACUTE INPATIENT HOSPITAL PSYCHIATRIC SERVICES. The care and treatment of a subacute inpatient with a primary psychiatric diagnosis must be under the direction of a Nebraska licensed psychiatrist who meets the state's licensing criteria and is enrolled as a Nebraska Medicaid provider . Subacute inpatient hospital psychiatric services must be prior-authorized by Nebraska Medicaid contracted peer review organization or management designee. In addition, out-of-state subacute hospitalizations must be approved by Nebraska Medicaid .

027.01 PROVIDER AGREEMENT. A hospital that provides subacute inpatient psychiatric services must complete the appropriate Nebraska Medicaid approved provider agreement form and submit the completed form to Nebraska Medicaid for approval and enrollment as a Nebraska Medicaid provider of subacute inpatient hospital psychiatric services. The hospital must submit with the provider agreement:

(A)A complete description of the psychiatric program and the elements of the program ;

(B)A statement of the total number of licensed inpatient psychiatric beds, designated as subacute psychiatric beds that are approved by the Nebraska Department of Health and Human Services, Division of Public Health or agency in the state in which the facility is located; a listing of the bed numbers for those licensed psychiatric beds; and the size of the proposed subacute inpatient psychiatric unit;

(C)Documentation that the subacute inpatient program meets the family-centered, community-based requirements in this chapter;

(D)A description of how beneficiary, group, and family psychotherapy services as well as other psycho-educational and rehabilitation services will be provided;

(E)A description of how the subacute inpatient hospital psychiatric services will interface with community services for discharge planning and service provision after discharge;

(F)A copy of the most recent Joint Commission ) or the American Osteopathic Association (AOA) accreditation survey; and

(G)Any other information requested.

027.01(i) ON-SITE REVIEW. Any facility requesting a provider agreement must make the facility available for an on-site review before issuance of a provider agreement.

027.02 STANDARDS FOR PARTICIPATION FOR SUBACUTE INPATIENT HOSPITAL PSYCHIATRIC SERVICE PROVIDERS. A hospital that provides subacute inpatient hospital psychiatric services must meet the following standards for participation to ensure that payment is made only for subacute inpatient psychiatric treatment. The hospital or unit of an acute care hospital:

(A)Is maintained for the care and treatment of beneficiaries with primary psychiatric disorders;

(B)Is licensed or formally approved as a hospital by the Nebraska Department of Health and Human Services Division of Public Health, or if the hospital is located in another state, the officially designated authority for standard-setting in that state;

(C)Is accredited by the Joint Commission or by the American Osteopathic Association (AOA);

(D)Meets the requirements for participation in Medicare for psychiatric hospitals;

(E)Has in effect a utilization review plan applicable to all Nebraska Medicaid beneficiaries ;

(F)Must have medical records that are sufficient to permit Nebraska Medicaid to determine the degree and intensity of treatment furnished to the beneficiary;

(G)Must meet staffing requirements Nebraska Medicaid finds necessary to carry out an active treatment program as described in this chapter;

(H)Must encourage the beneficiary and family members to be involved in the assessment of the beneficiary, the development of the treatment plan, and all aspects of the beneficiary's treatment unless prohibited by the beneficiary, through legal action, or because of federal confidentiality laws;

(I)Must be available to schedule meetings and sessions in a flexible manner to accommodate and work with a family, guardian, or caretaker schedule. This includes the ability to schedule sessions at a variety of times including weekends or evenings; and

(J)Must document their attempts to involve the beneficiary and the family in treatment plan development and treatment plan reviews. A variety of communication means should be considered to involve family. .

027.03 STANDARDS FOR PARTICIPATION FOR SUBACUTE INPATIENT HOSPITAL PSYCHIATRIC SERVICE PROVIDERS. Subacute inpatient psychiatric hospital must have staff adequate in number and qualified to carry out a subacute psychiatric program for treatment for beneficiaries who are in need of further psychiatric stabilization, treatment, rehabilitation, and recovery activities. The hospital must meet the following standards.

027.03(A) HOSPITAL PERSONNEL. Hospitals that provide subacute inpatient psychiatric services must be staffed with the number of qualified professional, technical, and supporting personnel, and consultants required to carry out an intensive and comprehensive treatment program that includes evaluation of beneficiary and family needs; establishment of beneficiary and family treatment goals; and implementation, directly or by arrangement, of a broad-range psychiatric treatment program including, at least, professional psychiatric, medical, nursing, social services, psychological, psychotherapy, psychiatric rehabilitation, and recovery therapies required to carry out an individual treatment plan for each patient and their family. The following standards must be met:

(i)Qualified professional psychiatric staff must be available to evaluate each beneficiary at the time of admission, including diagnosis of any intercurrent disease. Services necessary for the evaluation include:

(1) Initial diagnostic interview;

(2) Nursing assessment by a licensed registered nurse (RN);

(3) Substance use disorder assessment and development of a substance use disorder addendum as appropriate;

(4) Laboratory, radiological, and other diagnostic tests as necessary; and

(5) A physical examination including a complete neurological examination when indicated within 24 hours after admission by a licensed physician, physician assistant (PA), or advanced practice registered nurse (APRN);

(ii)The number of qualified professional personnel and paraprofessionals, including licensed professional staff and technical and supporting personnel, must be adequate to ensure representation of the disciplines necessary to establish short-range and long-term goals; and to plan, carry out, and periodically revise a treatment plan for each client;

(1) Qualified staff must be available to provide treatment intervention, social interaction and experiences, education regarding psychiatric issues , appropriate nursing interventions and structured milieu therapy. Available services must include beneficiary, group, and family therapy, group living experiences, occupational and recreational therapy and other prescribed activities to maintain or increase the beneficiary’s capacity to manage their psychiatric condition and activities of daily living. A minimum of 42 structured, scheduled, and documented treatment hours are required per week; and

(2) The program must provide environmental and physical limitations required to protect the beneficiary's health and safety with a plan to develop the beneficiary's potential for return to their home, supervised adult living, or skilled nursing facility (NF). The treatment milieu must be a safe, organized, structured environment at the least restrictive level of care to meet the individualized treatment needs of the beneficiary.

027.03(B) MEDICAL DIRECTOR OF SUBACUTE INPATIENT SERVICES. Subacute inpatient psychiatric services must be under the supervision of a psychiatrist who is identified as the medical director and is qualified to provide the clinical direction and the leadership required for an intensive psychiatric subacute inpatient treatment program. The number and qualifications of additional psychiatrists must be adequate to provide essential psychiatric services. The medical director may also serve as the attending psychiatrist for each beneficiary depending on the size of the program. The following standards must be met:

(i)The medical director and any attending psychiatrists must meet the training and experience requirements for a psychiatrist licensed to practice in the state where services are provided;

(ii)The program must identify a covering or alternative psychiatrist when the medical director is not available to provide direction and supervision of the direct care of the beneficiary and the treatment program;

(iii)The psychiatrist's personal involvement in all aspects of the beneficiary's psychiatric care must be documented in the beneficiary's medical record, consisting of the physician's orders, the progress notes, and the nurse’s notes; and

(iv)The medical director or attending psychiatrist must be available, in person or by telephone, to provide assistance and direction to the treatment team as needed.

027.03(C) AVAILABILITY OF PHYSICIANS AND OTHER MEDICAL CONSULTATION. Physicians and other appropriate professional consultants must be available to provide medical, surgical, diagnostic, and treatment services, including specialized services. If medical, surgical, diagnostic, and treatment services are not available within the hospital, qualified physician consultants or attending physicians must be immediately available, or a satisfactory arrangement must be established for transferring patients to a general hospital certified for Medicare.

027.04 PROGRAM STANDARDS FOR PARTICIPATION. Subacute inpatient psychiatric services must have available licensed professionals and paraprofessionals with specific, identified duties and responsibilities to meet the acute and rehabilitative psychiatric needs of the beneficiaries being served. The following positions and services are required.

027.04(A) PROGRAM AND CLINICAL DIRECTOR. Must be a fully licensed clinician who is skilled and knowledgeable to provide leadership and clinical direction to the treatment team. The duties and responsibilities of a program or clinical director are:

(i)Oversee, implement, and coordinate all treatment services and activities provided within the program 24 hours a day;

(ii)Incorporate new clinical information and best practices into the program to assure effectiveness, viability and safety;

(iii)Oversee the process to identify, respond to and report crisis situations on a 24-hour per day, seven day per week basis;

(iv)Be responsible, in conjunction with the medical director or attending psychiatrist, for the program’s clinical management by representation in the multidisciplinary treatment team meetings providing supervision to all program professionals and paraprofessional staff;

(v)Communicate with the attending psychiatrist regarding individual treatment needs of the beneficiary;

(vi)Assure quality organization and management of clinical record documentation and confidentiality; and

(vii)Oversee and be responsible for the safety of beneficiaries and staff.

027.04(B) NURSING SERVICES. All nursing services must be under the supervision of a registered professional nurse who is qualified by education and experience for the supervisory role. The number of registered professional nurses and other nursing personnel must be adequate to formulate and carry out the nursing components of a treatment plan for each beneficiary. The following standards must be met:

(i)The registered professional nurse supervising the nursing program must have a master's degree in psychiatric or mental health nursing or its equivalent from a school of nursing accredited by the National League for Nursing, or must be qualified by education and experience in the care of the beneficiary with mental illness, and have demonstrated competence to:

(1) Provide a comprehensive nursing assessment;

(2) Participate in interdisciplinary formulation of treatment plans;

(3) Provide skilled nursing care and therapy; and

(4) Direct, supervise, and train others who assist in implementing and carrying out the nursing components of each beneficiary's treatment plan;

(ii)The staffing pattern must ensure the direct nursing coverage by a registered professional nurse 24 hours each day for:

(1) Direct care; and

(2) Supervising care performed by other nursing personnel;

(iii)The number of registered professional nurses must be adequate to formulate a nursing care plan in writing for each beneficiary and to ensure that the plan is carried out; and

(iv)Registered professional nurses and other nursing personnel must be prepared by continuing in-service and staff development programs for active participation in interdisciplinary meetings affecting the planning or implementation of nursing care plans for beneficiaries. The meetings include diagnostic conferences, treatment planning sessions, and meetings held to consider alternative services and transitioning to the most appropriate treatment service and community resources.

027.04(C) PSYCHOLOGICAL SERVICES. Psychological services must be available through employment or contractual arrangement with a licensed psychologist. Psychological consultation must be available by a qualified licensed psychologist capable of providing diagnostic and treatment services. The following standards must be met:

(i)Psychologists, consultants, and supporting personnel must be adequate in number and be qualified to assist in essential diagnostic formulations, and to participate in:

(1) Program development and evaluation of program effectiveness;

(2) Training and research activities;

(3) Therapeutic interventions ; and

(4) Interdisciplinary conferences and meetings held to establish diagnoses, goals, and treatment programs; and

(ii)Psychological testing must be ordered and directed by a psychiatrist.

027.04(D) PSYCHOTHERAPY SERVICES. Licensed clinicians must be employed in the facility to provide psychotherapy services according to the therapist's scope of practice and according to the individualized treatment plan for the beneficiary. Licensed clinicians may include psychologists (Psy.D.), licensed independent mental health practitioners (LIMHP), licensed mental health practitioners (LMHP), licensed alcohol and drug counselors (LADC), and advanced practice registered nurses (APRN). Individual, group, and family psychotherapy must be available to each beneficiary and provided according to the beneficiary’s individual treatment plan. Services must be able to meet the unique needs of each beneficiary. Minimum requirements for psychotherapy offered and available to the beneficiary are:

(i)Individual therapy minimum two times weekly;

(ii)Group therapy minimum three times weekly; and

(iii)Family therapy and intervention as appropriate and consented to by the beneficiary. With consent of the beneficiary, family therapy must be provided at the frequency and intensity to meet the unique needs of beneficiary and the family.

027.04(E) LICENSED ADDICTION AND DRUG ABUSE SERVICES. Substance use disorder assessment, development of a substance use disorder addendum as needed, and treatment must be available to beneficiaries whose problems and symptoms indicate the possibility of or an established substance abuse problem, in addition to the primary psychiatric diagnosis. Licensed clinicians able to provide assessment, develop a substance use disorder addendum, and provide treatment of substance use disorder problems must provide services according to and within their scope of practice. Usually, services are provided by a licensed alcohol and drug counselor (LADC).

027.04(F) PSYCHOEDUCATIONAL SERVICES. Psychoeducational services must be offered in the program, and providers must have psychoeducational services available to beneficiaries on a daily basis. Services may include education for diagnosis, treatment and relapse, life skills, medication management and symptom management. Services must be provided by a qualified professional or paraprofessional staff. Medication education must be provided by a registered nurse (RN). Other psychoeducational services may be provided by a paraprofessional whose education and training provides competency to provide the service.

027.04(G) CASE MANAGEMENT SERVICES AND SOCIAL SERVICES STAFF. Case Management and social services staff must be under the supervision of the program or clinical director. The case management and social service staff must be adequate in numbers and be qualified to fulfill responsibilities related to the specific needs of individual beneficiaries and their families.

The role and responsibility of case management and social services staff is to:

(i) Assist the beneficiary with accessing community resources and services;

(ii) Consult with other staff and community agencies to coordinate beneficiary care;

(iii) Assist the beneficiary with accessing alternative services and maintaining a safe living environment according to the treatment plan; and

(iv) Perform daily case management services and maintain a summary of services in the beneficiary’s clinical record.

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027.04(H) ANCILLARY SERVICES. Recreational or activity therapy services must be available and offered to the beneficiary daily and directly supervised by the program or clinical director who has supervisory responsibility to the entire treatment team and the services they provide.

027.04(I) PSYCHIATRIC TECHNICIANS. The program must have available paraprofessional staff who are members of the multi-disciplinary team. The role and responsibility of the psychiatric technician is to:

(i)Intervene in the treatment milieu;

(ii)Provide treatment interventions to the beneficiary which meet the specific psychiatric needs of the beneficiary as identified in the treatment plan;

(iii)Demonstrate competency in applying the learned treatment interventions; and

(iv)Have direct knowledge of policies and procedures of the agency.

027.04(I)(1) PSYCHIATRIC TECHNICIANS. Psychiatric technicians must have completed the program’s initial training program and continued ongoing training requirements. 75 percent of the psychiatric technician staff must have completed a Bachelor of Science (BS) or Bachelor of Arts (BA) degree in the human services field or have five years’ experience providing health care services.

027.05 COVERAGE CRITERIA FOR SUBACUTE INPATIENT PSYCHIATRIC HOSPITAL SERVICES. Nebraska Medicaid covers subacute inpatient hospital psychiatric services for beneficiaries age 21 and over when the services meet the criteria in this chapter and when the following requirements are met:

(A)The attending psychiatrist must personally and face-to-face evaluate the beneficiary and document the psychiatric evaluation and diagnosis formulation within 24 hours of admission;

(B)The attending psychiatrist assumes accountability to direct the care of the beneficiary at the time of admission;

(C)The beneficiary must be treated by a psychiatrist personally and face-to-face a minimum of three times per week or more often, if medically necessary and the interaction must be documented in the beneficiary's clinical record;

(D)The attending psychiatrist describes the medical necessity and active treatment requirements for the beneficiary;

(E)The attending psychiatrist provides certification and recertification of the beneficiary's need for subacute inpatient psychiatric services; and

(F)Clinical supervision of the multi-disciplinary treatment team and treatment team planning meetings as necessary to meet the individualized treatment needs of the beneficiary.

027.06 TREATMENT PLANNING. An initial treatment plan must be implemented upon admission. The master or comprehensive treatment plan must be developed within 72 hours and reviewed by the treatment team a minimum of three times weekly. The master or comprehensive treatment plan must be developed from the recommendations made by the attending psychiatrist who has provided evaluation of the beneficiary and the input from all other assessments completed following admission to subacute inpatient treatment services. Comprehensive treatment plans must meet medical necessity requirements.

027.06(A) DISCHARGE PLANNING. Discharge planning must be a part of the comprehensive treatment plan. Discharge planning must be specific, realistic and individualized for the beneficiary from the time of admission and revised as medically necessary with treatment planning reviews.

027.07 CRITERIA FOR SUBACUTE INPATIENT PSYCHIATRIC HOSPITAL SERVICES. One or more of the following criteria must be present:

(A)The beneficiary can benefit from longer-term evaluation, stabilization, and treatment services;

(B)The beneficiary is at moderate to high risk to harm self or others;

(C)The beneficiary has active symptomatology ;

(D)The beneficiary has the ability to respond to intensive structured intervention services;

(E)The beneficiary is at moderate to high risk of relapse or symptom reoccurrence;

(F)The beneficiary has high need of professional structure and intervention services; or

(G)The beneficiary can be treated with short term intensive intervention services.

027.08 PRIOR AUTHORIZATION. All subacute inpatient psychiatric admissions must be prior-authorized by Nebraska Medicaid’s contracted peer review organization or management designee. If the admission is approved, the Nebraska Medicaid’s contracted peer review organization or management designee must assign a specific prior-authorization number. Providers must follow the Nebraska Medicaid’s contracted peer review organization or management designee requirements for facilitating prior authorization and continued stay review. Continued stay authorization is provided at a frequency appropriate for this short-term subacute program by the Nebraska Medicaid’s contracted peer review organization or management designee.

027.09 DOCUMENTATION IN THE BENEFICIARY’S CLINICAL RECORD. The medical records maintained by a hospital permit determination of the degree and intensity of the treatment provided to beneficiaries who receive services in a subacute inpatient psychiatric program. Clinical records must stress the psychiatric components of the record, including history of findings and treatment provided for the psychiatric condition for which the beneficiary is hospitalized. The clinical record must include:

(A)The identification data, including the beneficiary's name, date of service, provider's name, and beneficiary's legal status, whether the admission is voluntary , by the Board of Mental Health , or court mandated;

(B)A provisional or admitting diagnosis which is made on every beneficiary at the time of admission and includes the diagnoses of intercurrent diseases as well as the psychiatric diagnoses;

(C)The complaint of others regarding the beneficiary, as well as the beneficiary's comments;

(D)The psychiatric evaluation, including a medical history, which contains a record of mental status and notes the onset of illness, the circumstances leading to admission, attitudes, behavior, estimate of intellectual functioning, memory functioning, orientation, and an inventory of the beneficiary's strengths in a descriptive, not interpretative, fashion;

(E)A complete neurological examination, when indicated, recorded at the time of the admitting physical examination;

(F)Reports of consultations, psychological evaluations, electroencephalograms, dental records, and special studies;

(G)The beneficiary's treatment plan and treatment plan reviews;

(H)The treatment received by the beneficiary, which is documented in a manner and with a frequency to ensure that all active therapeutic efforts are included;

(I)Progress notes which are recorded by the psychiatrist or physician, nurse, social worker, and, when appropriate, others significantly involved in active treatment modalities. The frequency is determined by the condition of the beneficiary, but progress notes must be recorded daily by nursing staff, and at each contact by psychiatrist or physician and by all other treatment staff. Progress notes must contain a concise assessment of the beneficiary's progress and recommendations for revising the treatment plan as indicated by the beneficiary's condition;

(J)The psychiatric diagnosis contained in the final diagnosis

(K)Transition and discharge planning documentation including relapse and crisis prevention planning;

(L)Proof of family and community involvement; and

(M)The discharge summary, including a recapitulation of the beneficiary's hospitalization, recommendations for appropriate services concerning follow-up, and a brief summary of the beneficiary's condition on discharge.

027.10 CERTIFICATION AND RECERTIFICATION BY PSYCHIATRISTS FOR SUBACUTE INPATIENT HOSPITAL PSYCHIATRIC SERVICES. Nebraska Medicaid pays for covered subacute inpatient hospital psychiatric services only if a psychiatrist certifies, and recertifies at designated intervals, the medical necessity for the admission to and continued hospitalization for subacute inpatient psychiatric treatment services. Appropriate supporting material may be required. The psychiatrist's certification or recertification statement must document the medical necessity for the admission to and continued hospitalization for short-term inpatient psychiatric treatment, based on a current evaluation of the beneficiary's condition.

027.10(A) CERTIFICATION OR WRITTEN ORDER REQUIRED. For beneficiaries admitted to a subacute program, a psychiatrist's certification by written order for admission is required at the time of admission.

027.10(B) FAILURE TO CERTIFY. If a hospital fails to obtain the required certification and recertification statements for the beneficiary’s stay, Nebraska Medicaid will not make payment for the services that are not certified.

027.11 HOSPITAL UTILIZATION REVIEW. A site visit by Nebraska Medicaid staff for purposes of utilization review may be required for further clarification.

027.12 BILLING. Providers must submit claims for subacute inpatient hospital psychiatric services on the appropriate Nebraska Medicaid approved health care claim form. Providers must enter the prior authorization number as required for subacute inpatient services.

027.13 LIMITATIONS. For subacute inpatient hospital psychiatric services, the following limitations apply:

(A)Care must be provided by and directly supervised by a licensed psychiatrist. The psychiatrist must be licensed in the state where the service is being delivered;

(B)All subacute inpatient hospital psychiatric services must be prior-authorized; and

(C)Payment for subacute inpatient hospital services is made according to this title .

027.14 DOCUMENTATION. Additional documentation from the beneficiary's medical record may be requested by Nebraska Medicaid prior to considering authorization of payment of subacute inpatient psychiatric care.

027.15 EMERGENCY PROTECTIVE CUSTODY (EPC). A hospital may be reimbursed for beneficiaries under an emergency protective custody (EPC) order in an acute care hospital without designated psychiatric beds for an average of three to five days, up to seven days under the following conditions:

(A)The hospital is licensed by the Nebraska Department of Health and Human Services Division of Public Health;

(B)The hospital is accredited by the Joint Commission

or the American Osteopathic Association (AOA);

(C)The admitting and attending physician is a psychiatrist;

(D)The hospital provides a setting that is separate from the rest of the hospital activities and is a safe, therapeutic environment;

(E)The hospital provides an active treatment program in the form of assessment and diagnostic interventions;

(F)The hospital emergency protective custody (EPC) program is approved by Nebraska Medicaid ; and

(G)The hospital emergency protective custody (EPC) program meets all other standards for inpatient hospital psychiatric care.

028. ADULT INPATIENT HOSPITAL PSYCHIATRIC SERVICES. The care and treatment of an inpatient with a primary psychiatric diagnosis who is receiving inpatient care must be under the direction of a psychiatrist or physician who meets the State's licensing criteria and is enrolled as a provider with Nebraska Medicaid with a primary specialty of psychiatry. Inpatient hospital psychiatric services must be prior-authorized by the Department-contracted peer review organization or management designee. In addition, out-of-state hospitalizations must be approved by Nebraska Medicaid.

028.01 PROVIDER AGREEMENT. A hospital which provides inpatient psychiatric services must complete the appropriate Nebraska Medicaid approved provider agreement form and submit the completed form to Nebraska Medicaid for approval and enrollment as a provider. The hospital must submit with the provider agreement:

(A)A complete description of the psychiatric program and the elements of the program ;

(B)A statement of the total number of licensed psychiatric beds, as approved by the Nebraska Department of Health and Human Services, Division of Public Health or agency in the state in which the facility is located; a listing of the bed numbers for those licensed psychiatric beds; and the size of the proposed psychiatric unit;

(C)Documentation that the inpatient program meets the family-centered, community-based requirements in this chapter;

(D)A description of how family psychotherapy services will be provided;

(E)A description of how the hospital services will interface with community services for discharge planning and service provision after discharge;

(F)A copy of the most recent Joint Commission or American Osteopathic Association (AOA) accreditation survey; and

(G)Any other information requested.

028.01(i) ON-SITE REVIEW. Any facility requesting a provider agreement must make the facility available for an on-site review before issuance of a provider agreement.

028.01(ii) STANDARDS FOR PARTICIPATION FOR INPATIENT HOSPITAL PSYCHIATRIC SERVICE PROVIDERS. A hospital that provides inpatient hospital psychiatric services must meet the following standards for participation to ensure that payment is made only for active treatment. The hospital:

(1) Is maintained for the care and treatment of patients with primary psychiatric disorders;

(2) Is licensed or formally approved as a hospital by the Nebraska Department of Health and Human Services, Division of Public Health, or if the hospital is located in another state, the officially designated authority for standard - setting in that state;

(3) Is accredited by the Joint Commission or by the American Osteopathic Association (AOA);

(4) Meets the requirements for participation in Medicare for psychiatric hospitals;

(5) Has in effect a utilization review plan applicable to all Nebraska Medicaid beneficiaries;

(6) Must have medical records that are sufficient to permit Nebraska Medicaid to determine the degree and intensity of treatment furnished to the client; and

(7) Must meet staffing requirements Nebraska Medicaid finds necessary to carry out an active treatment program in compliance with this chapter.

028.01(iii) DISTINCT PART OF A HOSPITAL AS A PSYCHIATRIC UNIT. A distinct part of a hospital may be considered a psychiatric unit if it meets the standards for participation, even though the hospital of which it is a part does not.

028.01(iv) STAFFING STANDARDS FOR PARTICIPATION. The hospital must have staff adequate in number and qualified to carry out an active program of treatment for beneficiaries who are provided services in the hospital. The hospital must meet the following standards.

028.01(iv)(1) HOSPITAL PERSONNEL. Hospitals which provide inpatient psychiatric services must be staffed with the number of qualified professional, technical, and supporting personnel, and consultants required to carry out an intensive and comprehensive active treatment program that includes evaluation of individual and family needs; establishment of individual and family treatment goals; and implementation, directly or by arrangement, of a broad-range therapeutic program including, at least, professional psychiatric, medical, surgical, nursing, social work, psychological, and activity therapies required to carry out an individual treatment plan for each beneficiary and their family. The following standards must be met:

(a)Qualified professional and technical personnel must be available to evaluate each beneficiary at the time of admission, including diagnosis of any intercurrent disease. Services necessary for the evaluation include:

(i)Laboratory, radiological, and other diagnostic tests;

(ii)Obtaining psychosocial data;

(iii)A complete family assessment in compliance with the requirements in this chapter;

(iv)Carrying out psychiatric and psychological evaluations; and

(v)Completing a physical examination, including a complete neurological examination when indicated, shortly after admission;

(b)The number of qualified professional personnel, including consultants and technical and supporting personnel, must be adequate to ensure representation of the disciplines necessary to establish short-range and long-term goals; and to plan, carry out, and periodically revise a treatment plan for each beneficiary based on scientific interpretation of:

(i)The degree of physical disability and indicated remedial or restorative measures, including nutrition, nursing, physical medicine, and pharmacological therapeutic interventions;

(ii)The degree of psychological impairment and appropriate measures to be taken to relieve treatable distress and to compensate for nonreversible impairments where found;

(iii)The capacity for social interaction, and appropriate nursing measures and milieu therapy to be undertaken, including group living experiences, occupational and recreational therapy, and other prescribed activities to maintain or increase the beneficiary's capacity to manage activities of daily living; and

(iv)The environmental and physical limitations required to protect the beneficiary's health and safety with a plan to compensate for these deficiencies and to develop the beneficiary's potential for return to their own home, a foster home, a skilled nursing facility (NF), a community mental health center, or other alternatives to full-time hospitalization.

028.01(iv)(2) DIRECTOR OF INPATIENT PSYCHIATRIC SERVICES AND MEDICAL STAFF. Inpatient psychiatric services must be under the supervision of a clinical director, service chief, or the equivalent who is qualified to provide the leadership required for an intensive treatment program. The number and qualifications of physicians must be adequate to provide essential psychiatric services. The following standards must be met:

(a)The clinical director, service chief, or equivalent must meet the training and experience requirements for a psychiatrist or a physician for Nebraska Medicaid ;

(b)The medical staff must be qualified legally, professionally, and ethically for the positions to which they are appointed;

(c)The number of physicians must be commensurate with the size and scope of the treatment program;

(d)The physician's personal involvement in all aspects of the beneficiary's psychiatric care must be documented in the beneficiary's medical record ; and

(e)The physician must be available, in person or by telephone, to provide assistance and direction as needed.

028.01(iv)(3) AVAILABILITY OF PHYSICIANS AND OTHER PERSONNEL. Physicians, advanced practice registered nurses (APRN), and other appropriate professional personnel must be available at all times to provide necessary medical, surgical, diagnostic, and treatment services, including specialized services. If medical, surgical, diagnostic, and treatment services are not available within the hospital, qualified consultants or attending physicians must be immediately available, or a satisfactory arrangement must be established for transferring beneficiaries to a general hospital certified for Medicare.

028.01(iv)(4) NURSING SERVICES. Nursing services must be under the direct supervision of a registered professional nurse who is qualified by education and experience for the position. The number of registered professional nurses, licensed practical nurses (LPN), and other nursing personnel must be adequate to formulate and carry out the nursing components of a treatment plan for each beneficiary. The following standards must be met:

(a)The registered professional nurse supervising the nursing program must have a master's degree in psychiatric or mental health nursing or its equivalent from a school of nursing accredited by the National League for Nursing, or must be qualified by education or experience in the care of the mentally ill, and have demonstrated competence to:

(i)Participate in interdisciplinary formulation of treatment plans;

(ii)Give skilled nursing care and therapy; and

(iii)Direct, supervise, and train others who assist in implementing and carrying out the nursing components of each beneficiary's treatment plan;

(b)The staffing pattern must ensure the availability of a registered professional nurse 24 hours each day for:

(i)Direct care;

(ii)Supervising care performed by other nursing personnel; and

(iii)Assigning nursing care activities not requiring the services of a professional nurse to other nursing service personnel according to the beneficiary's needs and the preparation and competence of the nursing staff available;

(c)The number of registered professional nurses, including nurse consultants, must be adequate to formulate a nursing care plan in writing for each beneficiary and to ensure that the plan is carried out; and

(d)Registered professional nurses and other nursing personnel must be prepared by continuing in-service and staff development programs for active participation in interdisciplinary meetings affecting the planning or implementation of nursing care plans for beneficiaries. The meetings include diagnostic conferences, treatment planning sessions, and meetings held to consider alternative facilities and community resources.

028.01(iv)(5) PSYCHOLOGICAL SERVICES. The psychological services must be under the supervision of a licensed psychologist. The psychology staff, including consultants, must be adequate in numbers and be qualified to plan and carry out assigned responsibilities. The following standards must be met:

(a)The psychology department or service must be under the supervision of a licensed psychologist;

(b)Psychologists, consultants, and supporting personnel must be adequate in number and be qualified to assist in essential diagnostic formulations, and to participate in:

(i)Program development and evaluation of program effectiveness;

(ii)Training and research activities;

(iii)Therapeutic interventions ; and

(iv)Interdisciplinary conferences and meetings held to establish diagnoses, goals, and treatment programs; or

(c)Psychotherapy must be ordered and directed by a physician or advanced practice registered nurse (APRN) .

028.01(iv)(6) SOCIAL WORK SERVICES AND STAFF. Social work services must be under the supervision of a qualified social worker. The social work staff must be adequate in numbers and be qualified to fulfill responsibilities related to the specific needs of individual beneficiaries and their families, the development of community resources, and consultation with other staff and community agencies. The following standards must be met:

(a)The director of the social work department or service must have a master's degree from an accredited school of social work and must meet the experience requirements for certification by the Academy of Certified Social Workers and must be licensed by the Nebraska Department of Health and Human Services, Division of Public Health as a mental health practitioner; and

(b)Social work staff, including other social workers, consultants, and other assistants or case aides, must be qualified and numerically adequate to:

(i)Provide psychosocial data for diagnosis and treatment planning, and for direct therapeutic services to beneficiaries, patient groups, or families; to develop community resources, including family or foster care programs; to conduct appropriate social work research and training activities; and to participate in interdisciplinary conferences and meetings concerning diagnostic formulation and treatment planning, including identification and utilization of other facilities and alternative forms of care and treatment;

(c) Qualified therapists, consultants, volunteers, assistants, or aides must be sufficient in number to provide comprehensive therapeutic activities, including occupational, recreational, and physical therapy (PT), as needed, to ensure that appropriate treatment is provided to each beneficiary, and to establish and maintain a therapeutic milieu. The following standards must be met:

(i)Occupational therapy (OT) services must be provided preferably under the supervision of a graduate of an occupational therapy (OT) program approved by the Council on Education of the American Medical Association who is licensed by the Nebraska Department of Health and Human Services, Division of Public Health or is eligible for the National Registration Examination of the American Occupational Therapy Association. In the absence of a full-time, fully-qualified occupational therapist (OT), an occupational therapy assistant (OTA) may function as the director of the activities program with consultation from a fully-qualified occupational therapist (OT);

(ii)When physical therapy (PT) services are offered, the services must be given by or under the supervision of a qualified physical therapist (PT) who is a graduate of a physical therapy (PT) program approved by the Council on Medical Education of the American Medical Association in collaboration with the American Physical Therapy Association or its equivalent and is licensed by the Nebraska Department of Health and Human Services, Division of Public Health. In the absence of a full-time, fully-qualified physical therapist (PT), physical therapy (PT) services must be available by arrangement with a certified local hospital, or by consultation or part-time services furnished by a fully-qualified physical therapist (PT);

(iii) Educational program services, when required by law, must be available. Educational program services must only be one aspect of the treatment plan, not the primary reason for admission or treatment. Educational program services are not covered for payment by Nebraska Medicaid ;

(iv)Recreational or activity therapy services must be available under the direct supervision of a member of the staff who has demonstrated competence in therapeutic recreation programs;

(v)Other occupational therapy (OT), recreational therapy, activity therapy, physical therapy assistants (PTA), or aides must be directly responsible to qualified supervisors and must be provided special on-the-job training to fulfill assigned functions;

(vi)The total number of rehabilitation personnel, including consultants, must be sufficient to:

(1) Permit adequate representation and participation in interdisciplinary conferences and meetings affecting the planning and implementation of activity and rehabilitation programs, including diagnostic conferences; and

(2) Maintain all daily scheduled and prescribed activities, including maintenance of appropriate progress records for individual beneficiaries; and

(vii)Volunteer service workers must be:

(1) Under the direction of a paid professional supervisor of volunteers;

(2) Provided appropriate orientation and training; and

(3) Available daily in sufficient numbers to assist beneficiaries and their families in support of therapeutic activities.

028.02 COVERAGE CRITERIA FOR INPATIENT HOSPITAL SERVICES. Nebraska Medicaid covers inpatient hospital psychiatric services for beneficiaries age 21 and over when the services meet the criteria in this chapter and when the following requirements are met:

(A)The attending physician must personally and face-to-face evaluate the beneficiary and write the psychiatric evaluation and diagnosis formulation;

(B)The beneficiary must be treated by a physician or advanced practice registered nurse (APRN) personally and face-to-face at least six out of seven days and the interaction must be documented in the beneficiary's clinical record;

(C)A psychiatrist or physician for Nebraska Medicaid serves as the attending physician and defines the medical necessity and active treatment requirements noted in this chapter’s General Requirements; and

(D)The treatment plan must be developed and supervised by a multi-disciplinary team under the direction and supervision of the physician. It must be implemented upon admission and must be reviewed every 30 days or more often if medically necessary by the multi-disciplinary team. Treatment plans must meet the medical necessity and active treatment requirements in this chapter.

028.03 ADMISSION CRITERIA FOR INPATIENT HOSPITAL PSYCHIATRIC SERVICES. One or more of the following problems must be present:

(A)The beneficiary needs a specific form of psychiatric treatment that can only be provided in the hospital, and the structured environment of the hospital is necessary for the beneficiary's treatment;

(B)Specific observations are needed for evaluation and disposition;

(C)Specific observations are needed for following treatment, or control of behavior is necessary for effective somatic therapy or psychotherapy;

(D)The beneficiary's disorder is a serious threat to their adaptation to life and continuing developmental process, and hospitalization at this time is necessary to control this factor;

(E)The beneficiary is experiencing psychiatric symptoms, the magnitude of which is not tolerable to self or society and that cannot be alleviated through treatment;

(F)The beneficiary is unable to be cared for by self or others, due to psychiatric disorder;

(G)All beneficiaries must require and receive active treatment as defined in federal regulations , which is available only in an inpatient setting, except that beneficiaries that are age 65 and older in an institution for mental disease (IMD) pursuant to this chapter ); or

(H)Ambulatory care services in the community do not meet the treatment needs of the beneficiary. In those communities where outpatient resources are not available, the community pattern of referral must be used when appropriate.

028.03(i) GUIDELINES FOR INTERPRETATION. Admission of a beneficiary age 21 and older to an acute care facility or an acute level of care may be made only after all resources at a less restrictive level have been explored and deemed inappropriate. The following will not be accepted as adequate medical indicators for hospital inpatient admission:

(1)Non-availability of group home, halfway house, residential treatment or other placement alternatives;

(2)Admission to support or arrange placement in group home, halfway house, or residential treatment;

(3)Admission solely for emergency placement or protective custody;

(4)Admission due to failure of current placement;

(5)Reason for acute level of care is to obtain Nebraska Medicaid benefits that would otherwise not be reimbursed;

(6)Admission to avoid placement in the criminal justice system;

(7)Admission for conduct disorders or behavioral issues that do not demonstrate an imminent danger to self or others;

(8)Social and family problems; and

(9)Psychometric evaluation including learning disabilities.

028.03(ii) BENEFICIARY ASSESSMENT. Admission to an acute care facility must meet the first two elements listed below plus at least one other element from this beneficiary assessment section. The additional element must be as a result of the major psychiatric disorder referred to in the first element below . In addition, one element from the acute services section must be met. Elements 1 and 2 must be met on all admissions, plus one of the elements from 3 to 7:

(1)Documented evidence of a major psychiatric disorder that necessitates 24-hour medical supervision and daily physician or advanced practice registered nurse (APRN) contact; and

(2)Documented initial treatment plan with provisions for:

(a)Resolution of acute medical problems;

(b)Evaluation of, and needs assessment for, medications;

(c)Protocol to ensure beneficiary's safety; and

(d)Discharge plan initiated at the time of admission.

(3)Demonstrates imminent danger to self or others at the time of admission evidenced by at least one of the following:

(a)Suicide attempt or specific suicide plan with access to means;

(b)Danger to others through a specific action or activity;

(c)Command hallucination with suicidal or homicidal content;

(d)Hallucinations, delusional behavior, or other bizarre psychotic behavior;

(4)Presence of other behavior or symptoms to such a degree or in such a combination that acute care is the least restrictive treatment available as demonstrated by at least one of the following:

(a)Physical aggression toward family, peers, or coworkers which could not be considered self-protective;

(b)Explosive behavior without provocation or serious loss of impulse control;

(c)Dangerous, assaultive, uncontrolled or extreme impulsive behavior which puts the beneficiary at significant risk ;

(d)Severe impairment in concentration or hyperactivity; or

(e)Behaviors consistent with an acute psychiatric disorder which may include significant mental status changes; and there is documented evidence that no medical condition would account for the symptoms;

(5)Severe impairment in psychosocial functioning as demonstrated by at least one of the following:

(a)Psychotic behavior, delusions, paranoia, or hallucinations; or

(b)Severe decompensation and interference with baseline functioning;

(6)Documented failure of current intensive outpatient treatment including two or more of the following indications:

(a)Intensification or perseverance of severe psychiatric symptoms;

(b)Noncompliance with medication regime;

(c)Lack of therapeutic response to medication; or

(d)Lack of beneficiary participation in or response to outpatient treatment modalities; or

(7)Admissions ordered by the court will be covered when accompanied by substantiation of medical necessity.

028.03(iii) DOCUMENTATION SUPPORT. Documentation supports the need for controlled, clinical observation and psychiatric evaluation, where acute care is the least restrictive treatment alternative.

028.03(iv) JUSTIFICATION FOR CONTINUED STAY. The beneficiary must meet the first two elements listed below plus two additional elements for the approval of continued stay. Elements 1 and 2 must be met on all admissions, plus one of the elements from 3 to 7.

(1)Evidence of a major psychiatric disorder that necessitates 24-hour medical supervision and physician or advanced practice registered nurse (APRN) contact; and

(2)A comprehensive treatment plan and clinical pathway of inpatient care must be completed within 72 hours of admission and implemented to facilitate the beneficiary's progression toward living in a less supervised setting. Documentation must support the beneficiary's and family's active involvement with the treatment goals and with revisions in the treatment plan as appropriate based on the beneficiary's progress or lack of progress.

(3)Isolation, seclusion, or restraint procedures within the last 72 hours requiring 24-hour medical supervision and supported by medical record documentation;

(4)Continuing evidence of symptoms and behaviors reflecting significant risk, imminent danger, or actual demonstrated danger to self or others; requiring one-to-one suicideor homicide precautions , close observation, step down precautions including checks every 15–60-minute ;

(5)Monitoring or adjustment of psychotropic medication(s) related to lack of therapeutic effect or complication(s) in the presence of complicating medical and psychiatric conditions necessitating 24-hour medical supervision and supported by medical record documentation;

(6)Persistence of psychotic symptoms and continued temporary inability of the beneficiary to perform the activities of daily living or meet their basis needs for nutrition and safety due to a psychiatric disorder or the temporary mental state of the beneficiary; or

(7)Continued need for 24-hour medical supervision, reevaluation or diagnosis of a beneficiary exhibiting behaviors consistent with acute psychiatric disorder. Referral for physician or advanced practice registered nurse (APRN) review is necessary if symptoms are unimproved or worse within any sevenday interval.

028.03(v) SIGNS AND SYMPTOMS. In addition to the admission criteria, one or more of the following signs or symptoms of the problem must be present:

(1)A suicide attempt that requires acute medical intervention or suicidal ideation with a lethal plan and the means to carry out this plan;

(2)Psychiatric decompensation to a level in which the beneficiary is not able to communicate or perform life-sustaining activities of daily living;

(3)Delusions or hallucinations that significantly impair the beneficiary's ability to communicate or perform life-sustaining activities of daily living;

(4)Catatonia;

(5)The presence of combined illnesses where neurological or other disease process coexists with a psychiatric disturbance, demanding special diagnostic or treatment interventions, which exceed non-hospital capacity;

(6)Aggression to others causing physical injury or homicidal ideation with a lethal plan and the means to carry out the plan, that is the result of a severe emotional psychiatric decompensation; and

(7)Medication initiation or change when the beneficiary has a documented history of reactions to psychotropic medications that have resulted in the need for acute medical care in a hospital or an emergency room.

028.04 PRIOR AUTHORIZATION PROCEDURES. All inpatient admissions must be prior-authorized by the Nebraska Medicaid’s contracted peer review organization or management designee. Each beneficiary will have a specific prior-authorization number assigned by the Nebraska Medicaid’s contracted peer review organization or management designee if the admission is approved. Providers should follow the Nebraska Medicaid’s contracted peer review organization or management designee requirements on facilitating prior authorization.

028.05 DOCUMENTATION IN THE BENEFICIARY’S CLINICAL RECORD. The medical records maintained by a hospital permit determination of the degree and intensity of the treatment provided to beneficiaries who receive services in the hospital. For inpatient hospital psychiatric services, clinical records must stress the psychiatric components of the record, including history of findings and treatment provided for the psychiatric condition for which the beneficiary is hospitalized. All documents from the beneficiary's medical record submitted to Nebraska Medicaid must contain sufficient information for identification. The medical record must include:

(A)The identification data, including the beneficiary's legal status and whether the admission is voluntary a Mental Health Board commitment, or court mandated;

(B)A provisional or admitting diagnosis which is made on every beneficiary at the time of admission and includes the diagnoses of intercurrent diseases as well as the psychiatric diagnoses;

(C)The complaint of others regarding the beneficiary, as well as the beneficiary's comments;

(D)The psychiatric evaluation, including a medical history, which contains a record of mental status and notes the onset of illness, the circumstances leading to admission, attitudes, behavior, estimate of intellectual functioning, memory functioning, orientation, and an inventory of the beneficiary's strengths in a descriptive, not interpretative, fashion;

(E)A complete neurological examination, when indicated, recorded at the time of the admitting physical examination;

(F)A social history sufficient to provide data on the beneficiary's relevant past history, present situation, social support system, community resource contacts, and other information relevant to good treatment and discharge planning;

(G)A family assessment as described in this chapter;

(H)Reports of consultations, psychological evaluations, electroencephalograms, dental records, and special studies;

(I)The beneficiary's treatment plan and treatment plan reviews;

(J)The treatment received by the beneficiary, which is documented in a manner and with a frequency to ensure that all active therapeutic efforts are included;

(K)Progress notes which are recorded by the psychiatrist or physician, nurse, social worker, and, when appropriate, others significantly involved in active treatment modalities. The frequency is determined by the condition of the beneficiary, but progress notes must be recorded daily by nursing staff, and at each contact by psychiatrist or physician and by all other therapeutic staff . Progress notes must contain a concise assessment of the beneficiary's progress and recommendations for revising the treatment plan as indicated by the beneficiary's condition;

(L)The psychiatric diagnosis contained in the final diagnosis ;

(M)Transition and discharge planning documentation;

(N)Proof of family and community involvement;

(O)A copy of the appropriate Nebraska Medicaid approved confidential report certification; and

(P)The discharge summary, including a recapitulation of the beneficiary's hospitalization, recommendations for appropriate services concerning follow-up, and a brief summary of the beneficiary's condition on discharge.

028.06 CERTIFICATION AND RECERTIFICATION BY PSYCHIATRISTS. Nebraska Medicaid pays for covered inpatient hospital psychiatric services only if a psychiatrist or physician certifies, and recertifies at designated intervals, the medical necessity for the services of the hospital inpatient stay. Appropriate supporting material may be required. The psychiatrist's or physician's certification or recertification statement must document the medical necessity for the admission to and continued hospitalization for inpatient psychiatric treatment, based on a current evaluation of the beneficiary's condition. For beneficiaries admitted to a hospital, a psychiatrist's or physician's certification by written order for admission is required at the time of admission for inpatient services.

028.06(A) FAILURE TO CERTIFY OR RECERTIFY. If a hospital fails to obtain the required certification and recertification statements in an individual case, Nebraska Medicaid must not make payment for the case.

028.07 HOSPITAL UTILIZATION REVIEW (UR). . A site visit by Nebraska Medicaid for purposes of utilization review (UR) may be required for further clarification.

028.08 BILLING. Providers must submit claims for inpatient hospital psychiatric services on the appropriate Nebraska Medicaid approved health care claim form or electronic claim.

028.09 OTHER REGULATIONS. For inpatient services provided by an institution for mental disease (IMD), public or private, see the requirements in this chapter, inpatient hospital services for beneficiaries age 65 and over in institutions for mental disease (IMD's).

028.10 LIMITATIONS. For inpatient hospital psychiatric services, the following limitations apply:

(A)Care must be supervised by a psychiatrist or physician. All inpatient hospital services must be prior-authorized; and

(B)Payment for inpatient hospital services is made according to this title .

028.11 FORM COMPLETION. Inpatient hospital psychiatric service providers must enter the review number from Nebraska Medicaid contracted peer review organization or management designee as required. Payment for approved services is made to the hospital.

028.12 EXCEPTIONS. Additional documentation from the beneficiary's medical record may be requested by Nebraska Medicaid's psychiatric consultants prior to considering authorization of payment.

028.13 EMERGENCY PROTECTIVE CUSTODY (EPC) SERVICES IN AN ACUTE CARE HOSPITAL. Emergency protective custody (EPC) services may be reimbursed in an acute care hospital without licensed psychiatric beds for an average of three to five days, up to seven days under the following conditions:

(A)The hospital is licensed by the Nebraska Department of Health and Human Services, Division of Public Health;

(B)The hospital is accredited by the Joint Commission or the American Osteopathic Association (AOA);

(C)The admitting and attending physician is a psychiatrist;

(D)The hospital provides a setting that is separate from the rest of the hospital activities and is a safe, therapeutic environment;

(E)The hospital provides an active treatment program in the form of assessment and diagnostic interventions;

(F)The hospital emergency protective custody (EPC) services is approved by Nebraska Medicaid ; and

(G)The hospital emergency protective custody (EPC) services meets all other standards for inpatient hospital psychiatric care.

028.13(i) EMERGENCY PROTECTIVE CUSTODY (EPC) SERVICES LIMITATION. The exception for emergency protective custody (EPC) services is available only to hospitals that do not have licensed psychiatric beds.

029. INPATIENT HOSPITAL SERVICES FOR BENEFICIARIES AGE 65 AND OVER IN INSTITUTIONS FOR MENTAL DISEASE (IMD).

029.01 LEGAL BASIS. Nebraska Medicaid covers institution for mental disease (IMD) services, for beneficiaries age 65 and over according to federal regulations Nebraska Medicaid provides institution for mental disease (IMD) services according to Nebraska statutes.

029.02 STANDARDS FOR PARTICIPATION. To participate in Nebraska Medicaid , the institution for mental disease (IMD) must:

(A)Be in conformity with all applicable federal, state, and local laws;

(B)Be licensed as a hospital by the Nebraska Department of Health and Human Services, Division of Public Health or the licensing agency in the state where the institution for mental disease (IMD) is located;

(C)Be certified as meeting the conditions of participation for hospitals in federal regulations ;

(D)Be accredited by the Joint Commission or the American Osteopathic Association (AOA), and submit a copy of the most recent accreditation survey with the appropriate Nebraska Medicaid approved provider agreement form ;

(E)Meet the definition of an institution for mental disease (IMD) as stated in this chapter;

(F)Meet the current Joint Commission or American Osteopathic Association (AOA) standards of care; and

(G)Meet all requirements in this chapter except active treatment.

029.02(i) PROVIDER AGREEMENT. The provider must complete the appropriate Nebraska Medicaid approved provider agreement form , and submit the form, along with a copy of its current Joint Commission or American Osteopathic Association (AOA) accreditation survey, program, policies, and procedures to Nebraska Medicaid to enroll in Nebraska Medicaid as a provider. If approved, Nebraska Medicaid notifies the institution for mental diseases (IMD) of its provider number.

029.02(ii) ANNUAL UPDATE. With the annual cost report, the provider must submit a copy of all program information, their most recent license and accreditation certificates, and any other information specifically requested by Nebraska Medicaid. Claims will not be paid if this has not been received and approved. This information must be submitted with a new copy of the appropriate Nebraska Medicaid approved provider agreement f.

029.02(iii) MONTHLY REPORTS. The institution for mental diseases (IMD) must submit a monthly report to Nebraska Medicaid . The report must be submitted by the 15th of the following month. The report must contain:

(1)The names of all Nebraska Medicaid beneficiaries admitted or discharged during the month; and

(2)The date of each Nebraska Medicaid beneficiary's admission or discharge.

029.02(iv) RECORD REQUIREMENTS. The institution for mental diseases (IMD) must enter the appropriate Nebraska Medicaid approved inpatient mental health services form or electronic claim that is submitted to Nebraska Medicaid.

029.02(iv)(1) TRANSFER. Transfer to another institution for mental diseases (IMD) or readmission constitutes a new admission for the receiving facility.

029.02(iv)(2) AN INDIVIDUAL WHO APPLIES FOR NEBRASKA MEDICAID. For an individual who applies for Nebraska Medicaid while in the institution for mental diseases (IMD), the certification must be:

(a)Made by the team that develops the individual plan of care as outlined in this chapter; and

(b)Cover any period before application for which claims are made.

029.02(iv)(3) NEBRASKA MEDICAID. When Nebraska Medicaid eligibility is determined, authorization for previous and continued care must be obtained from the Department contracted peer review organization or management designee.

029.03 ADMISSION CRITERIA. As outlined in this chapter.

029.04 SIGNS AND SYMPTOMS. As outlined in this chapter.

029.05 PRIOR AUTHORIZATION AND INITIAL CERTIFICATION PROCEDURES. Institution for mental diseases (IMD) services for beneficiaries age 65 or older must be prior-authorized as follows:

(A)Admissions must be prior-authorized by the Nebraska Medicaid's contracted peer review organization or management designee. Providers should follow the Nebraska Medicaid’s contracted peer review organization or management designee requirements on facilitating prior authorization. The appropriate Nebraska Medicaid approved confidential report form received from the peer review organization or management designee must be maintained in the beneficiary's medical record;

(B)A psychiatrist must pre-certify, at the time of admission, that the beneficiary requires inpatient services in a psychiatric hospital. The psychiatrist must complete, sign, and date the appropriate Nebraska Medicaid approved confidential report f within 48 hours after admission or at the time of application for medical assistance if this date is later than the date of admission. The 48-hour period does not include weekends or holidays. Copies of the admission notes, and plan of care may be attached to the signed and dated appropriate Nebraska Medicaid approved confidential report form to certify that inpatient services are or were needed;

(C) The facility must contact Nebraska Medicaid for determination of medical eligibility;

(D)The facility must complete the appropriate Nebraska Medicaid approved inpatient mental health services form , attach a copy of the completed appropriate Nebraska Medicaid approved confidential report form , and forward to Nebraska Medicaid . The facility must retain the original copy of the appropriate Nebraska Medicaid approved confidential report form in the beneficiary's medical record;

(E)The document number on the appropriate Nebraska Medicaid approved inpatient mental health services form must be entered on each Nebraska Medicaid approved health care claim form or standard electronic health care claim transaction and submitted to Nebraska Medicaid; and

(F)When the individual is discharged or expires, the facility must complete the appropriate form and forward to Nebraska to close the authorization.

029.06 TRANSFERS. Initial certification procedures must be followed for each transfer or readmission.

029.07 SIXTY-DAY RECERTIFICATION. A psychiatrist must recertify, in the beneficiary's record, the beneficiary's need for continued care in a mental hospital or need for alternative arrangements at least every 60 days after the initial certification.

029.08 INTERDISCIPLINARY PLAN OF CARE. The psychiatrist and the facility interdisciplinary team must develop and implement an individual written plan of care for each beneficiary within 48 hours after the beneficiary's admission. This plan of care must be placed in the beneficiary's chart when completed. This requirement is met by completion of the appropriate form, which is retained in the beneficiary's record. The written plan of care must include:

(A)Diagnoses, symptoms, complaints, and complications indicating the need for admission;

(B)A description of the beneficiary's functional level;

(C)Objectives;

(D)Any orders for:

(i)Medications;

(ii)Treatments;

(iii)Restorative and rehabilitative services;

(iv)Activities;

(v)Therapies;

(vi)Social services;

(vii)Diet; and

(viii)Special procedures recommended for the beneficiary's health and safety;

(E)Plans for continuing care, including review and modification of the plan of care;

(F)Appropriate medical treatment in the institution for mental diseases (IMD) every 60 days;

(G)Appropriate social services every 60 days;

(H)Family involvement; and

(I)Plans for discharge, including referrals for outpatient follow-up care.

029.09 FACILITY INTERDISCIPLINARY PLAN OF CARE TEAM REVIEW. The attending or staff psychiatrist and other personnel involved in the beneficiary's care must review each plan of care at least every 90 days. The beneficiary's record must contain documentation of the 90-day interdisciplinary team review.

029.10 ADMISSION EVALUATION. Institution for mental diseases (IMD) staff must develop an admission evaluation for each beneficiary within 30 days after the beneficiary's admission. This evaluation must be placed in the beneficiary's record when completed. The admission evaluation must include:

(A)The appropriate form ;

(B)A medical evaluation, including:

(i)Diagnosis;

(ii)Summary of current medical findings;

(iii)Medical history;

(iv)Mental and physical functional capacity;

(v)Prognosis;

(vi)The psychiatrist's recommendation concerning the beneficiary's admission to the mental hospital or the beneficiary's need for continued care in the mental hospital, if the beneficiary applies for Nebraska Medicaid while in the mental hospital;

(C)A psychiatric evaluation;

(D)A social evaluation; and

(E)An initial plan of care sufficient to meet the beneficiary's needs until the facility interdisciplinary team has developed the individual written plan of care.

029.11 ADMISSION EVALUATION. The institution for mental diseases (IMD) must make available to the psychiatrist current information on resources available for continued out-of-hospital care of beneficiaries and must arrange for prompt transfer of appropriate medical and nursing information to ensure continuity of care upon the beneficiary's discharge. Federal regulations require that, when the beneficiary is approved for an alternate plan of care, the institution for mental diseases (IMD) is responsible for discharge planning. In cooperation with community regional mental health programs, the institution for mental diseases (IMD) must:

(A)Initiate alternate care arrangements;

(B)Assist in beneficiary transfer; and

(C)Follow-up on the beneficiary's alternate care arrangements.

029.11(i) TRANSFER. When the beneficiary is being transferred to a long-term care (LTC) facility , the facility's staff must be included in the discharge process and must receive appropriate and adequate medical and nursing information to ensure continuity of care. The institution for mental diseases (IMD) must also contact Nebraska Medicaid .

030. MEDICALLY MONITORED INPATIENT WITHDRAWAL MANAGEMENT (MMIW). Medically monitored inpatient withdrawal management (MMIW) is a non-hospital intervention that provides 24-hour medically monitored evaluation under physician-approved policies and procedures or clinical protocols. This service is suitable for beneficiaries that require 24-hour care, but do not require the full resources of an acute care general hospital or a medically managed intensive inpatient program.

030.01 ACCREDITATION. Medically monitored inpatient withdrawal management (MMIW) services must be accredited by a national accrediting agency for the appropriate inpatient setting.

030.02 REQUIREMENTS. The following requirements must be met for the medically monitored inpatient withdrawal program (MMIW):

(A) A physician, physician assistant (PA), or advanced practice registered nurse (APRN) must complete a physical assessment within 24 hours of admission or immediately, if medical necessity arises;

(B) A licensed medical professional including a physician, physician assistant (PA), and advanced practice registered nurse (APRN) or a licensed therapist operating within their scope of practice, must complete a mental status examination as part of the intake and assessment process;

(C) A physician, physician assistant (PA), or advanced practice registered nurse (APRN) must be available to provide on-site care and further evaluation on a daily basis and be available 24 hours a day by telephone to provide access to the patient;

(D) A licensed physician, physician assistant (PA), advanced practice registered nurse (APRN), or therapist operating within their scope of practice must conduct a substance use assessment, including the risk to self or others, and determination of appropriate level of care;

(E) The substance use assessment must be used to develop the individual treatment plan; and

(F) The withdrawal management program must provide random urine drug testing, health education, and addiction education services and laboratory and toxicology tests, as ordered by the physician, physician assistant (PA) or advanced practice registered nurse (APRN).

History

• Effective 2026-06-28

Chapter 21 Rehabilitation Care in Hospitals

Neb. Admin. Code tit. 471, ch. 21 Rehabilitation Care in Hospitals {#sec-471-nac-21 omnilex-key=us-ne-regs-official--title-471--471 NAC 21}

21-001 Definitions

Activities of Daily Living: Activities performed by the client relating to self-care, such as bathing, continence, eating, dressing, grooming, mobility, toileting, and transferring.

Distinct Part Unit: A Medicare-certified hospital-based substance abuse, psychiatric, or physical rehabilitation unit that is certified as a distinct part unit for Medicare.

Initial Evaluation: See 471 NAC 21-003.02A

Rehabilitation Hospitals and Distinct Part Units in Acute Care Hospitals: Hospitals that are licensed as rehabilitation hospitals by the licensing agency of the state in which they are located, and distinct parts as defined in these regulations.

Rehabilitation Services: Any medical or remedial services recommended by and within the scope of practice under state law of a physicianw, for maximum reduction of physical or mental disability and restoration of a client to the client’s best possible functional level.

Rehabilitation Team: A multidisciplinary coordinated team, comprised of individuals described in 471 NAC 21-003.02(i)-(vii), which is responsible for performing the initial evaluation, determining the extent to which rehabilitation is possible, identifying rehabilitation goals, and developing the rehabilitation program.

21-002 Provider Requirements

21-002.01 General Provider Requirements: To participate in the Nebraska Medical Assistance Program (Medicaid), providers of rehabilitation services shall comply with all applicable participation requirements codified in 471 NAC Chapters 2 and 3. In the event that provider participation requirements in 471 NAC Chapters 2 or 3 conflict with requirements outlined in 471 NAC Chapter 21, the individual provider participation requirements in 471 NAC Chapter 21 shall govern.

21-002.02 Specific Provider Requirements: Rehabilitation services must be provided in a hospital or a distinct part of a hospital that:

i. Provides rehabilitation services;

ii. Is licensed or formally approved as a hospital by the Nebraska Department of Health and Human Services, Division of Public Health or, if the hospital is located in another state, the authority responsible for licensing or formal approval in that state;

iii. Has licensed and certified rehabilitation beds;

iv. Meets the requirements for participation in Medicare for rehabilitation hospitals; and

v. Has in effect a utilization review plan which applies to all Medicaid clients.

21-002.02A Provider Agreement: A hospital which provides rehabilitation services shall complete and sign Form MC-20, "Medical Assistance Hospital Provider Agreement" (see 471-000-91) and submit the completed form to the Department for approval and enrollment as a provider. Each hospital shall have a separate provider agreement (and a separate provider number) for rehabilitation services. The hospital shall submit a description of the rehabilitation program with the provider agreement.

21-002.02A1 Out-of-State Hospital Provider Agreement: In addition to a completed and signed Form MC-20, an out-of-state hospital shall also submit documentation of its certification/accreditation status from the state survey agency in the state where the hospital is located. The Department will not process claims received from an out-of-state hospital until all information required under this section has been received.

Also see 471 NAC 10-010.03J, Out-of-State Hospital Rates, and 10-010.06G, Payment to an Out-of-State Hospital for Outpatient Hospital and Emergency Room Services.

21-002.02B Hospital Level of Rehabilitation Care: The Rehabilitation hospital must provide a hospital level of rehabilitative care. Hospitals with a significant number of rehabilitation team members working on a part time basis must provide evidence to establish that the hospital did, in fact, provide a hospital level of rehabilitative care. Evidence documenting the hospital level of rehabilitative care includes, but is not limited to:

1. Verification that team conferences were held at least once every two weeks;

2. Verification that there was a need for, and involvement of, various allied health professionals; and,

3. Verification of the intensity of the rehabilitative program.

21-003 Service Requirements

21-003.01 General Requirements

21.003.01A Medical Necessity: Rehabilitation services must be provided in accordance with the medical necessity guidelines outlined in 471 NAC 1-002.02A.

21-003.01B Prior Authorization of Medical Rehabilitation Care: Medicaid requires prior authorization of all medical inpatient rehabilitation services to determine the medical necessity, appropriateness of setting, and length of stay. Prior authorization functions, admission reviews, concurrent reviews, and retrospective prepayment reviews are conducted by the peer review organization (PRO), an entity contracted with Medicaid to perform these services. The PRO also performs reconsideration reviews of inpatient hospital denials when requested by the provider.

21-003.01C Services Provided for Clients Enrolled in the Nebraska Medicaid Managed Care Program: See 471 NAC 1-002.01.

21-003.01C1 Delayed Enrollment: When a client is in an acute care medical or rehabilitation facility prior to the client’s enrollment in Managed Care, the effective date of enrollment is delayed until the client is discharged from the facility or transferred to a lower level of care. See 482 NAC 2-002.05D.

21-003.01D HEALTH CHECK (EPSDT) Treatment Services: See 471 NAC Chapter 33.

21-003.02 Covered Services: Medicaid covers rehabilitation services for patients requiring a hospital level of care, and a rehabilitation program which incorporates a multidisciplinary coordinated team approach to upgrade his/her ability to function as independently as possible. A program of this scope usually includes:

i. Intensive skilled rehabilitation nursing care;

ii. Physical therapy;

iii. Occupational therapy; and

iv. If needed, speech therapy;

v. Nursing staff to provide general nursing services, and support the other disciplines by monitoring the patient's activities on the nursing floor to ensure that s/he participates in carrying out the activities of daily living utilizing the training received in therapy;

vi. Ongoing general and, as needed, direct supervision of a physician with special training or experience in the field of rehabilitation (For coverage limitations, billing, and payment of physicians services, see 471 NAC 18-000.); and,

vii. If needed, a psychologist and/or social worker to help resolve any psychological and social problems which are impeding rehabilitation. (For coverage limitations, billing, and payment of psychological services, see 471 NAC 20-000 and/or 32-000.)

21-003.02A Rehabilitation Evaluation: When a client is admitted to the hospital for rehabilitation care, an assessment must be made of his/her:

i. Medical condition;

ii. Functional limitations;

iii. Prognosis;

iv. Possible need for corrective surgery;

v. Attitude toward rehabilitation; and

vi. The existence of any social problems affecting rehabilitation.

After these assessments are made, the physician, in consultation with the rehabilitation team, decides whether rehabilitation is possible; what the reasonable rehabilitation goals are; and what type of rehabilitation program is required to achieve these goals.

21-003.02A1 Limitations to Coverage of the Initial Evaluation:

21-003.02A1a Duration of Evaluation: When more than 10 days are required to complete the initial evaluation, the Department will carefully review the case to ensure that the additional time was necessary. The Department may request, and the hospital shall submit, documentation showing the necessity of the additional time. Inpatient hospital care is required for this period, and covered under Medicaid if the client's condition warrants a multidisciplinary team evaluation.

21.003.02A1b Identical or Similar Admission Conditions: If, during a previous hospital stay, the client completed a program for essentially the same condition for which inpatient hospital care is now being provided, the Department covers the initial evaluation period only if:

i. A change in circumstances has occurred which makes an evaluation reasonable and necessary; or,

ii. The subsequent admission is to an institution utilizing advanced techniques or technology not available in the first institution.

21-003.02A1c Dementia or Senility: In view of the client's limited rehabilitation potential, a multidisciplinary team evaluation is not considered reasonable and necessary for a client who is demented or severely senile.

21-003.02A2 Mental Confusion: Medicaid does not cover hospitalization for rehabilitation following an evaluation if mental confusion with an inability to learn is the only existing disability. Alternatively, the fact that an individual is "confused" is not a basis for concluding that a multidisciplinary team evaluation is not warranted.

21-003.02B Rehabilitation Program: Medicaid covers hospitalization in cases where the rehabilitation team determines, after the initial evaluation, that a significant practical improvement can be expected in a reasonable period of time. Rehabilitation goals must be realistic and reasonable. Vocational rehabilitation is generally not considered a realistic goal for most clients receiving rehabilitation services under Medicaid. For the majority of clients, the most realistic rehabilitation goal is self-sufficiency in:

1. Bathing;

2. Ambulation;

3. Toileting;

4. Eating;

5. Dressing;

6. Homemaking; or

7. Sufficient improvement in the areas of self-sufficiency to allow the client to live in the community with assistance rather than in an institution.

In assessing the reasonableness of the established goal or the likelihood that the rehabilitation goal can be achieved in a reasonable period of time, considerable weight must be given to the rehabilitation team's judgment, except where experience indicates that in a significant number of cases the team's judgment has proven to be unreliable. An expectation of the attainment of complete independence in the activities of daily living is not necessary, but there must be an expectation of an improvement that would be of a practical benefit to the client.

21-003.02C Team Conferences: Rehabilitation team conferences must be held at least every 2 weeks to:

1. Assess the individual's progress or the problems impeding progress;

2. Consider possible resolutions to the problems;

3. Reassess the continuing validity of the rehabilitation goals established at the time of the initial evaluation;

4. Reassess the need for any adjustment in these goals or in the prescribed treatment program; and

5. Develop discharge plans.

Team conferences may be a formal or informal, but must involve interactive discussion regarding the patient. The decisions made during conferences must be recorded in the patient's clinical record. The Department may request, and the hospital shall provide, documentation of team conferences.

21-003.02D Discharge: Medicaid covers a maximum of 3 days to discharge the client. If more than 3 days is needed to safely discharge the client, payment for additional days will be made only when adequate justification for the delayed discharge is submitted to the Department.

21-003.03 Non-Covered Services

21-003.03A Poor Candidate for Rehabilitation: When the initial evaluation results in a conclusion that the client is a poor candidate for rehabilitation care, Medicaid limits coverage of inpatient hospital care to a reasonable number of days needed to permit appropriate placement of the client. An intensive rehabilitation program under these circumstances is not considered reasonable and necessary to the treatment of the client's illness or injury.

21-003.03B Further Progress is Unlikely: Rehabilitation services are covered until further progress toward the established rehabilitation goal is unlikely, or further progress may be achieved in a less intensive setting. In making decisions as to whether further progress may be carried out in a less intensive setting, the Department considers:

1. The degree of improvement which has occurred; and

2. The type of program required to achieve further improvement.

When further progress is unlikely, coverage is provided through the time it is reasonable for the physician, in consultation with the rehabilitation team, to have concluded that further improvement would not occur, and effected the client's discharge. Because planning is an integral part of any rehabilitation program and must begin upon the client's admittance to the facility, an extended period of time for discharge action is not reasonable after:

1. Established goals have been reached;

2. A determination has been made that further progress is unlikely; or

3. Care in less intensive setting is appropriate.

21-004 Billing and Payment for Chiropractic Services

21-004.01 Billing

21-004.01A General Billing Requirements: Providers shall comply with all applicable billing requirements codified in 471 NAC Chapter 3. In the event that billing requirements in 471 NAC Chapter 3 conflict with billing requirements outlined in this 471 NAC Chapter 21, the billing requirements in 471 NAC Chapter 21 shall govern.

21-004.01B Specific Billing Requirements

21-004.01B1 Billing Instructions: The provider shall bill Medicaid in accordance with the billing instructions included in this Chapter.

21-004.02 Payment

21-004.02A General Payment Requirements: Medicaid will reimburse the provider for services rendered in accordance with the applicable payment regulations codified in 471 NAC Chapter 3. In the event that payment regulations in 471 NAC Chapter 3 conflict with payment regulations outlined in this 471 NAC Chapter 21, the payment regulations in 471 NAC Chapter 21 shall govern.

21-004.02B Specific Payment Requirements

21-004.02B1 Payment for Inpatient Care: All rehabilitation services, regardless of the type of hospital providing the service, will be reimbursed on a per diem basis. This includes services provided at a facility enrolled as a provider for rehabilitation services which is not a licensed rehabilitation hospital or a Medicare-certified distinct part unit. The per diem rate will be the sum of the following:

1. The hospital-specific base payment per diem rate (See Appendix 471-000-82, Inpatient Hospital Services, Section III.A.1);

2. The hospital-specific capital per diem rate (See Appendix 471-000-82, Inpatient Hospital Services, Section III.A.2); and

3. If applicable, the hospital's direct medical education per diem rate (See Appendix 471-000-82, Inpatient Hospital Services, Section III.A.3).

Payment for each discharge equals the per diem rate times the number of approved patient days. Payment is made for the day of admission but not for the day of discharge.

21-004.02B2 Payment for Outpatient Hospital and Emergency Room Services: See 471 NAC 10-010.06, Payment for Outpatient Hospital and Emergency Room Services.

21-005 Evaluation Report and Plan of Care : The hospital shall submit an evaluation report to the Medical Director of the Division of Medicaid and Long-Term Care, or the Medicaid designated contractor, by the end of the second week following admission. The evaluation report must outline a detailed plan of care, and identify time frames applicable to each goal included in the rehabilitation program. The plan of care must contain a detailed staff report describing the client's:

1. Progress;

2. Problems; and

3. Discharge planning, involving possible relocation of the client to the most appropriate setting.

History

• Effective 2018-05-09

Chapter 22 Respiratory Therapy Services

Neb. Admin. Code tit. 471, ch. 22 Respiratory Therapy Services {#sec-471-nac-22 omnilex-key=us-ne-regs-official--title-471--471 NAC 22}

001. SCOPE AND AUTHORITY . The regulations govern the services provided under Nebraska’s Medicaid program as defined by Nebraska Revised Statute (Neb. Rev. Stat.) §§ 68-901 et seq.

002. DEFINITIONS .

002.01 RESPIRATORY THERAPY. Services that are prescribed by a physician for the assessment, diagnostic evaluation, treatment, management, and monitoring of patients with deficiencies and abnormalities of cardiopulmonary function. Performed by respiratory therapists or technicians, physical therapists, nurses and other qualified personnel.

003. PROVIDER REQUIREMENTS .

003.01 GENERAL PROVIDER REQUIREMENTS. To participate in Nebraska Medicaid, providers of respiratory therapy services must comply with all applicable participation requirements codified in 471 Nebraska Administrative Code (NAC) 1, 2 and 3. In the event that provider participation requirements in 471 NAC 1, 2 or 3 conflict with requirements outlined in 471 NAC 23, the individual provider participation requirements in 471 NAC 22 will govern.

003.02 SERVICE SPECIFIC PROVIDER REQUIREMENTS. Respiratory therapy services must be provided by or under the direct supervision of a respiratory therapist licensed by the Nebraska Department of Health and Human Services, Division of Public Health, or, if provided out of state, similarly recognized by the respiratory therapy association or licensing entity of that state.

004. SERVICE REQUIREMENTS .

004.01 GENERAL SERVICE REQUIREMENTS.

004.01(A) MEDICAL NECESSITY. Nebraska Medicaid incorporates the definition of medical necessity from 471 NAC 1. Services and supplies that do not meet the 471 NAC 1 definition of medical necessity are not covered. In addition to meeting these requirements, respiratory therapy services are considered to be reasonable and necessary for the diagnosis or treatment of an individual's illness or injury only if they also satisfy additional conditions.

004.01(B) CONDITIONS IN ADDITION TO MEDICAL NECESSITY.

004.01(B)(i) CONSISTENT WITH THE NATURE AND SEVERITY OF THE INDIVIDUAL'S COMPLAINTS AND DIAGNOSIS. A patient's primary diagnosis alone must justify the need for respiratory therapy. If the primary diagnosis alone is insufficient, the need for respiratory therapy must be justified by medical evidence documenting the need based on:

(1) The combination of secondary and primary diagnoses; or

(2) The severity of the secondary diagnosis alone.

004.01(B)(ii) REASONABLE IN TERMS OF MODALITY AMOUNT FREQUENCY AND DURATION OF THE TREATMENTS. In addition to being considered reasonable and necessary based on the nature and severity of the patient's condition, respiratory therapy must also be reasonable and necessary with respect to modality, amount, frequency, and duration of treatments.

004.01(B)(ii)(1) DISCHARGE. It is expected that the level and intensity of the care is modified as discharge nears. If the amount and frequency of respiratory therapy provided throughout the hospital stay remains constant and the primary or secondary diagnosis indicates that, under normal circumstances, a decline in amount and frequency could be anticipated, the provider must submit an explanation to Nebraska Medicaid.

004.01(B)(iii) GENERALLY ACCEPTED BY THE PROFESSIONAL COMMUNITY AS BEING SAFE AND EFFECTIVE TREATMENT FOR THE PURPOSE USED. In the absence of evidence to the contrary, it may be presumed that respiratory therapy is an accepted treatment and may be covered.

004.01(C) PHYSICIAN CERTIFICATION. Respiratory therapy services must be provided only on written orders by a licensed Nebraska physician, or, if provided out of state, a licensed physician of that state. Services must be recertified by a physician every 30 days, or more frequently if the patient's condition necessitates.

004.01(D) ADDITIONAL GUIDELINES FOR COVERAGE CRITERIA. Medicaid covers respiratory therapy services only when there is a distinction, or decision, made with respect to the individual patient’s condition and the need for the services.

004.02 COVERED SERVICES.

004.02(A) PLACE OF SERVICE. Nebraska Medicaid covers respiratory therapy in hospitals and long-term care facilities.

004.02(A)(i) HOSPITAL. When provided by a respiratory therapist or technician, the services are covered as ancillary services. When provided by a nurse, the services are covered as nursing services. If the services are reasonable and necessary, they are covered regardless of where in the hospital they are provided, such as an emergency room or Intensive Care Unit (ICU).

004.02(A)(ii) LONG TERM CARE FACILITIES. See 471 NAC 12.

004.02(B) RESPIRATORY THERAPY SERVICES. Respiratory care services include:

(i) The application of techniques for support of oxygenation and ventilation in the acutely ill patient;

(ii) The therapeutic use and monitoring of medical gases (especially oxygen), bland and pharmacologically active mists and aerosols and equipment as resuscitators and ventilators;

(iii) Bronchial hygiene therapy, including deep breathing and coughing exercises, intermittent positive pressure breathing (IPPB), postural drainage, chest percussion and vibration, and nasotracheal suctioning;

(iv) Diagnostic tests for evaluation by a physician, such as pulmonary function tests, spirometry, and blood gas analyses;

(v) Pulmonary rehabilitation techniques that include:

(1) Exercise conditioning;

(2) Breathing retraining; and

(3) Patient education regarding the management of the patient's respiratory problems; and

(vi) Periodic assessment and monitoring of the acute and chronically ill patients for indications for, and the effectiveness of, respiratory therapy services.

004.02(C) INTENSIVE CARE AND RECOVERY ROOM PATIENTS. Intensive care and recovery room patients that require respiratory monitoring, support, and therapy qualify for coverage if the treatment is reasonable and necessary.

004.02(D) PREOPERATIVE BRONCHIAL HYGIENE THERAPY. Preoperative bronchial hygiene therapy may be reasonable and necessary when the patient has a presumptive condition that by itself requires respiratory therapy. In the absence of a presumptive condition, preoperative respiratory therapy is reasonable and necessary if the prescribing physician adequately documents the medical necessity for it.

004.02(E) POSTOPERATIVE BRONCHIAL HYGIENE THERAPY. Respiratory therapy services aiding bronchial hygiene are reasonable and necessary in the postoperative patient with identifiable pulmonary complications or in patients with underlying pulmonary diseases. The provider must document the medical necessity for the therapy when billing Nebraska Medicaid. Routine procedures when provided on a routine basis to most postoperative patients are not considered necessary and are not covered under Nebraska Medicaid.

004.02(F) SETTING UP EQUIPMENT AND INSTRUCTING PATIENTS IN ITS USE. Setting up respiratory equipment and instructing patients in the use of equipment, or on postural drainage and breathing exercises, is considered reasonable and necessary. Once patients have been instructed, services of a respiratory therapist or nurse are not reasonable and necessary, and are not covered by Nebraska Medicaid. Any monitoring of the equipment or of the effects of the treatment is expected to be carried out by a staff nurse as part of the regular nursing activities. Use of a respiratory therapist for these activities is considered a duplication of services and is not covered. Payment may be made for use of the equipment and covered gases or drugs used in connection with the equipment.

004.02(G) OXYGEN THERAPY. Oxygen therapy is covered if the need and the effectiveness is documented. Use of continuous oxygen without periodic assessment of arterial PO₂ or oxygen saturation must be medically necessary, and supported by sufficient documentation. The physician's order must state the oxygen device and the specific flow rate or concentration of oxygen desired. A prescription for "oxygen as needed" does not meet these requirements. An intermittent or pro re nata (PRN) oxygen therapy order must include time limits and specific indications for initiating and terminating therapy.

004.02(H) STRUCTURED PATIENT EDUCATION PROGRAM. Instructing a patient on the use of equipment or breathing exercises is considered reasonable and necessary to the treatment of the patient's condition and can be given to a patient during the course of their treatment by the health personnel involved, unless these activities are of a complexity that warrants a structured patient education program. A structured program generally is not considered reasonable and necessary and is not covered by Nebraska Medicaid.

005. BILLING AND PAYMENT FOR RESPIRATORY THERAPY SERVICES .

005.01 BILLING.

005.01(A) GENERAL BILLING REQUIREMENTS. Providers must comply with all applicable billing requirements codified in 471 NAC 3. In the event that individual billing requirements in 471 NAC 3 conflict with billing requirements outlined in this 471 NAC 22, the individual billing requirements in 471 NAC 22 will govern.

005.01(B) SPECIFIC BILLING REQUIREMENTS.

005.01(B)(i) PROCEDURE CODES. The provider must use the appropriate American Medical Association’s Current Procedural Terminology (CPT) or Healthcare Common Procedure Coding System (HCPCS) procedure codes when billing Nebraska Medicaid.

005.01(B)(ii) REQUIRED CLAIMS. Depending on the place of service, the provider must bill as follows:

(1) If the service is provided in a hospital, the hospital makes payment to the respiratory therapist. The hospital submits claims to Nebraska Medicaid for respiratory therapy services provided in the hospital to inpatients and outpatients using the appropriate claim form or electronic format; or

(2) If the service is provided in a long term care facility, the facility must contract for services not readily available in the facility. Depending on the type of provider, reimbursement is claimed as follows:

(a) If services are provided by another licensed hospital or rehabilitation agency, the long term care facility makes payment to the provider. The long term care facility is reimbursed for the payment as an allowable cost under the long term care reimbursement plan; or

(b) If services are provided by a facility staff member or by an individual under contract to the facility, the long term care facility makes payment to the individual. The facility is reimbursed under the long term care reimbursement plan.

005.01(B)(iii) DOCUMENTATION. Respiratory therapy services are subject to pre-or post payment utilization reviews. To help determine medical necessity for the treatments provided by the therapist, the following documentation must accompany each outpatient hospital claim:

(1) A copy of the respiratory therapist's progress notes and anticipated goals; and

(2) Information on the claim or as an attachment that includes:

(a) The location where the services were provided;

(b) The date of onset of the patient's condition; and

(c) The patient's diagnosis.

005.02 PAYMENT.

005.02(A) GENERAL PAYMENT REQUIREMENTS. The Department will reimburse the provider for services rendered in accordance with the applicable payment regulations codified in 471 NAC 3. In the event that individual payment regulations in 471 NAC 3 conflict with payment regulations outlined in this 471 NAC 22, the individual payment regulations in 471 NAC 22 will govern.

005.02(B) SPECIFIC PAYMENT REQUIREMENTS. Nebraska Medicaid does not reimburse the respiratory therapist directly; payment is made to the hospital or nursing home. Nebraska Medicaid may make exceptions to this policy. Prior authorization by Nebraska Medicaid is required in order to make direct payment to the respiratory therapist.

005.02(B)(i) PAYMENT FOR HOSPITAL SERVICES. See 471 NAC 10.

005.02(B)(ii) PAYMENT FOR NURSING HOME SERVICES. See 471 NAC 12.

History

• Effective 2021-12-26

Chapter 23 Speech Pathology and Audiology Services

Neb. Admin. Code tit. 471, ch. 23 Speech Pathology and Audiology Services {#sec-471-nac-23 omnilex-key=us-ne-regs-official--title-471--471 NAC 23}

TITLE 471 NEBRASKA MEDICAL ASSISTANCE PROGRAM SERVICES

CHAPTER 23 SPEECH-LANGUAGE PATHOLOGY AND AUDIOLOGY SERVICES

001. SCOPE AND AUTHORITY. These regulations govern the services provided under Nebraska’s Medicaid program as defined by Nebraska Revised Statute (Neb. Rev. Stat.) §§ 68‑901 et seq.

002. DEFINITIONS. The following definitions apply:

002.01 AUDIOLOGIST. An individual who practices audiology and who presents themselves to the public by any title or description of services incorporating the words audiologist, hearing clinician, hearing therapist, or any similar title or description of services.

002.02 PRACTICE OF AUDIOLOGY. The application of evidence-based practice in clinical decision making for the prevention, assessment, habilitation, rehabilitation, and maintenance of persons with hearing, auditory function, and vestibular function impairments, and related impairments. Practice of audiology does not include the practice of medical diagnosis, medical treatment, or surgery. Practices do include:

(A) Cerumen removal from the cartilaginous outer one-third portion of the external auditory canal when the presence of cerumen may affect the accuracy of hearing evaluations or impressions of the ear canal for amplification devices; and

(B) Evaluation, selection, fitting, and dispensing of hearing instruments, external processors of implantable hearing instruments, and assistive technology devices as part of a comprehensive audiological rehabilitation program.

002.03 PRACTICE OF SPEECH-LANGUAGE PATHOLOGY. The application of principles and methods associated with the development and disorders of human communication skills and with dysphagia and cognition services, in which principles and methods include screening, assessment, evaluation, treatment, prevention, consultation, and restorative modalities for speech, voice, language, language-based learning, hearing, swallowing, cognition, or other upper aero-digestive functions for the purpose of improving quality of life by reducing impairments of body functions and structures, activity limitations, participation restrictions, and environmental barriers. Practice of speech-language pathology does not include the practice of medical diagnosis, medical treatment, or surgery.

002.04 SPEECH-LANGUAGE PATHOLOGIST. An individual who presents themselves to the public by any title or description of services incorporating the words speech-language pathologist, speech therapist, speech clinician, and who has completed all requirements of the American Speech-Language-Hearing Association to practice speech-language pathology.

002.05 TREATING PRACTITIONER. Providers licensed and authorized to order therapy services and to prescribe durable medical equipment, prosthetics, orthotics, and medical supplies (DMEPOS) include physicians, nurse partitioners (NP), clinical nurse specialists, andphysician assistants (PAs).

003. PROVIDER REQUIREMENTS.

003.01 GENERAL PROVIDER REQUIREMENTS. To participate in Nebraska Medicaid, providers of speech-language pathology and audiology services must comply will all applicable provider participation requirements codified in these regulations. .

003.02 SPECIFIC PROVIDER REQUIREMENTS. If speech-language pathology or audiology services are provided outside Nebraska, the speech-language pathologist or audiologist must be licensed by the state in which the services are provided. If the applicable state does not provide licensure for speech-language pathologists or audiologists, the provider must:

(A) Have been granted a certificate of competency by the American Speech-Language-Hearing Association, or equivalent as recommended by the Board of Speech-Language Pathology and approved by Nebraska Medicaid. A photocopy of the certificate of competency must be submitted to Nebraska Medicaid with a signed and completed Medical Assistance Provider Agreement;

(B) Meet the equivalent educational and work experience requirements needed for a certificate of competency; or

(C) Have completed the academic program requirements and be acquiring the supervised work experience needed for the certificate of competency.

003.03 PROVIDER AGREEMENT. The speech-language pathologist or audiologist must complete a Medical Assistance Provider Agreement, and submit it to Nebraska Medicaid .

003.03(A) OUT OF STATE PROVIDERS. Out of state providers who are not licensed must submit a photocopy of the certificate of clinical competency to Nebraska Medicaid with a signed and completed Medical Assistance Provider Agreement.

004. SERVICE REQUIREMENTS.

004.01 MEDICAL NECESSITY. Nebraska Medicaid incorporates the definition of medical necessity set forth in these regulations . Services and supplies that do not meet the definition of medical necessity are not covered.

004.02 SERVICE CRITERIA. Nebraska Medicaid covers speech-language pathology and audiology services when the following criteria are met :

(i) The service is an evaluation; or

(ii) The service is restorative therapy with a medically appropriate expectation that the beneficiary’s condition will improve significantly within a reasonable period of time.

004.03 COVERED SERVICES. Nebraska Medicaid covers speech-language pathology and audiology services when the following criteria are met:

(1) The services are ordered by a licensed physician, nurse practitioner (NP), physician assistant (PA), or a treating practitioner;

(2) The services are medically necessary;

(3) The services are such that only a licensed speech-language pathologist or audiologist can safely and effectively perform the service;

(4) The speech-language pathology or audiology service meets at least one of the service criteria; and

(5) The services are offered through a home health agency.

004.03(A) MAINTENANCE PROGRAM. The speech pathologist or audiologist must:

(i) Evaluate the beneficiary’s needs;

(ii) Design a maintenance program; and

(iii) Instruct the beneficiaries, family members, or nursing facility staff in carrying out the program.

004.03(B) SERVICES FOR BENEFICIARIES AGE 21 AND OLDER. For beneficiaries age 21 and older, Nebraska Medicaid limits coverage to a combined total of 60 therapy sessions per fiscal year. The combined total of 60 therapy sessions per fiscal year includes all occupational therapy (OT), physical therapy (PT), speech-language pathology, and audiology sessions provided to the recipient.

004.04 NON-COVERED SPEECH-LANGUAGE PATHOLOGY AND AUDIOLOGY SERVICES. Nebraska Medicaid does not cover the following speech-language pathology or audiology services:

(A) Maintenance therapy ;

(B) Therapy for vocational and prevocational assessment and training;

(C) Therapy for functional capacity evaluations, educational testing, drivers training, or training in non-essential self-help or recreational activities, visual perception training, or treatment of psychological conditions;

(D) Therapy for dysfunctions that are self-correcting ;

(E) Therapy for delays in speech development that is not due to a specific medical condition or brain injury; or

(F) Therapy for the following conditions or diagnosis categories:

(ii) Behavior problems;

(iii) Attention disorders;

(iv) Conceptual handicap; or

(v) Learning disability.

005. BILLING AND PAYMENT FOR SPEECH-LANGUAGE PATHOLOGY AND AUDIOLOGY SERVICES.

005.01 GENERAL BILLING REQUIREMENTS. Providers must comply with all applicable billing requirements codified in these regulations .

005.02 BILLING INSTRUCTIONS. The provider must bill Nebraska Medicaid, using the appropriate claim form or electronic format.

005.03 USUAL AND CUSTOMARY CHARGE. The provider, or their authorized agent, must submit the provider's usual and customary charge for services rendered.

005.04 MEDICAL NECESSITY DOCUMENTATION. The provider must list the following information when submitting a claim for speech-language pathology or audiology services:

(1) The date of illness or injury onset;

(2) The date speech-language pathology or audiology plan was established;

(3) The date speech-language pathology or audiology services started; and

(4) The number of speech-language pathology or audiology visits from onset.

005.05 HOME HEALTH AGENCY. Services offered through home health agencies require prior authorization.

005.06 GENERAL PAYMENT REQUIREMENTS. Nebraska Medicaid will reimburse the provider for services rendered in accordance with these regulations .

005.07 PAYMENT FOR INDIVIDUAL PROVIDERS. Claims are paid by Nebraska Medicaid for covered speech-language pathology and audiology services in the amount equal to the lesser of:

(1) The provider's submitted charge; or

(2) The allowable amount for that procedure code in the Nebraska Medicaid Practitioner Fee Schedule in effect for that date of service.

History

• Effective 2026-06-28

Chapter 24 Visual Care Services

Neb. Admin. Code tit. 471, ch. 24 Visual Care Services {#sec-471-nac-24 omnilex-key=us-ne-regs-official--title-471--471 NAC 24}

001. SCOPE AND AUTHORITY . The regulations govern the services provided under Nebraska’s Medicaid program as defined by Nebraska Revised Statute (Neb. Rev. Stat.) §§ 68-901 et seq.

002. DEFINITIONS . The following definitions apply:

002.01 EYEGLASSES. A set of both lenses and a frame, used to correct deficiencies in vision.

002.02 SIMPLE PHOTOPHOBIA. A photophobia condition which is not caused by a disease or other significant health issue. Also referred to as a sensitivity.

003. PROVIDER REQUIREMENTS .

003.01 GENERAL PROVIDER REQUIREMENTS. To participate in Nebraska Medicaid, providers of visual care services must comply with all applicable participation requirements codified in 471 Nebraska Administrative Code (NAC) 1, 2 and 3. In the event that participation requirements in 471 NAC 1, 2 or 3 conflict with requirements outlined in this 471 NAC 24, the participation requirements in 471 NAC 24 will govern.

003.02 SERVICE SPECIFIC PROVIDER REQUIREMENTS. To participate in Nebraska Medicaid, providers of visual care services must:

(1) Be enrolled in Nebraska Medicaid by complying with provider agreement requirements;

(2) Be licensed to practice by the Nebraska Department of Health and Human Services, Division of Public Health, or if the service is provided in another state, be licensed by the other state;

(3) Practice within their scope of practice as defined in Neb. Rev. Stat. §§ 38-2601 to 38-2623, or if the service is provided in another state, within the scope of practice as defined by the licensing laws of the other state; and

(4) Comply with all applicable state and federal laws and regulations governing the provision of their services.

003.02(A) PROVIDER AGREEMENT. Providers of visual care services must complete and sign Form MC-19, Service Provider Agreement, and submit the completed form to the Department for approval to participate in Nebraska Medicaid.

003.02(B) CONTACT LENS SERVICES. Only providers whose licensure allows prescription, fitting, and supervision of adaptation, will be approved for payment of contact lenses.

004. SERVICE REQUIREMENTS

004.01 GENERAL REQUIREMENTS.

004.01(A) MEDICAL NECESSITY. Nebraska Medicaid incorporates the definition of medical necessity from 471 NAC 1 as is fully rewritten herein. Services and supplies that do not meet the 471 NAC 1 definition of medical necessity are not covered.

004.01(B) SERVICES PROVIDED FOR RECIPIENTS ENROLLED IN THE NEBRASKA MEDICAID MANAGED CARE PROGRAM. See 471 NAC 1.

004.01(C) EARLY AND PERIODIC, SCREENING, DIAGNOSIS, AND TREATMENT (EPSDT) SERVICES. See 471 NAC 33.

004.02 COVERED SERVICES. Nebraska Medicaid covers medically necessary and appropriate visual care services within program guidelines. Examination, diagnosis and treatment services are also allowable to diagnose or treat a specific eye illness, symptom, complaint, or injury.

004.02(A) EXAMINATION, DIAGNOSIS, AND TREATMENT SERVICES.

004.02(A)(i) EYE EXAMINATIONS.

004.02(A)(i)(1) RECIPIENTS AGE 21 AND OLDER. Eye examinations are limited to once every 24 months. More frequent eye examinations will be covered when medically necessary and appropriate to diagnose or treat a specific eye illness, symptom, complaint or injury.

004.02(A)(i)(2) RECIPIENTS AGE 20 AND YOUNGER. Eye examinations are limited to once every 12 months. More frequent eye examinations will be covered when medically necessary and appropriate to diagnose or treat a specific eye illness, symptom, complaint, or injury.

004.02(A)(ii) VISION THERAPY. Nebraska Medicaid covers vision therapy, orthopics, and is limited to 22 session.

004.02(B) FRAMES.

004.02(B)(i) COVERAGE CRITERIA. Eyeglass frames are covered once each coverage period when one of the following conditions is met:

(1) A medical reason of:

(a) The individual’s first pair of prescription eyeglasses;

(b) Size change needed due to growth; or

(c) A prescribed lens change, only if new lenses cannot be accommodated by the current frame.

(2) The recipient’s current frame is no longer useable due to irreparable wear, damage, breakage, or loss.

004.02(B)(ii) COVERAGE PERIOD.

004.02(B)(ii)(1) RECIPIENTS AGE 21 AND OLDER. Eyeglass frames are limited to once every 24 months. Replacement of frames which are irreparable due to breakage or loss, is allowed one additional time per coverage period.

004.02(B)(ii)(2) RECIPIENTS AGE 20 AND YOUNGER. Eyeglass frames are limited to once every 12 months. Eyeglass frames are covered more frequently if medically necessary.

04.02(B)(iii) FRAME SPECIFICATION. The following specifications apply to all eyeglass frames:

(1) Plastic and metal frames are covered; rimless frames are not covered;

(2) Discontinued frames with new prescription lenses are not covered; and

(3) Frame cases are covered with new eyeglasses.

004.02(B)(iv) FRAME REPAIR. Nebraska Medicaid covers frame repair if less costly than providing a new frame and if the repair would provide a serviceable frame for the recipient. Applicable manufacturer warranties are considered to be a third party resource, and must be utilized in accordance with 471 NAC 3.

004.02(C) LENSES.

004.02(C)(i) COVERAGE CRITERIA. Nebraska Medicaid covers one pair of eyeglass lenses each coverage period. If one lens meets the coverage criteria, both lenses may be provided, unless the prescribing practitioner specifies replacement of only one lens. In order to be covered one of the following conditions must be met:

(1) A medical reason including:

(a) The individual’s first pair of prescription eyeglasses;

(b) Size change needed due to growth; or

(c) A new prescription with the refraction correction meeting one of the following criteria:

(i) A change of 0.50 diopters in the meridian of greatest change when placed on an optical cross;

(ii) A change in axis in excess of 10 degrees for 0.50 cylinder, 5 degrees for 0.75 cylinder; or

(iii) A change of prism correction of ½ prism diopter vertically or 2 prism diopters horizontally or more.

(2) The current lenses are no longer useable due to damage, breakage, or loss.

004.02(C)(ii) COVERAGE PERIOD.

004.02(C)(ii)(1) RECIPIENTS AGE 21 AND OLDER. Eyeglass lenses are limited to once every 24 months.

004.02(C)(ii)(2) RECIPIENTS AGE 20 AND YOUNGER. Eyeglass lenses are limited to once every 12 months. Eyeglass lenses are covered more frequently if medically necessary.

004.02(C)(iii) LENS SPECIFICATION. The following specifications apply to all eyeglass lenses;

(1) Lenses are covered only if the refraction correction is at least 0.50 diopters in any meridian;

(2) Plastic or glass lenses are covered;

(3) All plastic lenses must include front surface scratch resistant coating that is factory applied or "in-house" dipped;

(4) Lenses must be of a quality at least equal to Z-80 standards of the American National Standard Institute; and

(5) All lenses dispensed must be prescribed by a licensed practitioner. A copy of the prescribing practitioner's original prescription must be maintained in the provider's records and must be available for review by the Department upon request.

004.02(C)(iv) COVERED SPECIAL LENS FEATURES AND LAB PROCEDURES.

(1) Bifocal and trifocal segments exceeding 28mm if necessary for specific employment or educational purposes, or due to a specific disability which limits head and neck movement.

(2) High index lenses if the refraction correction is at least +/- 10.00 diopters in meridian of greatest power when placed on an optical cross.

(3) Myodisc lenses when prescribed.

(4) Nylon cord, metal cord, or rimless mount only when the recipient purchases their own frames or uses previously purchased frames.

(5) Oversize lens charges if medically necessary or if the recipient purchases their own frame or uses previously purchased frame.

(6) Standard polycarbonate lenses for recipients age 20 and younger. For recipients age 21 and older, covered only if prescribed for significantly monocular vision.

(7) Thin polycarbonate lenses for recipients age 20 and younger. For recipients age 21 and older, covered only if the refraction correction is at least +/- 8.00 diopters in the meridian of greatest power when placed on an optical cross.

(8) Scratch resistant coating is required for plastic lenses. Additional scratch resistant coating is not covered.

(9) Slab-off prism if there is at least 3.00 diopters of anisometropia in the vertical meridian.

(10) Special base curve only if prescribed for aniseikonia.

(11) Tint only for chronic disorders which cause significant photophobia under indoor lighting conditions. Simple photophobia is not an accepted diagnosis for coverage.

(12) Ultraviolet lens coating only for chronic disorders that are complicated or accelerated by ultraviolet light.

004.02(C)(v) LENS REPLACEMENT. Replacement of lenses which are irreparable due to wear, damage, breakage, or loss, is limited to once per lens in 12 month period, for recipients age 21 years and older.

004.02(D) EYEGLASS FITTING. Nebraska Medicaid covers fitting of eyeglasses associated with provision Nebraska Medicaid covered lenses, frames, or both. Fitting includes:

(i) Measurement of anatomical facial characteristics;

(ii) Writing of laboratory specifications;

(iii) Ordering eyeglasses;

(iv) Verifying order once received;

(v) Final adjustment of the eyeglasses to the visual axes and anatomical topography;

(vi) Dispensing; and

(vii) Any associated overhead including shipping and postage charges.

004.02(E) CONTACT LENS SERVICES. Contact lens services include prescription, fitting, supervision of adaptation, and supply of contact lenses.

004.02(E)(i) COVERAGE CRITERIA. Nebraska Medicaid covers contact lens services only when prescribed for recipients with:

(1) Keratoconus;

(2) Aphakia excluding pseudophakia;

(3) High plus corrections of +12.00 diopters spherical equivalent or greater due to the visual field defect caused by a high plus correction;

(4) High minus corrections of -12.00 diopters spherical equivalent or greater, but only with an increase in binocular best visual acuity of at least 2 Snellen lines when comparing the contact lenses to the spectacle lens correction;

(5) Anisometropia, difference in correction of at least 6.00 diopters spherical equivalent in order to avoid double vision; or

(6) Other pathological conditions of the eye when useful vision cannot be obtained with eyeglasses.

004.02(E)(ii) REPLACEMENT CONTACT LENSES. Covered when required due to loss, damage, or for prescription changes when the recipient’s condition meets Nebraska Medicaid’s criteria for coverage of contact lens services.

004.03 NON-COVERED SERVICES. The following services are not covered by Nebraska Medicaid:

004.03(A) EYEGLASSES.

(i) Sunglasses;

(ii) Multiple pairs of eyeglasses for the same individual;

(iii) Non-spectacle mounted aids, hand-held or single lens spectacle mounted low vision aids, and telescopic and other compound lens systems; and

(iv) Replacement insurance.

004.03(B) SPECIAL LENS FEATURES AND LAB PROCEDURES.

(i) Anti-reflective and mirror lens coating;

(ii) Blended and progressive multifocal lenses;

(iii) Drilling, notching, grooving, faceting of lenses;

(iv) Edging or beveling of lenses for cosmetic reasons;

(v) Engraving;

(vi) Roll and polish edges; or

(vii) Photochromatic tints and sunglasses.

004.03(C) CONTACT LENSES.

(i) Prescribed for routine correction of vision; and

(ii) Disposable contact lenses.

005. BILLING AND PAYMENT FOR VISUAL CARE SERVICES .

005.01 BILLING.

005.01(A) GENERAL BILLING REQUIREMENTS. Providers must comply with all applicable billing requirements codified in 471 NAC 3. In the event that billing requirements in 471 NAC 3 conflict with billing requirements outlined in this 471 NAC 24, the billing requirements in 471 NAC 24 will govern.

005.01(B) SPECIFIC BILLING REQUIREMENTS.

005.01(B)(i) BILLING REQUIREMENTS. Providers must bill Nebraska Medicaid for visual care services on the appropriate claim form or electronic format.

005.01(B)(ii) USUAL AND CUSTOMARY CHARGE. The provider or their authorized agent must submit the provider's usual and customary charge for services rendered. The provider's total charge for services may not exceed the provider's usual and customary charge.

005.01(B)(iii) NON-COVERED SERVICES. If the provider furnishes items or services not covered by Nebraska Medicaid, on a private basis, the individual must pay the full charge of the items or services. The provider is prohibited from billing Nebraska Medicaid for any portion of the non-covered items or services.

005.01(B)(iv) BILLING THE RECIPIENT FOR FRAMES. Charges for frames purchased by a recipient on a private pay basis must include the associated fitting charge.

005.01(B)(v) BILLING FOR LENSES.

005.01(B)(v)(1) SCRATCH RESISTANT COATING. The cost for the scratch resistant coating must be included in the lens cost and is not billed under a separate procedure code. The laboratory invoice must indicate that the scratch resistant coating was provided. Nebraska Medicaid does not require that lenses with scratch resistant coating be warranted.

005.01(B)(v)(2) BILLING THE RECIPIENT.

005.01(B)(v)(2)(a) LENSES. Charges for lens purchased by a recipient on a private pay basis must include the associated fitting charge.

005.01(B)(v)(2)(b) SPECIAL LENS FEATURES AND LAB PROCEDURES. If non-covered lens features or lab procedures other than non-covered tints are desired by recipients, they must be purchased on a private pay basis.

005.01(B)(v)(2)(c) LENS TINTS. The recipient can be billed for non-covered lens tints under the following conditions:

(i) The recipient has been notified by the provider in writing that Nebraska Medicaid will not cover the lens tint; and

(ii) The recipient voluntarily agrees to reimburse the provider for the lens tint on a private pay basis.

005.02 PAYMENT.

005.02(A) GENERAL PAYMENT REQUIREMENTS. Nebraska Medicaid will reimburse the provider for services rendered in accordance with the applicable payment regulations codified in 471 NAC 3. In the event that payment regulations in 471 NAC 3 conflict with payment regulations outlined in 471 NAC 24, the payment regulations in 471 NAC 24 will govern.

005.02(B) SPECIFIC PAYMENT REQUIREMENTS.

005.02(B)(i) REIMBURSEMENT. Nebraska Medicaid pays for covered visual care services in an amount equal to the lesser of:

(1) The provider's submitted charge; and

(2) The allowable amount for the procedure code in the Nebraska Medicaid Practitioner Fee Schedule in effect for that date of service.

005.02(B)(ii) MEDICARE AND NEBRASKA MEDICAID CROSSOVER CLAIMS. For information on the payment of Medicare and Nebraska Medicaid crossover claims, see 471 NAC. 3.

005.02(B)(iii) COPAYMENT. For Nebraska Medicaid copayment requirements, see 471 NAC 3.

005.02(B)(iv) PAYMENTS FOR EYE EXAMS. Eye examinations provided primarily for the purpose of prescribing, fitting, or changing eyeglasses for refractive errors are reimbursed at the Nebraska Medicaid fee schedule allowable for intermediate level general ophthalmological services, as defined in the American Medical Association's Physicians' Current Procedural Terminology (CPT). Determination of the refractive state is reimbursed separately from examination services.

005.02(B)(v) PAYMENTS FOR VISION THERAPY TRAINING. Payment for vision therapy training includes all equipment and supplies necessary for home use.

History

• Effective 2021-12-27

Chapter 25 School-Based Services

Neb. Admin. Code tit. 471, ch. 25 School-Based Services {#sec-471-nac-25 omnilex-key=us-ne-regs-official--title-471--471 NAC 25}

001. SCOPE AND AUTHORITY . These regulations govern services provided in schools under the Medical Assistance Act, Nebraska Revised Statute (Neb. Rev. Stat.) §§ 68-901 to 68-991, and Neb. Rev. Stat. § 43-2511.

002. DEFINITIONS . The following definitions apply:

002.01 ACTIVITIES OF DAILY LIVING. Self-care activities routinely performed daily for an individual’s continued well-being, including mobility and transferring, dressing and grooming, bathing and personal hygiene, toileting, bladder care, and eating.

002.02 TRANSPORTATION. Transportation paid by Medicaid for a student both to and from a Medicaid reimbursable service required by the student’s Individual Education Plan (IEP) or Individualized Family Service Plan (IFSP).

002.03 OUTSIDE MEDICAL SERVICE. A medical service received in a facility not located on the premises of the educational facility the student attends.

002.04 PROVIDER. An enrolled Medicaid provider that is also a public school district, Education Services Unit (ESU), or approved cooperative.

002.05 SPECIALLY ADAPTED VEHICLE. A vehicle equipped with adaptive devices to medically accommodate physical disabilities of passengers.

002.06 TRANSPORTATION AIDE. An individual who assists with passenger needs and transportation accommodations required by a student’s Individual Education Plan (IEP) or Individualized Family Service Plan (IFSP).

003. PROVIDER REQUIREMENTS . To participate in school-based services, a provider must comply with all applicable provider participation requirements of 471 Nebraska Administrative Code (NAC) Chapters 2 and 3, and this chapter. If any applicable provider participation provision of 471 NAC Chapters 2 or 3 conflicts with any requirement of this chapter, the requirement of this chapter governs. Each person providing school-based services must be enrolled as an affiliated group member under the billing provider identification, provide services in compliance with any applicable requirements for licensure or certification, provide services in compliance with any applicable chapters of 471 NAC, be age 19 or older, and be employed by or under contract with the provider.

004. DIRECT SERVICE REQUIREMENTS .

004.01 GENERAL SERVICE REQUIREMENTS. School-based services must be medically necessary to meet the specific and covered needs of a student and the student’s family, if applicable, and be required by:

(A) A related service or supplementary aid or service in an Individual Education Program (IEP); or (B) An early intervention service in an Individualized Family Service Plan (IFSP).

004.02 SPECIFIC COVERED SERVICES AND REQUIREMENTS. When indicated in a child’s Individual Education Plan (IEP) or Individualized Family Service Plan (IFSP), the following are covered services within school-based services.

004.02(A) DIRECT SERVICES. Direct services that are available in the schools include:

(i) Physical therapy, occupational therapy, and speech pathology audiology services; (ii) Behavioral modification, psychotherapy services, psychological testing, and assessment needs for specific therapy services and evaluation, when not only medically necessary, but also:

(1) Necessary to diagnose, treat, cure, or prevent regression of significant functional impairments resulting from symptoms of a mental health disorder diagnosis; (2) Supported by evidence that the treatment improves symptoms and functioning for the individual client’s mental health or substance use disorder diagnosis; and (3) Reasonably expected to improve the individual’s condition or prevent further regression so that the services will no longer be necessary;

(iii) Nursing services, when provided through direct intervention in a face-to-face encounter; (iv) Personal assistance services, which assist with activities of daily living (and other activities listed in 471 NAC Chapter 15) and supplement a child’s own personal abilities and resources, when approved by a physician and provided by someone other than a legally responsible relative; (v) Transportation to an outside medical service, including the assistance of a Transportation Aide and the use of a specially adapted vehicle, subject to the following:

(1) The student must be in attendance at school on the day of the medical service to receive transportation services, and cannot be taken directly from home to the medical service; (2) Medical services must be provided on the same day as the transportation; (3) Only one round trip transportation per student is covered each day; and, (4) The transportation cannot duplicate what would otherwise have been received in the course of attending school; and

(vi) Visual care services to diagnose or treat a specific eye disorder, disease, symptom, complaint, or injury, and vision therapy. One assessment per calendar year is permitted, which must be performed in the school by a licensed optometrist.

005. INDIRECT SERVICES (NEBRASKA EDUCATION-BASED MEDICAID ADMINISTRATIVE CLAIMING) .

005.01 INDIRECT SERVICES. Reimbursement for indirect services, such as outreach that supports Medicaid services, are allowed if reasonable and necessary for the proper and efficient administration of Medicaid and if allowable according to the Nebraska Education-Based Medicaid Administrative Claiming (NEBMAC) document (attached hereto as Attachment A and incorporated herein by this reference).

006. REIMBURSEMENT METHODOLOGY FOR SCHOOL-BASED SERVICES: DIRECT AND INDIRECT SERVICES .

006.01 ADHERENCE TO NEBRASKA EDUCATION-BASED MEDICAID ADMINISTRATION (NEBMAC) DOCUMENT. All claims submitted by a provider must be based on random moment time studies which comply with the requirements of the Nebraska Education-Based Medicaid Administrative Claiming (NEBMAC) document (attached hereto as Attachment A and incorporated herein by this reference).

006.02 RETENTION OF RECORDS. Each public school district or Educational Service Unit (ESU) and approved cooperative participating in Medicaid administrative claiming must separately retain time-study methodology, instructions, financial accounting records, and other documents or records related to participation for a minimum of six years.

006.03 TIMELY FILING REQUIREMENTS. School districts, Educational Service Units (ESU’s) and approved cooperatives must file their claims no later than 15 months from the end of the quarter in which direct services or indirect services were provided.

006.04 PAYMENT METHODOLOGY. Expenditures for direct school-based health services that are within the scope of Medicaid coverage and furnished to Medicaid eligible children may be claimed as medical assistance. Expenditures for administrative activities in support of these school-based services including outreach and coordination may be claimed as costs of administering Medicaid.

006.04(A) DIRECT SERVICE QUARTERLY INTERIM SETTLEMENTS. Quarterly interim settlements for services will be based on the quarterly random moment time study (RMTS) and use of the interim cost reports compiled on a quarterly basis. The cost report then calculates the amount of reimbursement that each school district is eligible to receive as an interim payment.

006.04(A)(i) ANNUAL SETTLEMENT. On an annual basis, a cost settlement process must be completed by each school district. Each school district completes an annual cost report which compares their total Medicaid-allowable costs from the year to each school district’s Medicaid interim payments delivered during the quarterly reporting periods, to determine the final cost reconciliation and settlement. If a provider’s interim payments exceed the actual, certified costs for Medicaid services provided in schools to Medicaid clients, the provider must remit the federal share of the overpayment at the time the annual settlement cost report is submitted.

ATTACHMENT A

INTRODUCTION...........................................................................................................................................36

MEDICAID IN THE SCHOOL SETTING...........................................................................................................38

AGREEMENTS..............................................................................................................................................40

A. General............................................................................................................................................40

PRINCIPLES OF ADMINISTRATIVE CLAIMING..............................................................................................41

A. General............................................................................................................................................41

B. Operational Principles.....................................................................................................................42

1. Proper and Efficient Administration...........................................................................................42

2. Claiming for Allowable Activities Only........................................................................................42

3. Capture 100 Percent of Time......................................................................................................42

4. Parallel Coding Structure: Medicaid and Non-Medicaid Codes for Each Activity ......................43

5. Duplicate Payments....................................................................................................................43

6. Coordination of Activities...........................................................................................................44

7. Performing Direct Services v. Administrative Activities .............................................................45

8. Enhanced FFP Rates....................................................................................................................50

9. Individual Education Program (IEP) and Individualized Family Service Plan (IFSP) Activities ....50

10. Review and Approval of Program and Codes by CMS................................................................51

C. Activity Codes: Descriptions and Examples ....................................................................................52

1. Introduction................................................................................................................................52

CLAIMING ISSUES........................................................................................................................................64

A. Documentation ...............................................................................................................................64

B. Components of the Random Moment /Time-Studies ....................................................................66

1. Random Moment Sampling Methodology .................................................................................66

2. Time Study Participants..............................................................................................................66

3. Sample Universe.........................................................................................................................67

4. Cost Pool 1..................................................................................................................................67

5. Cost Pool 2..................................................................................................................................68

6. Sampling .....................................................................................................................................69

7. Process for Participating in the RMS Time Study .......................................................................70

8. Identify Total Pool of Time Study Participants ...........................................................................70

9. Identify Total Pool of Time Study Moments...............................................................................70

10. Randomly Select Moments and Randomly Match Each Moment to a Participant....................71

11. Sampling Requirements..............................................................................................................71

12. Sampling Methodology - Cost Pool 1 (Direct Service & Administrative Providers) ...................72

13. Sampling Methodology - Cost Pool 2 (Administrative Services Providers Only)........................73

14. Treatment of Summer Period.....................................................................................................74

15. Time-Study Documentation........................................................................................................75

16. Training for Staffing Time-study .................................................................................................75

17. Monitoring Process.....................................................................................................................76

18. Validation Process ......................................................................................................................76

C. Offset of Revenues..........................................................................................................................77

D. Cost Allocation Plans.......................................................................................................................77

E. Administrative Claiming Implementation Plan...............................................................................78

F. Timely Filing Requirements:............................................................................................................79

G. State Law Requirements.................................................................................................................79

H. Provider Agreements ......................................................................................................................79

I. Transportation as Administration...................................................................................................80

APPENDIX A – General Federal Overview of the Medicaid and IDEA Programs and the Applicability of School-based Administrative Claiming to these Programs...........................................................................2

A. Medicaid ...........................................................................................................................................2

1. Medicaid’s Role In School-Based Health Services Programs........................................................2

2. Early and Periodic Screening, Diagnosis and Treatment (EPSDT) ................................................3

3. Children’s Health Insurance Program (CHIP)...............................................................................4

B. Individuals with Disabilities Education Act (IDEA) ............................................................................5

1. Purpose of IDEA............................................................................................................................5

2. ChildFind .......................................................................................................................................6

3. Evaluation and Assessment Activities ..........................................................................................7

4. Individual Education Program (IEP) ..............................................................................................7

APPENDIX B - CLAIM PROCESS/PROCEDURES ............................................................................................10

A. General............................................................................................................................................10

B. Data Elements.................................................................................................................................11

C. Claim Calculation.............................................................................................................................11

INTRODUCTION

This Nebraska Education-Based Medicaid Administrative Claiming (NEBMAC) Guide is effective for the quarter beginning September 1, 2017. All Nebraska public school districts and Educational Service Units (ESU’s) are eligible to participate in the NEBMAC program. Effective June 1, 2017, Nebraska transitioned the NEBMAC program to a competitively procured statewide contractor for purposes of program administration in coordination and under the direction of HHS. Additional changes are now being presented to accommodate the state moving to a cost based reporting methodology for its direct service program which results in some changes to the time study process as outlined in this document.

The school setting provides a unique opportunity to enroll eligible children in the Medicaid program and to assist children who are already enrolled in Medicaid to access the benefits available to them. Medicaid offers reimbursement for both the provision of covered medical services and for the costs of administrative activities such as outreach which support the Medicaid program.

The purpose of the Nebraska Education-Based Medicaid Administrative Claiming Guide (referred to hereafter as the “Guide”) is to inform schools and other interested parties on the appropriate methods for claiming reimbursement for the costs of Medicaid administrative activities performed in the school setting.

The specific purpose of this Guide is to:

• Help schools and ESU’s prepare appropriate claims for administrative costs under the Medicaid program; • Ensure that the Medicaid program pays only for appropriate school-based administrative activities and that such activities are carried out effectively and efficiently; • Protect the fiscal integrity of the Medicaid program by providing a clear articulation of the requirements for school-based administrative claiming; • Help ensure consistency in the application of federal administrative claiming requirements and adherence to the provisions of the Centers for Medicare & Medicaid Services’ (CMS) “Medicaid School-Based Administrative Claiming Guide”; • Promote the flexibility afforded in the implementation of the Medicaid program; • Assist in the implementation of operational and oversight functions; and • Provide technical assistance for the intended audience.

Contemporary schools are engaged in a variety of activities that would not traditionally be thought of as education. In carrying out the mission of meeting the educational needs of their students, schools find themselves delivering many different services to students that help ensure that students come to school healthy and ready to learn and that students can benefit from instructional services.

Expenditures for direct school-based health services that are within the scope of Medicaid coverage and furnished to Medicaid eligible children may be claimed as “medical assistance” and are not within the scope of the administrative claims discussed in this guide (See Section II – Medicaid in the School Setting). Expenditures for administrative activities in support of these school-based services including outreach and coordination may be claimed as costs of administering the Nebraska Medical Assistance Program. These claims are the subject of this Guide. The Guide is intended to help public school districts and Educational Service Units (ESU’s) better understand when Medicaid reimbursement can be obtained for the administrative costs of school-based health services and how to prepare and submit appropriate claims for FFP.

At the national level, CMS reviews and assesses states' administrative claiming programs in accordance with applicable federal Medicaid law and regulations. CMS provides technical assistance to [Nebraska] DHHS to ensure ongoing integrity of the administrative claiming process. The development and implementation of the NEBMAC program is a collaborative process, as appropriate, involving the relevant entities: school districts, Educational Service Units, [Nebraska] DHHS, Nebraska Department of Education (NDE) and the federal government. [Nebraska] DHHS is responsible for the operation of Nebraska’s Medicaid program so it is important for schools ESU’s, and the Nebraska Department of Education to work closely with [Nebraska] DHHS for policy and technical assistance. This collaboration will help to ensure compliance with administrative claiming requirements. [Nebraska] DHHS is responsible for ensuring that applicable policies are applied uniformly throughout the state and that claims are submitted to CMS in conformance with such requirements.

The Medicaid program provides significant state operational and programmatic flexibility under federal regulation and oversight but federal Medicaid requirements only provide a framework for state Medicaid programs. Nebraska establishes and administers its Medicaid program within this framework. Therefore, even though federal Medicaid requirements are administered by CMS, schools need to contact and work through [Nebraska] DHHS.

The NEBMAC Program Coordinator, an employee of DHHS, provides oversight of the NEBMAC program and helps to ensure compliance with all local and federal regulations. The Program Specialist duties include, but are not limited to:

Training/Compliance

• Respond to requests for information from Local Education Agencies and ESUs. • Maintain and disseminate all NEBMAC training materials, including the approved NEBMAC Claiming Guide. • Ensure all policies and procedures related to the administration of the NEBMAC program are in compliance with state and federal guidelines. • Provide guidance on proper coding to DHHS contractor and supply necessary training materials as requested. • Attend training sessions with DHHS contractor, provide any updates to the program and answer questions.

Claim Review

• Review claims for completeness • Verify all necessary supporting documentation is included and/or available for review • Verification of the quarterly Participant List • Submission and certification of MAC financial cost reporting • Review of applied Indirect Cost Rate and Medicaid Eligibility Rate • Submission and review of individual district claims • Review claims to ensure that all claimed expenses are allowable • Notify school districts of any errors and return or adjust claims accordingly

Time Study Review

• Review the Random Moment Time Study (RMTS) compliance rate, ensuring each school district achieves the 85% participation level as required by CMS.

o Send a letter of warning to any school district not achieving the minimum compliance level. o Monitor the subsequent quarter to ensure compliance at the defined standards.

• For non-compliant entities, DHHS may deny both current claims and may prohibit the entity from claiming MAC expenses for the remainder of the fiscal year.

The Program Specialist will randomly select 5% of the sampled responses to ensure validity and appropriate coding.

For purposes of this methodology and throughout this Guide, several different terms are used to describe school-related administrative claiming units. This includes LEA’s (local education agencies), “districts,” “school districts,” and “Educational Service Units”. Reference to any should be considered reference to all unless some special meaning or rule applies to a specific type of claiming unit.

MEDICAID IN THE SCHOOL SETTING

Medicaid is a critical source of health care coverage for children. The Early and Periodic Screening, Diagnosis and Treatment (EPSDT) provision (also known in Nebraska as HEALTH CHECK or Well-Child) is Medicaid’s comprehensive and preventive child health program for individuals under the age of 21. A primary goal of HEALTH CHECK is to establish a medical home for each child. A medical home is the primary care provider who manages a coordinated, comprehensive, continuous health care program to address the child’s primary health needs. The medical home should provide or make arrangements for after- hours care and coordinate the child’s specialty needs. The medical home should follow the screening periodicity schedule guidelines published by the American Academy of Pediatrics and perform periodic screens when medically necessary. The purpose of this Guide is to explain how Nebraska public school districts and Educational Service Units can be involved in the HEALTH CHECK program as administrative agents of the Medicaid Division and receive Medicaid reimbursement for providing administrative outreach and services coordination to students who are eligible or potentially eligible for Medicaid services. This program allows Nebraska’s schools to become an “administrative arm” of the Medicaid agency through the assurance of health care coordination of students.

Even when appropriate health care services exist within a community, many beneficiaries of public health care programs do not readily access the primary and preventive services they or their children need. Among the primary reasons for the failure of persons to access services are: (a) the child in need is not being recognized as eligible for Medicaid which could fund the services needed; and (b) there is no system operating, however informal, to ensure that the services needed are identified and provided. By providing administrative outreach and care coordination, school-staff work to erase the “barriers-to-access” that may exist. However, administrative care coordination does not include the full development, implementation and monitoring of a care- or treatment-plan for individual students. Other providers of [Nebraska] DHHS including managed care plans, managed care organizations and public health nurses are responsible for primary care planning and management in some areas of the state. School districts are expected to coordinate services with all [Nebraska] DHHS providers.

Many of the administrative activities discussed in this Guide that are claimable to Medicaid are those associated with and in support of the provision of medical services reimbursable under Medicaid. (See Section IV.C). There are other administrative activities not associated with covered Medicaid medical services which may be covered in schools. These include Medicaid outreach, facilitating Medicaid eligibility determinations, medical/Medicaid related training and general administration (See Activity Codes, Section IV. C).

Schools can provide a wide range of health care and related services to their students which may or may not be reimbursable under the Medicaid program. The services can be categorized as follows:

• IDEA-related health services : The Individuals with Disabilities Education Act (IDEA) was passed to “assure that all children with disabilities have available to them… a free appropriate public education (FAPE) which emphasizes special education and related services designed to meet their individual needs.” IDEA authorizes federal funding to states for medical services provided to children through a child’s Individual Education Program (IEP) or Individualized Family Service Plan (IFSP) including children who are covered under Medicaid. In 1988, Section 1903(c) of the Act was amended to permit Medicaid payment for medical services provided to Medicaid eligible children under IDEA and included in the child’s IEP/IFSP.

Nebraska is referred to as a “Birth-mandate State” since Nebraska R.R.S. §79-1132 requires that special education and related services are to be provided for infants and toddlers upon verification of a disability (ies). An infant or toddler with disabilities is a child, two years of age or younger, who needs early intervention (known in Nebraska as Early Development Network) services because they are experiencing developmental delays in one of the following areas: cognitive development; physical development; communication development; social or emotional development, adaptive development or has a diagnosed physical or mental condition that has a high probability of resulting in developmental delay. Services are provided through an IFSP) that is developed and implemented for each infant or toddler who is determined to be eligible for early intervention (EI) or Early Development Network (EDN) services. The plan is based on multidisciplinary evaluation and any other relevant information. Provision of these services “to meet the unique needs of the child” is done so at no cost to the child or family and is to begin immediately upon verification of the disability which may be as early as birth.

• “Section 504” - related health services: Section 504 of the Rehabilitation Act of 1973 requires local school districts to provide or pay for certain services to make education accessible to children with disabilities. These services may include health care services similar to those covered by IDEA and Medicaid. These services are typically described in a Section 504 plan and are provided free of charge to eligible individuals.

• General health care services : These services are typically mandated by the school district or state and include health care screenings, vision exams, hearing tests, a scoliosis exam, et cetera and provided free of charge to all students. Services provided by the school nurse (e.g., attending to a child’s sore throat, dispensing medicine, etc.) may also fall into this category. These general health care services often resemble EPSDT/Health Check/Well-Child services.

Federal matching funds are available under Medicaid for the cost of administrative activities that directly support efforts to identify and enroll potentially eligible persons into Medicaid and that directly support the provision of medical services covered under the Nebraska Medical Assistance Program (NMAP/Medicaid). To the extent that school employees perform administrative activities that are in support of the Nebraska Medicaid Program, federal reimbursement may be available.

While schools are legally liable to provide IDEA-related health services at no cost to eligible students, Medicaid reimbursement is available for these services because Section 1903(c) of the Act requires Medicaid to be primary to the U.S. Department of Education for payment of the health-related services provided under IDEA.

The direct medical services are paid by the Nebraska Medical Assistance Program (NMAP/Medicaid) and referred to as “Medicaid in Public Schools” (MIPS). Currently, Occupational Therapy (OT), Physical Therapy (PT) and Speech/Language Pathology/Therapy (SLP/ST) related services are claimed for reimbursement by public school districts, with an intended expansion of services effective September 1, 2017 to include Nursing Services, Vision Services, Mental and Substance Abuse Services, Personal Assistance Services and Transportation Services. Associated costs are excluded from any calculation of administrative costs and the administrative claim.

As prescribed in the Medicare Catastrophic Coverage Act [of 1988] (MCCA), Medicaid covers these direct services only under the following conditions:

• Services are identified in the child’s Individual Education Program (IEP) or Individualized Family Service Plan (IFSP) to meet the his/her unique needs as required to provide a Free Appropriate Public Education (FAPE); • Services are medically necessary and included in a Medicaid covered category (speech therapy, physical therapy, etc.); • Services are included in Nebraska’s plan or available under EPSDT; and • Medical services are only claimed for those provided to Medicaid eligible students.

AGREEMENTS

A. General

Any public school district or Educational Service Unit (ESU) may participate in Medicaid administrative claiming (NEBMAC). School districts and ESU’s receiving payment for Medicaid administrative activities being performed in the school setting are acting as agents for the Nebraska Department of Health and Human Services. Such activities may be paid under Medicaid only if they are necessary for the proper and efficient administration of the Nebraska Medicaid Program. Both ESU’s and public school districts may claim related costs as long as the costs are allowable according to the NEBMAC Guide. Additionally, claimed costs must be incurred by the participating entity and all other elements of a proper claim must be present.

In Nebraska, DHHS is the only entity that may submit claims to CMS in order to receive FFP for allowable Medicaid costs. This requirement necessitates that every participating agency be covered, either directly or indirectly, through an intergovernmental agreement which describes and defines the relationship between public school districts/Educational Service Units conducting claimable activities, [Nebraska] DHHS and NDE. Such intergovernmental agreements must be in place in order to claim federal matching funds.

As of the beginning (September 1) of the 2017-18 school fiscal year, all participating public school districts and ESU’s will participate in the NEBMAC program utilizing HHS’ competitively procured statewide contractor for purposes of program administration in coordination and under the direction of HHS.

ESUs may provide contracted service providers to their member districts, and in some instances the same provider may work in several districts and the ESU. For purposes of the NEBMAC Program and to avoid duplication of staff reporting, ESU contracted providers may only be included once on the ESUs list of staff eligible to participate in the NEBMAC program. ESU’s making administrative claims shall use an average of their member school districts’ Medicaid eligibility rates weighted for enrollment but may only include their own cost-pool expenditures in order to calculate claims pursuant to this methodology.

Each public school district and ESU participating in Medicaid administrative claiming shall separately maintain the financial accounting records in accordance with the [United States] Office of Management and Budget (OMB) requirements and standards 2 CFR Part 225) for purposes of audits.

PRINCIPLES OF ADMINISTRATIVE CLAIMING

A. General

ESU, school or school district employees perform administrative activities that directly support the Medicaid program. Some or all of the costs of these administrative activities may be reimbursable under Medicaid. However, an appropriate claiming mechanism must be used. The random moment time study (RMTS) is used for identifying and categorizing Medicaid administrative activities and direct service activities performed by employees. The time-study also serves as the basis for developing claims for the costs of administrative activities that may be properly reimbursed under Medicaid/NEBMAC. (See Section V.B), and is used in the calculation of MIPS Cost Settlements

The time-study, including the activity codes, represent the actual duties and responsibilities of participating ESU, school and school district employees, consistent with the operational principles discussed below (See Section IV.C for activity codes).

Effective September 1, 2017, activity codes listed in Section IV shall be used. No alteration of the activity codes is acceptable.

B. Operational Principles

1. Proper and Efficient Administration

According to the federal statute, in order for the cost of any activities to be allowable and reimbursable under Medicaid, activities must be necessary for the proper and efficient administration of the plan (referring to the Medicaid state plan) and the costs must be reasonable and necessary.

The principle of being necessary for the proper and efficient administration of the Medicaid state plan was applied in developing time-study activity codes. For example, outreach activities are considered to be in support of the Medicaid program if they are in regard to explaining Medicaid requirements. By contrast, outreach with respect to explaining the requirements of education programs or other program requirements are not in support of the Medicaid program and must be accounted for separately.

2. Claiming for Allowable Activities Only

Medicaid can only pay for administrative expenditures related to, or in support of health care services that are included in the state Medicaid plan or services which are reimbursed under Medicaid for Medicaid eligible individuals. For example, where school employees assist a Medicaid-eligible child to obtain medical services that are included in the child’s IEP or IFSP, if the provider furnishing the medical services is not participating in Nebraska’s Medicaid program or is not part of a managed care organization (MCO) participating in Nebraska’s Medicaid program, FFP is not available for the services; furthermore, FFP is not available for the administrative activities to assist the child in accessing such services. These activities are not claimable because they are not considered in support of the operation of the Medicaid state plan (even if the services are included in Nebraska’s Medicaid program).

3. Capture 100 Percent of Time

In order to ascertain the portion of time and activities that are related to administering the Medicaid program, DHHS must approve the allocation methodology. Effective September 1, 2013, the approved allocation methodology for Nebraska LEAs is the use of Random Moment Time Studies (RMTS).

To participate in the statewide NEBMAC and MIPS Cost Settlement programs, an LEA or ESC must require certain district staff to participate in a quarterly RMTS time study that covers the period for which claimed administrative and direct service activities were performed. This time study in turn, provides the basis for calculating amounts owed to the districts for these activities.

While many school district staff participate in administrative activities that are eligible for reimbursement by Medicaid, most do so only for a portion of their normal workday and at varying intervals. The time study allows LEA staff to document what they were doing during their sampled moment and determine what portion of the day was spent on Medicaid-covered activities. Details on how to conduct the time study are discussed in Section V, Claiming Issues, of this guide.

In order to ensure that all of the time-study participants are appropriately reflected in the time-study, staff classifications and associated supporting documentation (such as position descriptions) for time-study participants have been reviewed and considered in developing the time-study activity codes. This ensures that the unique responsibilities and functions performed by participants, as well as special factors and programs applicable to the participating ESU’s, schools or school districts are accounted for and included in the time-study codes. As these codes were formulated, they were compared against staff classifications and supporting position descriptions to ensure that all functions being performed are identified and incorporated into the codes. (See also Section V.A Documentation.)

4. Parallel Coding Structure: Medicaid and Non-Medicaid Codes for Each Activity

The time-study activity codes must capture all of the activities performed by the time-study participants as indicated by Principle 2 and distinguish Medicaid activities from similar activities that are not Medicaid reimbursable. For example, a school employee who provides referrals for both Medicaid and non-Medicaid programs needs to appropriately allocate his or her time between these programs. This can be accomplished through the use of “parallel” time-study activity codes. In the above example, a time-study would include an activity code such as “Non-Medicaid Outreach” and its parallel code “Medicaid Outreach” (See Codes 1.a and 1.b in Section IV.C) or “Referrals to Non-Medicaid Enrolled Providers and Referral, Coordination and Monitoring of Non-Medicaid Services” and a parallel code such as “Referral, Coordination and Monitoring of Medical Services to Medicaid Enrolled Providers” (see Codes 8.a and 8.b in Section IV.C). Using a parallel coding structure ensures that the time-study captures 100 percent of the time spent on referrals and allocates it to the appropriate program. As noted in Section V.B.5, all staff in the sample universe are to be trained on proper coding procedures including reporting activities under the parallel codes before sampling begins.

5. Duplicate Payments

Federal, state and local governmental resources should be expended in the most cost-effective manner possible. In determining the administrative costs that are reimbursable under Medicaid, duplicate payments are not allowable. That is, districts may not claim FFP for the costs of allowable administrative activities that have been or should have been reimbursed through an alternative mechanism or funding source. Just as DHHS must provide assurances to CMS and of non-duplication through its administrative claims and the claiming process, districts must provide like assurances to [Nebraska] DHHS. Furthermore, in no case should a school district or ESU claim or be paid more than the actual cost of that program or claiming unit including state, local and federal funds.

Examples of activities for which the costs may not be claimable as Medicaid administration due to the potential for duplicate payments:

• An activity that has been or will be paid as a medical assistance service or as a service of another non-Medicaid program (See Section IV.B Principle 6 on performing direct services vs. administrative activities); • An activity that is included as part of a managed care rate and is reimbursed by the managed care organization.

It is important to distinguish between duplicate payments for the same activity and the inefficient use of resources which may result in the unnecessary performance of an activity more than once.

Coordination of activities is intended to mitigate the duplicate performance of services or administrative activities and is discussed in Principle 6 (Coordination of Activities).

There are many situations in which a Medicaid-eligible child with special needs receives IEP or IFSP services from the school and well child, primary, preventive and acute care services from a managed care organization (MCO). MCO services can be provided at a school-based, school-linked clinic, doctor’s office or elsewhere. In those situations where the same Medicaid-eligible child receives IEP or IFSP services from both a school and an MCO, Nebraska makes concerted efforts to ensure that Medicaid is not paying for the same services twice, once to the MCO and again to the school.

Any mechanism under which managed care rates are set and adjusted addresses the activities and services being furnished in the school setting.

6. Coordination of Activities

In addition to avoiding duplicate payments as discussed above in Principle 5, duplicate performance of activities must also be avoided. Under Principle 1, allowable administrative activities must be necessary “for the proper and efficient administration of the Nebraska Medicaid Program as well as for the operation of all governmental programs. Therefore, it is important that the school not perform activities that are already being offered or should be provided by other entities or through other programs. As appropriate, [Nebraska] DHHS, schools carefully coordinates efforts of NDE, providers, community and non-profit organizations and other entities related to the activities performed.

All agencies and persons involved must take whatever steps are necessary to ensure that appropriate coordination occurs among providers. These assurances are included in language implementing Medicaid managed care contracts. In addition, schools are required under IDEA to provide services listed in a child’s IEP or IFSP. Therefore, Medicaid managed care contracts contain provisions that specifically exclude these services from the capitation rate paid to cover the costs of providing other medical services to Medicaid eligible children.

The following are examples of activities that are or need to be coordinated:

• Activities performed by an MCO for Medicaid enrollees such as case management functions. To avoid duplication of these functions by school personnel, coordination mechanisms are established between the school and appropriate entities, such as the MCO and [Nebraska] DHHS.

• Payment rate setting mechanism. [Nebraska] DHHS and schools coordinate their activities, payments to providers, third party payers and rate setting mechanisms to ensure that duplicate payments are not made and that medical services and administrative activities are provided as efficiently and effectively as possible. For example, MCO payment rates are adjusted to reflect the activities and services being furnished in the school setting.

• An activity that is provided/conducted by another governmental component. For example, it is not necessary for EPSDT educational materials, such as pamphlets and flyers which have already been developed by [Nebraska] DHHS to also be developed by schools. It would be inefficient in the allocation of Medicaid program and school resources to do so. In order to avoid this, ESU’s and school districts/schools coordinate and consult with [Nebraska] DHHS to determine the appropriate activities related to EPSDT and the availability of existing materials.

7. Performing Direct Services v. Administrative Activities

School employees often perform both direct services (e.g., medical, vocational or social services, teaching) and administrative activities (e.g., outreach or care coordination). The time-study and activity codes capture and clearly distinguish direct services from administrative activities. Direct services like those addressed by Nebraska’s MIPS program have different funding sources, claiming mechanisms and documentation requirements related to each program or type of activity and therefore should not be claimed as an administrative expense. The RMTS activity codes are designed to capture all administrative activities and direct services that may be performed in the school but only some of those activities are reimbursable under Medicaid. The time-study methodology identifies costs of medical and other direct services like OT, PT and SLP. Proper application of the time-study methodology will ensure that those costs are not included in claims for Medicaid administrative activities.

The activity codes used in the time-study distinguish between different types of activities and direct services as well as their respective funding sources. For example, as indicated in the activity code system in Subsection C, Medicaid program outreach is to be reported under Code 1.b, education program outreach under Code 1.a, Direct Medical services under Code 4.a and 4.b, and educational services under Code 3.

As indicated in Principle 4, payments for allowable Medicaid administrative activities must not duplicate payments that have been or should have been included as part of direct medical services, capitation rate or through some other state or federal program as specified in 2 CFR Part 225. It is the school district’s and ESU’s responsibility to ensure there is no duplication in a claim prior to submitting a claim to [Nebraska] DHHS.

Activities that are considered integral to or an extension of the specified covered service are included in the rate set for the direct service and therefore, should not be claimed as an administrative expense. For example, when a school provides medical services such as OT, PT and/or SLP, practitioners (therapists) should not bill separately for the cost of a referral as an administrative expense through MIPS or any other Public Assistance (PA) program. These activities are properly paid as part of the medical service/therapy and reimbursed at the Federal Medical Assistance Percentage (FMAP), nor may these activities be claimed as an additional cost through administrative case management which is defined below.

a. Case Management as Administration

The federal State Medicaid Manual (SMM) Section 4302 identifies certain activities that may be properly claimed as administrative case management. An allowable administrative cost must be directly related to Nebraska’s State [Medicaid] Plan or waiver service and be necessary for the “proper and efficient administration of the state plan.”

Some examples of administrative case management services addressed at SMM Section 4302.2 (G)(2), are:

• Medicaid eligibility determinations and redeterminations; • Medicaid intake processing; • Medicaid preadmission screening for inpatient care; • Prior authorization for Medicaid services; • Utilization review; and • Medicaid outreach.

As indicated in the SMM, CMS and [Nebraska] DHHS may make determinations regarding whether or not other activities are necessary for the proper and efficient administration of the state plan. Examples of activities that are performed in a school-based setting may be found in the time-study activity codes included in Section IV.C of this Guide.

While some case management activities may fall within the scope of both administrative and targeted case management, claims may not be made for the same costs both as targeted case management and administrative case management per the duplicate payment provision discussed above.

b. Case Management as a Service

Federal Sections 1905(a) (19) and 1915(g) (2) of the Act (42 United States Code (U.S.C.) 1396d (a) (19) and 42 U.S.C. 1396n (g) (2), respectively) define case management (CM), also referred to as services coordination (SC), as services which will assist an individual eligible under the state [Medicaid] plan in gaining access to needed medical, social, educational and other services. Case management services are referred to as targeted case management (TCM) services when the services are not furnished in accordance with requirements pertaining to state wideness or comparability. TCM services are included in the NMAP/Medicaid as an optional service. This flexibility enables Nebraska to target case management services to specific classes of individuals and/or to individuals residing in specified areas. If a child is receiving TCM through the school or through another provider, extra care must be taken to ensure that there is no duplication of services or payment. All TCM should be reported under Activity “4, Direct Medical Services” in Section IV.C.

c. Allocable Share of Costs

i. Medicaid Eligibility Rate (MER)

Many school-based medical activities are provided both to Medicaid and non-Medicaid eligible students. Therefore, costs applicable to these activities must be allocated to both groups. This allocation of costs involves the determination and application of the proportional share of Medicaid students to the total number of students. Development of the proportional Medicaid share, which is sometimes referred to as the Medicaid Eligibility Rate (MER), Medicaid percentage, allocable share or discount rate, should relate to and be based on the claiming unit (the entity submitting the claim). [Nebraska] DHHS and the NDE work with the schools and ESU’s to determine the MER for the claiming unit.

Annually, districts are required by State statute to submit to NDE, student information as of the last Friday in September. Beginning in the fall of 2005, NDE began annually capturing names, dates of birth, and gender data for their Nebraska Staff and Student Record System (NSSRS). A file of Medicaid eligible recipients is then compared to NDE’s file (by school district) in order to identify the number of Medicaid eligible students in each district. Dividing the number of matches identified for each district by the total number of students in each district results in the proportional Medicaid share for each district for that school year (Sep-Aug).

In order to determine the MER for participating ESU’s, total number of matches identified for all districts within the ESU is divided by the total number of students in all districts within the ESU. The result is the proportional Medicaid share for that ESU.

The proportional Medicaid share is then applied to the total costs of a specific activity for which the claiming unit is submitting claims for FFP. This process is necessary to ensure that only the costs related to Medicaid eligible children are claimed to Medicaid. Note that not all activities are subject to the proportional Medicaid share. Activities such as outreach and facilitating eligibility determinations are not discounted at all while others are totally unallowable and therefore discounted in total (100%).

ii. Provider Participation Rate

Through the use of time-studies that contain specific activity codes, costs of school personnel are distributed to certain activities (time-study codes) to determine the administrative cost allocable to the Medicaid program. The participation rate is based on the four (4) criteria listed below and the universe of activity codes used in the time-study as a group must capture the following categories of costs:

(1) Unallowable - the activity is unallowable as administration under the Medicaid program; (2) 100% Medicaid Share - the activity is solely attributable to the Medicaid program and as such is not subject to the application of the Medicaid share percentage. This is sometimes referred to as “not discounted”; (3) Proportional Medicaid Share - the activity is allowable as administration under the Medicaid program but the allocable share of costs must be determined by applying the percentage of the Medicaid eligible population or MER for each school district or ESU included in the time-study This is sometimes referred to as “discounted”; or (4) Reallocated Activities - those activities that are reallocated across other codes based on the percentage of time spent on allowable/unallowable administrative activities.

OMB 2 CFR Part 200 - Super Circular states that “a cost is allocable to a particular cost objective if the goods or services involved are chargeable or assignable to such cost objective in accordance with relative benefits received” (emphasis added). To establish the proportional Medicaid share, Medicaid eligible students must be determined and counted for each school/school district or ESU that is submitting a claim. This number serves as the numerator in a fraction with the denominator being the total number of students in the same entity. This fractional value is the MER and is then applied to the total costs applicable to the proportional Medicaid share time-codes to determine the costs applicable to Medicaid administrative activities. Note that the number of those Medicaid eligible and the total number of students must be identified for the same time period. For example, total enrollment at the opening of school in August compared with Medicaid enrollment in November may not be used. Section 7.a above further describes the MER as it is calculated for Nebraska School Districts and ESU’s. See IV.7.a for further explanation of Nebraska’s method of gathering information for MER calculations.

In the following example, administrative claims are developed on a school district basis. The purpose of applying a proportional Medicaid share is to determine the amount to be allocated between Medicaid and non-Medicaid students. The following example establishes how much of the costs related to the activity should be allocated to Medicaid. The amount of federal financial participation rate is currently 50% for all allowable administrative services. This percentage is used to determine the appropriate claim based on the activity costs that are allocable to Medicaid.

For example, an administrative activity may involve: "Referring students for necessary medical health, mental health or substance abuse services covered by Medicaid." While the activity may be intended to benefit only Medicaid students, medical referrals would affect services provided to both Medicaid and non-Medicaid students. That is, both groups would benefit from the activity and therefore the costs associated with such referral activities must be allocated accordingly.

The allocation of costs applies to activities that are performed with respect to a population of children that includes Medicaid and non-Medicaid-eligible children such as referral and monitoring of services. Specifically, children with an IEP may have medical (Medicaid covered) services included in their IEP’s. Some of these children may be eligible for Medicaid and some may not. When the IEP coordinator performs administrative activities such as referral and monitoring of services for such children, they typically do not know who is and who is not eligible for Medicaid. For that reason, a Medicaid percentage is applied to the time spent on this activity to determine the proportion of the time that is allowable as a Medicaid administrative activity.

For outreach activities that are performed to identify potentially Medicaid eligible students and enroll them in the Medicaid program, schools do not need to determine which of these students are later determined eligible or which students apply for the program. Discounting is not applicable for this type of activity.

8. Enhanced FFP Rates

Claiming for Translation and Interpretation Services CMS policy permits reimbursement at the standard 50% federal matching rate for translation/interpretation activities that are claimed as an administrative expense, so long as they are not included and paid for as part of the rate for direct services. With the enactment of CHIPRA in 2009, States were given the option to claim a higher matching rate for translation/interpretation services (75% under Medicaid; 75% or the State's enhanced FMAP + 5%, whichever is higher, under CHIP) that are claimed as administration and are related to enrollment, retention and use of services under Medicaid and CHIP for certain populations.

9. Individual Education Program (IEP) and Individualized Family Service Plan (IFSP) Activities

Section 411(k) (13) of the Medicare Catastrophic Coverage Act [of 1988] (MCCA) (Public Law (P.L.) 100-360) amended Section 1903(c) of the Act (42 U.S.C. 1396b(c)) to permit Medicaid payment for services provided to children under the Individuals with Disabilities Education Act (IDEA) through an Individual Education Program (IEP). IDEA provisions require school staff to perform a number of education-related activities that can generally be characterized as ChildFind, evaluation (initial), reevaluation and development of an IEP (See also Appendix A). Nebraska schools have a responsibility to develop and implement an Individualized Family Service Plan (IFSP) for each infant or toddler who has a verified disability and is thereby determined to be eligible for early intervention (IDEA “Part C”) services. Likewise, schools are responsible for developing and implementing an IEP for each child from three (3) to 21 who has a verified disability and is thereby determined to be eligible for “Part B” Special Education services. See IDEA-related health services in Section II (Medicaid in the School Setting) for additional information.

IDEA related activities conducted by school staff are briefly described below:

ChildFind: All children with disabilities residing in the state who are in need of special education and related services must be identified, located and evaluated.

Initial Evaluations and Reevaluation: Before special education and related services are provided, an initial evaluation must be conducted by the responsible public school district (usually the resident district) in order to determine whether a child has a disability and their special/specific educational needs. A re-evaluation is a determination as to whether the child continues to be disabled and is performed in regards to the continuation of the educational needs of the child. These evaluations are usually initiated by the Student Assistance Team (SAT) and performed by a Multidisciplinary [evaluation] team (MDT) as outlined in NDE’s “Regulations and Standards for Special Education Programs.” More commonly known in Nebraska as “Rule 51,” these regulations may be found at Title 92 Nebraska Administrative Code (NAC) Chapter 51.

Individual Education Program (IEP): IEP’s are addressed in Appendix A to the Guide.

Individualized Family Service Plan (IFSP): IFSP’s are addressed in Appendix A to the Guide.

Schools conduct activities listed above for the purpose of fulfilling education-related services as mandated by IDEA. As such, associated costs of these activities are not allowable as administrative costs covered by the Medicaid program. In developing and reporting under the time-study activity codes, education-related activities must be clearly identified and distinguished as non-Medicaid activities. In general, these activities could be reported under time-study Codes 1.a, 2.a or 3 in Subsection C.

It is important to distinguish ChildFind activities from Medicaid outreach for the purpose of claiming FFP under Medicaid. In accordance with IDEA, schools conduct ChildFind activities to identify children with disabilities who need special education and related services. Regardless of whether the ChildFind activities result in finding eligible children for whom an IEP or IFSP is developed, ChildFind costs are not allowed under Medicaid as administration. This type of outreach can be distinguished from outreach to identify children who might be eligible for Medicaid; such Medicaid outreach activities are allowable.

Various education-related statutes obligate schools to furnish or make payment for services provided in the school setting for which Medicaid payment is not available. Section 1903(c) of the Act clarifies that Medicaid payment is available for medical services contained in a child’s IEP or IFSP established under IDEA so long as the child is eligible and the services are otherwise reimbursable under Medicaid but no other education-related statutes obligate Medicaid payment. For example, Section 504 of the Rehabilitation Act of 1973 requires local school districts to provide or pay for certain services to make education accessible to children with impairments; these services are described in a Section 504 plan. The 1903(c) exception is very specific and does not extend to services provided pursuant to a Section 504 plan. Education agencies such as school districts are required to pay for Section 504 services and there is no provision to make the education agencies secondary to Medicaid. Consequentially, federal Medicaid funds are not available for these services.

IDEA is described further in Appendix A to this Guide.

10. Review and Approval of Program and Codes by CMS

CMS reviews claims made by [Nebraska] DHHS, particularly in situations involving the establishment of a new program in the state such as a school-based administrative claiming program in order to determine the allowability of such claims for federal matching funds. Furthermore, as discussed below and in Section V.D on Cost Allocation Plans, [United States] DHHS’s Division of Cost Allocation (DCA), in coordination and consultation with CMS, is required to approve public assistance cost allocation plans (CAP’s). CAP’s must incorporate, by reference, time-study and cost allocation methodology adopted by [Nebraska] DHHS for schools to develop and document claims submitted to [Nebraska] DHHS.

Federal regulations (42 CFR 433.34) require that a single state agency have an approved public assistance CAP under the Medicaid state plan and on file with [United States] DHHS that meets certain regulatory requirements (Subpart E of 45 CFR Part 95). In Nebraska, that single state agency is [Nebraska] DHHS. As indicated in Subpart E of 45 CFR Part 95 and referenced in 2CFR Part 225, Attachment D, a state’s public assistance CAP is an official document which describes the procedures that the state uses in identifying, measuring and allocating state agency costs incurred in support of all programs administered or supervised by the state such as Temporary Assistance for Needy Families (TANF), Medicaid, Food Stamps, Child Support Enforcement (CSE), adoption assistance, Foster Care and Social Service Block Grant (SSBG).

Furthermore, there are certain items that must be in the public assistance CAP which [Nebraska] DHHS must submit before providing FFP to school districts for administrative claiming. The public assistance CAP makes explicit reference to the methodologies, claiming mechanisms, interagency agreements and other relevant issues pertinent to the allocation of costs and submission of claims by LEA’s, (school districts and ESU’s).

[Nebraska] DHSS works with its regional CMS office in Kansas City, on an ongoing basis to assure a proper and accurate Cost Allocation Plan is in place and is properly applied as described above and further required by [United States] DHHS’s CMS.

The required elements of public assistance CAP’s are further discussed in the Cost Allocation Plan section of the Guide (Section V.D) as is the review and approval process for such plans.

C. Activity Codes: Descriptions and Examples

1. Introduction

When staff perform duties related to the proper administration of Nebraska’s Medicaid program (NMAP), federal funds (FFP) may be accessed for the costs of providing these administrative services. To identify the cost of providing these administrative services and direct services, time-studies of must be conducted. The time-study identifies the time spent on the Medicaid administrative activities that are allowable and reimbursable under the Medicaid program. Effective September 1, 2017, coding scheme/activity codes as listed below must be used and may not be modified.

The indicators below, which follow each Code, provide the application of the FFP rate, allowability or non-allowability designation and the proportional Medicaid share status of the Code. In order to maintain coding objectivity by time-study participants, time-study sheets used by employees do not include references to rates of FFP, proportional or total Medicaid or whether such codes are allowable or unallowable under Medicaid.

a. Application of FFP rate

50 percent Refers to an activity that is allowable as administration under the Medicaid program and claimable at 50 percent.

75 percent Refers to the Enhanced FFP rate allowable under the Children’s Health Insurance Program Reauthorization Act of 2009 (CHIPRA), Public Law No. 111-3, enacted on February 4, 2009 for translation or interpretation services.

b. Unallowable Activities

U Refers to an activity that is unallowable as administration under the Medicaid program and therefore claimable only at zero (0) percent. This is regardless of whether or not the population served includes Medicaid eligible individuals.

c. Application of Medicaid Share

TM (Total Medicaid) Refers to an activity that is 100 percent allowable as administration under the Medicaid program.

PM (Proportional Medicaid) Refers to an activity which is allowable as administration under the Medicaid program but for which the allocable share of costs must be determined by the application of the proportional Medicaid share (Medicaid Eligibility Rate). The Medicaid share is determined as the ratio of Medicaid eligible students to total students.

d. Reallocated Activities

R Refers to those general administrative activities performed by time-study participants which must be reallocated across other activity codes on a pro rata basis. These reallocated activities are reported under Code 9, “General Administration.” Note that certain functions such as payroll, maintaining inventories, developing budgets, executive direction, etc., are considered overhead and therefore are only allowable through the application of an approved indirect cost rate.

Staff should document time spent on each of the following coded activities:

| Code | Activity | Reimbursement | | --- | --- | --- | | CODE 1.a | Non-Medicaid Outreach | U | | CODE 1.b | Medicaid Outreach | TM/50 Percent FFP | | CODE 2.a | Facilitating Application for Non-Medicaid Programs | U | | CODE 2.b | Facilitating Medicaid Eligibility Determination | TM/ 50 Percent FFP | | CODE 3 | School-Related and Educational Activities | U | | CODE 4.a | Direct Medical Service not on IEP | U | | CODE 4.b | Direct Medical Service on an IEP | U | | CODE 5.a | Transportation for Non-Medicaid Service | U | | CODE 5.b | Transportation-Related Activities in Support of Medicaid Covered Services | PM/50 Percent FFP | | CODE 6.a | Non-Medicaid Translation | U | | CODE 6.b | Translation Related to Medicaid Services | PM/75 Percent FFP | | CODE 7.a | Program Planning, Policy Development and Interagency Coordination Related to Non-Medical Services | U | | CODE 7.b | Program Planning, Policy Development and Interagency Coordination Related to Medical Services | PM/50 Percent FFP | | CODE 8.a | Non-Medical/Non-Medicaid Related Training | U | | CODE 8.b | Medical/Medicaid Related Training | PM/50 Percent FFP | | CODE 9.a | Referral, Coordination and Monitoring of Non- Medicaid Services | U | | CODE 9.b | Referral, Coordination and Monitoring of Medicaid Services | PM/50 Percent FFP | | CODE 10 | General Administration | R | | CODE 11 | Non Paid, Non Work | N/A |

The following activity codes represent a set of activity categories including administrative and direct services that are used and adapted to reflect Nebraska’s specific program titles, etc. These codes were developed in accordance with the principles discussed in other sections of this Guide and must be used by schools effective September 1, 20017.

TIME STUDY CODE DESCRIPTIONS

1A. Non-Medicaid Outreach – U

All participating time-study participants should use this code when performing activities that inform individuals about their eligibility for non-Medicaid social, vocational and outreach programs (including special education) and how to access them; describing the range of benefits and how to obtain them. Both written and oral methods may be used. Includes related paperwork, clerical activities or staff travel required to perform these activities.

1. Informing families about wellness programs and how to access these programs.
2. Providing information related to the applications for non-Medicaid programs. (e.g., foster care family coordination, WIC referrals, local shelters, emergency food assistance, day care, and indigent programs).
3. Scheduling and promoting activities that educate individuals about the benefits of healthy life styles and practices.
4. Conducting general health education programs or campaigns that address life-style changes in the general population (e.g., dental prevention, anti-smoking, alcohol reduction, etc.).
5. Conducting campaigns that encourage persons to access social, educational, legal or other services not covered by Medicaid.
6. Assisting in early identification of children with special medical/dental/mental health needs through various child find activities. (e.g., contacting a nurse to communicate the child’s needs, completing observations on students to determine needs, etc.).
7. Outreach activities in support of programs that are 100 percent funded by state general revenue.
8. Developing outreach materials such as brochures or handbooks for these programs.
9. Making arrangements with presenters of health education programs.
10. Parent conferences on truancy, drugs, gangs, etc.

1B. Medicaid Outreach – TM/50 Percent FFP

School staff should use this code when performing activities that inform eligible or potentially eligible individuals about Medicaid and how to access the program. Such activities include providing information to parents of potentially eligible children on how to apply for Medicaid or information on how to reenroll children who are already eligible and whose eligibility is soon to expire. Education about Medicaid may only be conducted for the populations served by the school districts, i.e., students and their parents or guardians.

1. Informing Medicaid eligible and potential Medicaid eligible children and families about the benefits and availability of services provided by Medicaid (including preventive treatment and screening) including services provided through the ESPDT program.
2. Developing and/or compiling materials to inform individuals about the Medicaid program (including EPSDT) and how and where to obtain those benefits. Note: This activity should not be used when Medicaid-related materials are already available to the schools (such as through the New Mexico Human Services Department Medical Assistance Division (HSD/MAD), the Medicaid agency). As appropriate, school developed education materials should have prior approval of the HSD/MAD.
3. Distributing literature about the benefits, eligibility requirements, and availability of the Medicaid program, including EPSDT.
4. Assisting HSD/MAD to fulfill the education objectives of the Medicaid program by informing individuals, students and their families about health resources available through the Medicaid program.
5. Providing information about Medicaid EPSDT screening (e.g., dental, vision) that will help identify medical conditions that can be corrected or improved by services offered through the Medicaid program.
6. Contacting pregnant and parenting teenagers about the availability of Medicaid prenatal and well-baby care programs and services.
7. Providing information regarding Medicaid managed care programs and health plans to individuals and families and how to access that system.
8. Encouraging families to access medical/dental/mental health services provided by the Medicaid program.

2A. Facilitating Application for Non-Medicaid Programs – U

This code should be used by school staff when informing an individual or family about non-Medicaid programs such as Temporary Assistance for Needy Families (TANF), Food Stamps, Women, Infants, and Children (WIC), day care, legal aid, and other social or educational programs and referring them to the appropriate agency to make application.

1. Explaining the eligibility process for non-Medicaid programs, including IDEA.
2. Assisting the individual or family collect/gather information and documents for the non-Medicaid program application (e.g., foster care family coordination, WIC referrals, local shelters, emergency food assistance, day care, Indigent programs etc.).
3. Assisting the individual or family in completing the application, including necessary translation activities.
4. Developing and verifying initial and continuing eligibility for the Free and Reduced Lunch Program.
5. Developing and verifying initial and continuing eligibility for non-Medicaid programs.
6. Providing necessary forms and packaging all forms in preparation for the non-Medicaid eligibility determination.

2B. Facilitating Medicaid Eligibility Determination – TM/50 Percent

School staff should use this code when assisting an individual with the Medicaid eligibility process. Includes related paperwork, clerical activities, or staff travel required to perform these activities. This activity does not include the actual determination of Medicaid eligibility.

1. Verifying an individual’s current Medicaid eligibility status for purposes of the Medicaid eligibility process.
2. Explaining Medicaid eligibility rules and the Medicaid eligibility process to prospective applicants.
3. Assisting individuals or families to complete a Medicaid eligibility application.
4. Gathering information related to the application and eligibility determination for an individual, including resource information, as a prelude to submitting a formal Medicaid application.
5. Providing necessary forms and packaging all forms in preparation for the Medicaid eligibility determination.
6. Referring an individual or family to the local Income Support Division Office to make application for Medicaid benefits.
7. Assisting the individual or family in collecting/gathering required information and documents for the Medicaid application.
8. Participating as a Medicaid eligibility outreach outstation, but does not include determining eligibility.

3. School Related and Educational Activities – U

This code should be used for school-related activities, including social services, educational services, teaching services, employment and job training, and other activities that are not Medicaid-related. These activities include the development, coordination, and monitoring of a student’s education plan. Includes related paperwork, clerical activities, or staff travel required to perform these activities.

1. Providing classroom instruction (including lesson planning).
2. Testing, correcting papers.
3. Developing, coordinating, and monitoring the Individualized Education Program (IEP) for a student, which includes ensuring annual reviews of the IEP are conducted, parental sign-offs are obtained, and the actual IEP meetings with the parents, except for the development of the medical component, e.g., the individualized treatment plan, of the IEP. (This would also refer to the same activities performed in support of an Individualized Family Service Plan (IFSP).)
4. Compiling attendance reports.
5. Performing activities that are specific to instructional, curriculum, and student-focused areas.
6. Reviewing the education record for students who are new to the school district.
7. Providing general supervision of students, e.g., playground, lunchroom.
8. Monitoring student academic achievement.
9. Providing individualized instruction (e.g., math concepts) to a special education student.
10. Conducting external relations related to school educational issues/matters.
11. Compiling report cards.
12. Carrying out discipline.
13. Performing clerical activities specific to instructional or curriculum areas.
14. Activities related to the educational aspects of meeting immunization requirements for school attendance.
15. Compiling, preparing, and reviewing reports on textbooks or attendance.
16. Enrolling new students or obtaining registration information.
17. Conferring with students or parents about discipline, academic matters or other school related issues.
18. Evaluating curriculum and instructional services, policies, and procedures.
19. Participating in or presenting training related to curriculum or instruction (e.g., language arts workshop, computer instruction).
20. Translating an academic test for a student.

4A. Direct Medical Services, Not Covered as IDEA/IEP Service – U

This code should be selected when school district staff are providing direct client care services that are not IDEA and/or not IEP services. This code includes the provision of all non-IDEA/IEP medical services reimbursed through Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) services. This code includes pre and post activities associated with the actual delivery of the direct client care services, e.g., paperwork or staff travel required to perform these services.

Examples of non-IDEA and/or non-IEP direct client care services as follows:

1. Medical Screenings (including scoliosis), Vision Screenings, Hearing Screenings, Dental Screenings, EPSDT Screenings, and nurse consults for non-Direct Service services;
2. Administering first aid;
3. Administering medication other than those medications outlined in the IEP as direct client care nursing services under the Direct Service program, e.g., providing immunizations;
4. Making referrals for and/or coordinating medical or physical examinations and necessary medical evaluations not covered as direct client care services under the Direct Service Program, as a result of a direct medical service;

4B. Direct Medical Services, Covered as IDEA/IEP Service – U

This code will be assigned when school district staff (employees or contracted staff) provides direct client services as covered services delivered by school districts under the Direct Service Program. These direct client services may be delivered to an individual and/or group in order to ameliorate a specific condition and are performed in the presence of the student(s). This code includes the provision of all IDEA/IEP medical (i.e., health-related) services. It also includes functions performed pre and post of the actual direct client services (when the student may not be present), for example, paperwork, or staff travel directly related to the direct client services. Examples of activities reported under this code, include IDEA/IEP direct client services with the Student/Client present:

1. Audiologist services, including evaluation and therapy services (only if included in the student’s IEP);
2. Physical Therapy services, including evaluation and therapy services (only if included in the student’s IEP);
3. Occupational Therapy services, including evaluation and therapy services (only if included in the student’s IEP);
4. Speech Language Pathology Therapy services, including evaluation and therapy services (only if included in the student’s IEP);
5. Counseling Services, including counseling, evaluation, and therapy services (only if included in the student's IEP);
6. Nutritional Assessments and Counseling (only if included in the student’s IEP);
7. Nursing Services on the IEP and time spent administering/monitoring medication only if it is included as part of an IEP and documented in the IEP. Medicaid administration would not include those that are provided to the entire student population, i.e. administration of aspirin, but are specifically those called for in the IEP;
8. Case Management Services, including medical/functional assessments and developing a comprehensive plan of care; and
9. Specialized Transportation Services (only if included in the student's IEP).

This code also includes pre and post time directly related to providing direct client care services when the student/client is not present. Examples of pre and post time activities when the student/client is not present include: time to complete all paperwork related to the specific direct client care service, such as preparation of progress notes, translation of session notes, review of evaluation testing/observation, planning activities for the therapy session, travel to/from the therapy session, or completion of billing activities.

5A. Transportation for Non-Medicaid Programs – U

School district employees should use this code when assisting an individual to obtain transportation to services not covered by Medicaid, or accompanying the individual to services not covered by Medicaid. Includes related paperwork, clerical activities or staff travel required to perform these activities.

1. Scheduling or arranging transportation to social, vocational, and/or educational programs and activities.

5B. Transportation-Related Activities in Support of Medicaid-Covered Services – PM/50 Percent FFP

School district employees should use this code when assisting an individual to obtain transportation to services covered by Medicaid. This does not include the provision of the actual transportation service or the direct costs of the transportation (bus fare, taxi fare, etc.), but rather the administrative activities involved in providing transportation. Includes related paperwork, clerical activities or staff travel required to perform these activities. See Section VI for a more detailed and thorough discussion of Medicaid transportation policy.

1. Scheduling or arranging transportation to Medicaid covered services.

6A. Non-Medicaid Translation –

School employees who provide translation services for non-Medicaid activities should use this code. Includes related paperwork, clerical activities or staff travel required to perform these activities.

1. Arranging for or providing translation services (oral or signing services) that assist the individual to access and understand social, educational, and vocational services.
2. Arranging for or providing translation services (oral or signing services) that assist the individual to access and understand state education or state-mandated health screenings (e.g., vision, hearing, scoliosis) and general health education outreach campaigns intended for the student population.
3. Developing translation materials that assist individuals to access and understand social, educational, and vocational services.

6B. Translation Related to Medicaid Services – PM/75 Percent FFP

Translation may be allowable as an administrative activity, if it is not included and paid for as part of a medical assistance service. However, translation must be provided either by separate units or separate employees performing solely translation functions for the school, and it must facilitate access to Medicaid covered services. School employees who provide Medicaid translation services should use this code. Includes related paperwork, clerical activities or staff travel required to perform these activities.

1. Arranging for or providing translation services (oral and signing) that assist the individual to access and understand necessary care or treatment covered by Medicaid. This includes alternative languages, Braille, sign language and translation due to illiteracy.
2. Developing translation materials that assist individuals to access and understand necessary care or treatment covered by Medicaid.

7A. Program Planning, Policy Development and Interagency Coordination Related to Non-Medical Services – U

School staff should use this code when performing activities associated with developing strategies to improve the coordination and delivery of non-medical services to school age children. Non-medical services may include social services, educational services, vocational services, and state or state education mandated child health screenings provided to the general school population. Employees who position description includes program planning, policy development, and interagency coordination may use this code. If schools so choose, they may be explicit in the position descriptions with respect to the specific functions. Includes related paperwork, clerical activities or staff travel required to perform these activities.

1. Identifying gaps or duplication of non-medical services (e.g., social, vocational educational and state mandated general health care programs) to school age children and developing strategies to improve the delivery and coordination of these services.
2. Developing strategies to assess or increase the capacity of non-medical school programs.
3. Monitoring the non-medical delivery systems in schools.
4. Developing procedures for tracking families’ requests for assistance with non-medical services and the providers of such services.
5. Evaluating the need for non-medical services in relation to specific populations or geographic areas.
6. Analyzing non-medical data related to a specific program, population, or geographic area.
7. Working with other agencies providing non-medical services to improve the coordination and delivery of services and to improve collaboration around the early identification of nonmedical problems.
8. Defining the relationship of each agency’s non-medical services to one another.
9. Developing advisory or work groups of professionals to provide consultation and advice regarding the delivery of non-medical services and state-mandated health screenings to the school populations.
10. Developing non-medical referral sources.
11. Coordinating with interagency committees to identify, promote and develop non-medical services in the school system.

7B. Program Planning, Policy Development and Interagency Coordination Related to Medical Services – PM/50 Percent FFP

This code should be used by school staff when performing activities associated with the development of strategies to improve the coordination and delivery of medical/dental/mental health services to school age children and adolescents, and when performing collaborative activities with other agencies and/or providers. Employees who position description includes program planning, policy development, and interagency coordination may use this code. If schools so choose, they may be explicit in the position descriptions with respect to the specific functions. This code refers to activities such as planning and developing procedures to track requests for services; the actual tracking of requests for Medicaid services would be coded under Code 9B. Includes related paperwork, clerical activities or staff travel required to perform these activities.

1. Identifying gaps or duplication of medical/dental/mental services to school age children and developing strategies to improve the delivery and coordination of these services.
2. Developing strategies to assess or increase the capacity of school medical/dental/mental health programs.
3. Monitoring the medical/dental/mental health delivery systems in schools.
4. Developing procedures for tracking families’ requests for assistance with medical/dental/mental services and providers, including Medicaid. (This does not include the actual tracking of requests for Medicaid services.)
5. Evaluating the need for medical/dental/mental services in relation to specific populations or geographic areas.
6. Analyzing Medicaid data related to a specific program, population, or geographic area.
7. Working with other agencies and/or providers that provide medical/dental/mental services to improve the coordination and delivery of services, to expand access to specific populations of Medicaid eligibles, and to increase provider participation and improve provider relations.
8. Working with other agencies and/or providers to improve collaboration around the early identification of medical/dental/mental problems.
9. Developing strategies to assess or increase the cost effectiveness of school medical/dental/mental health programs.
10. Defining the relationship of each agency’s Medicaid services to one another.
11. Working with Medicaid resources, such as HSD/MAD and Medicaid managed care organizations, to make good faith efforts to locate and develop EPSDT health services referral relationships.
12. Developing advisory or work groups of health professionals to provide consultation and advice regarding the delivery of health care services to the school populations.
13. Working with HSD/MAD to identify, recruit and promote the enrollment of potential Medicaid providers.
14. Developing medical referral sources such as directories of Medicaid providers and managed care organizations, which will provide services to targeted population groups.
15. Coordinating with interagency committees to identify and promote recipients’ access to Medicaid EPSDT services.

8A. Non-Medical/Non-Medicaid Related Training – U

School staff should use this code when coordinating, conducting, or participating in training events and seminars for outreach staff regarding the benefit of the programs other than the Medicaid program. For example, training may include how to assist families to access the services of education programs, and how to more effectively refer students for those services. Includes related paperwork, clerical activities, or staff travel required to perform these activities.

1. Participating in or coordinating training that improves the delivery of services for programs other than Medicaid.
2. Participating in or coordinating training that enhances IDEA child find programs.

8B. Medical/Medicaid Related Training – PM/50 Percent FFP

School staff should use this code when coordinating, conducting, or participating in training events and seminars for Medicaid training staff regarding the benefits of medical/Medicaid related services, how to assist families to access such services, and how to more effectively refer students for services. Include related paperwork, clerical activities, or staff travel required to perform these activities.

1. Participating in or coordinating training that improves the delivery of medical/Medicaid related services.
2. Participating in or coordinating training that enhances early identification, intervention, screening and referral of students with special health needs to such services (e.g., Medicaid EPSDT services). (This is distinguished from IDEA child find programs.)
3. Participating in training on Medicaid school-based direct services and administrative requirements.

9A. Referral, Coordination & Monitoring of Non-Medicaid Services – U

School staff should use this code when making referrals for, coordinating, and/or monitoring the delivery of non-Medicaid covered services or the delivery of non-medical services, such as educational services. Includes related paperwork, clerical activities or staff travel required to perform these activities.

1. Making referrals for and coordinating access to social and educational services such as child care, employment, job training, and housing.
2. Making referrals for, coordinating, and/or monitoring the delivery of state education agency mandated child health screens (e.g., vision, hearing, scoliosis).
3. Making referrals for, coordinating, and monitoring the delivery of scholastic, vocational, and other non-health related examinations.
4. Making referrals for, coordinating, and monitoring the delivery of services that are provided to all students in the school.
5. Gathering any information that may be required in advance of these non-Medicaid related referrals.
6. Participating in a meeting/discussion to coordinate or review a student’s need for scholastic, vocational, and non-health related services not covered by Medicaid.
7. Monitoring and evaluating the non-medical components of the individualized plan as appropriate.

9B. Referral, Coordination and Monitoring of Medicaid Services – PM/50 Percent FFP

School staff should use this code when making referrals for, coordinating, and/or monitoring the delivery of medical (Medicaid covered) services. Referral, coordination and monitoring activities related to services in an IEP are reported in this code. Activities that are part of a direct service are not claimable as an administrative activity. Furthermore, activities that are an integral part of or an extension of a direct medical service, e.g., patient follow-up, patient assessment, patient counseling, patient education, patient consultation, and billing activities, should be reported under Code 4A/4B, Direct Medical Services. Includes related paperwork, clerical activities, or staff travel necessary to perform these activities.

1. Identifying and referring adolescents who may be in need of Medicaid family planning services.
2. Making referrals for and/or coordinating medical or physical examinations and necessary medical/dental/mental health evaluations.
3. Making referrals for and/or scheduling EPSDT screens, periodic screens, and appropriate immunization but not referrals for state-mandated health screening or other primary and preventive services provided free of charge to all students.
4. Referring students for necessary medical health, mental health, or substance abuse services covered by Medicaid.
5. Arranging for any Medicaid covered medical/dental/mental health diagnostic or treatment services that may be required as the result of a specifically identified medical/dental/mental health need.
6. Gathering any information that may be required in advance of medical/dental/mental health referrals.
7. Participating in a meeting/discussion to coordinate or review a student’s needs for health related services covered by Medicaid.
8. Providing follow-up contact to ensure that a child has received the prescribed medical/dental/mental health services covered by Medicaid.
9. Coordinating the delivery of community based medical/dental/mental health services for a child with special/severe health care needs.
10. Coordinating the completion of the prescribed services, termination of services, and the referral of the child to other Medicaid service providers as may be required to provide continuity of care.
11. Providing information to other staff on the child’s related medical/dental/mental health services and plans.
12. Monitoring and evaluating the Medicaid service components of the IEP as appropriate.
13. Coordinating medical/dental/mental health service provision with managed care plans as appropriate.

10. General Administration – R

1. Taking lunch, breaks, leave, or other paid time not at work.
2. Establishing goals and objectives of health-related programs as part of the school’s annual or multi-year plan.
3. Reviewing school or district procedures and rules.
4. Attending or facilitating school or unit staff meetings, training, or board meetings.
5. Performing administrative or clerical activities related to general building or district functions or operations.
6. Providing general supervision of staff, including supervision of student teachers or classroom volunteers, and evaluation of employee performance.
7. Reviewing technical literature and research articles.
8. Other general administrative activities of a similar nature as listed above that cannot be specifically identified under other activity codes.

11. Not-Paid/Not-Worked – R

Non-paid time/non-work time is time during the school work day for which a participant in the time study is not working AND is not being compensated. Examples of activities reported under this code:

1. Part-time/Contracted staff whose sampled moment occurs during non-scheduled work hours.
2. Staff member takes an unpaid day off during the sampled moment
3. Non-paid sick time.
4. Non-paid leaves of absence.
5. No longer employed by the program

CLAIMING ISSUES

A. Documentation

The time-study methodology and instructions, as well as the cost allocation requirements issued to the schools stipulate the documentation schools and ESU’s must maintain to support claims submitted to [Nebraska] DHHS. The documentation for administrative activities must clearly demonstrate that the activities/services directly support the administration of the Medicaid program. In accordance with federal statutes, state regulations and the Nebraska Medicaid plan, claimants (school districts, and ESU’s) are required to maintain/retain adequate source documentation to support all Medicaid payments for administrative claiming. The basis for this requirement can be found in federal statute and regulations. See Section 1902(a)(4) of the Act and 42 CFR 431.17 as well as 45 CFR 74.53 and 42 CFR 433.32(a) requiring source documentation to support accounting records and 45 CFR 74.20 and 42 CFR 433.32(b-c) regarding the retention period for records. The administrative claiming records must be made available for review by state and federal staff or their designees upon request during normal working hours (Section 1902(a)(4) of the Act implemented at 42 CFR 431.17). It is the district’s responsibility to ensure that claims submitted are in conformance with the applicable policies and in conformance with such requirements.

Documentation maintained in support of administrative claims must be sufficiently detailed to permit DHHS or CMS to determine whether the activities are necessary for the proper and efficient administration of the state plan. Simply checking a box on a time-study form does not facilitate independent validation of the sample results.

In the past, federal agencies have generally accepted minimal documentation of time-study random moment sampling. However, circumstances under which school-based administrative activities are sampled for purposes of FFP under the Medicaid program differ from other time-study and random moment sampling. In other instances, costs to be distributed are generally federally reimbursable and the results of the sample only determine the percentage of the costs that are directed to each federal program. When sampling is conducted to determine federal financial participation under the Medicaid program for the costs of school-based administrative activities, a vast majority of the costs are not federally reimbursable. Therefore, it is critically important for additional documentation to be maintained in order to verify the appropriateness of claims in terms of allowability and allocability and to limit the risk of erroneous claiming.

The burden of proof and validation of time-study sample results remains the responsibility of the schools/ESU. To meet this requirement, the RMTS survey include space for a brief narrative description of the Medicaid activity, function or task being performed.

Additional guidance regarding documentation for compensation of salary and wages is found in OMB 2 CFR Part 200 - Super Circular OMB 2 CFR Part 200 - Super Circular makes a distinction between documentation of costs and the methods/ mechanisms for allocating such costs. While costs must be documented at least on a monthly basis, time-studies which are conducted for purposes of allocating costs can occur on a quarterly basis or some other statistically valid time frame. ASMB C-10, U.S. Department of Health and Human Services’ implementation guide for OMB 2 CFR Part 225, provides further guidance on the requirements and circumstances dictating the frequency of time and effort reporting. Other principles related to documentation and documentation requirements that apply in addition to the above requirements are:

• The documentation related to salaries and wages, including personnel activity reports, is required;
• Accounting records should be supported by source documentation such as canceled checks, electronic funds transfers, paid bills, payrolls, contract and sub grant award documents;
• The documentation related to foster care payments and administrative costs is required;
• Case management services based on time-studies are an acceptable form of documentation for a given period;
• Costs must be verified as being incurred in a particular federal program;
• Undocumented personnel costs are not allowed; and
• Adequate documentation for labor costs is required.

Position descriptions can be useful as supporting documentation for staff participating in time-studies. However, position or job descriptions are often generic and may indicate that “other administrative duties” are included without providing a definition for those administrative functions. In many cases, these “other administrative duties” may be understood to include the performance of Medicaid related activities and the completion of time-studies. In that regard, it may be helpful, though it is not required, to include in the time-study participants’ position descriptions further explanation or documentation of the Medicaid related activities performed, particularly if the position descriptions do not reflect any aspect of the performance of such activities. However, schools are not required to modify job descriptions in order to incorporate time-study activities. Furthermore, CMS does not require position descriptions to be maintained for staff who are not participating in the school-based administrative claiming program.

B. Components of the Random Moment /Time-Studies

1. Random Moment Sampling Methodology

To determine the proportion of claims for administrative activities in support of the NEBMAC program, proportion of claims for direct service activities, and the proper allocation of costs, DHHS utilizes a Random Moment Time Study (RMTS) time study methodology that is monitored and administered at the state level by DHHS staff and its selected contractor. Details concerning the RMTS process and the individuals who may participate are described below.

2. Time Study Participants

Any LEA or ESU staff member who spends part of their working time performing program-related administrative or direct service activities, and meets the eligibility criteria, is eligible for inclusion in one of two cost pools for purposes of the time study.

When a district constructs the list of staff that is included in the time study, it determines first whether the individuals in those positions perform administrative and/or direct service activities that support the NEBMAC and MIPS programs and then includes them in the appropriate category. Each category of staff will fall into one of two mutually exclusive cost pools. The purpose of two cost pools is to group staff into “like” categories.

• Cost Pool 1 is made up of direct service/therapy personnel and is the same listing of providers currently in the State plan.

• Cost Pool 2 is made up of staff involved in administrative activities rather than direct service activities. Staff that are 100% federally funded should be excluded from participation in the program, e.g. staff whose salary and benefits are paid entirely from IDEA or other federal funds.

The following categories of staff have been identified as appropriate participants for the time studies. All staff will be reported into one of two cost pools: “Cost Pool 1” or “Cost Pool 2”. The two cost pools are mutually exclusive, i.e., no staff should be included in both pools. The following provides an overview of the eligible categories in each cost pool.

The MSBS program includes a number of direct medical services, also known as Direct Services that may include: physical, occupational, speech therapies, etc. These services are reimbursable by Medicaid if they are determined to be medically necessary in accordance with Medicaid policy, are part of the Medicaid-eligible recipient’s IEP or IFSP for the treatment of an identified medical condition, and are provided by a qualified professional. Staff that fall under this description and are involved in these types of activities are included in Cost Pool 1.

In addition, school staff may be involved in administrative services in support of the Medicaid Program although they are not involved in the provision of direct services or direct-service providers. These activities may include, but are not limited to: Medicaid outreach; facilitating Medicaid eligibility determinations; translations related to Medicaid services; program planning, policy development, and interagency coordination related to medical services; medical/Medicaid-related training; referral, coordination, and monitoring of Medicaid services; and scheduling referrals for medical services. Staff that fall under this description are considered “non-Direct Service” providers and are included in Cost Pool 2.

3. Sample Universe

A basic step in the development of an approvable time-study is the determination of the sample universe. That is, school district staff/person(s) who will participate in (be sampled under) the time-study. All staff will be reported into one of two cost pools: “Cost Pool 1” or “Cost Pool 2”, and the following provides an overview of the eligible categories in each cost pool.

4. Cost Pool 1

Staff that participate in administrative activities and are eligible to submit claims for the Direct Service (DS) Program are included in Cost Pool 1. The RMTS Study will also be utilized to determine Direct Service cost reimbursement. Cost Pool 1 staff includes:

Occupational Therapist, Licensed Occupational Therapy Asst, Licensed Occupational Therapy Paraprofessional (Supervised) Physical Therapist, Licensed Physical Therapy Assistant, Licensed Physical Therapy Paraprofessional (Supervised) Physician Psychologist, Provisionally Licensed Psychologist, Licensed Independent Mental Health Practitioner, Licensed (LIMHP) Mental Health Practitioner, Licensed (LMHP) Mental Health Practitioner, Provisionally Licensed (PLMHP) Alcohol and Drug Counselor, Licensed (LADC) Alcohol and Drug Counselor, Provisionally Licensed Behavioral Analyst, Board Certified Behavioral Analyst Assistant, Board Certified Behavioral Technician, Registered Registered Nurse (RN), Licensed Practical Nurse (LPN), Licensed Health Technician (Supervised) Health Paraprofessional (Supervised) Audiologist, Licensed Speech Pathologist, Licensed Speech Pathologist, Medicaid Enrolled Speech Paraprofessional (Supervised) Personal Assistant Service Provider Optometrist, Licensed Ophthalmologist, Licensed

5. Cost Pool 2

Staff included in Cost Pool 2 are non-Direct Service personnel that are involved in administrative activities. In addition to the categories listed below, if an LEA or ESU identifies a staff member who typically or potentially performs allowable Medicaid administrative functions: the district may seek permission from the DHHS Program Manager to include those additional staff members.

Aides Bilingual Specialist Counselor Diagnostician Interpreter Orientation and Mobility Specialist Principal/Asst Principal Program Specialist Special Education Administrator/Asst Special Education Teacher Student Services Personnel Social Worker, Bachelors Level (BSW) Social Worker, Masters Level (MSW)

Medicaid administrative activities may be performed by school employees who also provide direct medical services (e.g., nurses, physical therapists, educational staff such as the Director of Exceptional Student Education and teachers’ aides). However, if the costs of such staff are completely offset, there would be no purpose to include them in the sample universe. That is, only staff for whom some costs remain after any applicable offsets should be included in the time-study. For example, if federal funding sources or third party payors other than Medicaid meet 100 percent of the costs of social workers, there would be no reason to include such workers in the time-study and they must be excluded from participation. Furthermore, due to the offset, costs of such staff would also not be included in the costs to be allocated.

It may also be appropriate to exclude certain other workers from the study. For example, medical staff hired by the schools as contractors and reimbursed on a fixed fee basis such as audiologists paid a set amount for each hearing test performed and others who do not perform any other administrative activities should not be included in the time-study. Such workers should not be included in the sample universe and therefore their costs would be excluded from the base to be allocated.

Allocation of certain costs required to be funded by sources other than the Medicaid program may need to be offset from Medicaid costs or may be precluded from allocation to the Medicaid program. However, school staff whose salary costs are not entirely met by one or more federal grant(s) may be eligible to be included in the sample. Thus, if funds from an educational grant pay only a percentage of the individual’s costs, that person can be sampled as long as the costs are offset by the funds from the educational grant. Also, any matching funds required by the educational grant should be excluded. In addition, staff members such as physical therapy aides may need to be included in the sample universe and not simply allocated based on the activities of associated professionals (e.g., physical therapists).

If a time-study participant’s salary is funded by local public school dollars, staff can be included in the sample universe. If third party funds only partially cover the salary, staff can be included in the time-study but such amounts need to be applied in offsetting the claims made under the Medicaid program. The determination of which employees should be included in the sample universe and which costs of such employees should be included in the cost-pool and the conditions associated with the funding source must all be considered in determining the universe of participants for the time-study.

A list of the job titles of school staff who participate in Medicaid administrative activities and therefore would be included in the sample universe should be maintained.

6. Sampling

Once compiled statewide, each cost pool is sampled to identify participants in the RMTS time study. The sample is selected from each statewide cost pool, along with the total number of eligible time study moments for the quarter. Using a statistically valid random sampling technique, the desired number of random moments is selected from the total pool of moments. Next, each randomly selected moment is matched up using a statistically valid random sampling technique, with an individual from the total pool of participants.

Each time the selection of a moment and the selection of a name occurs, both the minute and the name are returned to the overall sample pool to be available for selection again. In other words, the random selection process is done with replacement so that each moment and each person are available to be selected each time a selection occurs. This step guarantees the randomness of the selection process.

Each selected moment is defined as a specific one-minute unit of a specific day from the total pool of time study moments and is assigned to a specific time study participant. Each moment selected from the pool is included in the time study and coded according to the documentation submitted by the employee.

7. Process for Participating in the RMS Time Study

The RMS time study model is used to measure the percentage of time school district staff spends in performance of Medicaid administrative and direct service activities by sampling and assessing the activities of a randomly selected cross-section of individuals included in Cost Pool 1 and Cost Pool 2. These individuals are queried at random over a billing quarter about their activities during a specified moment on a certain date. The results of these queries are then tallied and averaged for the quarter; these averages total the reimbursable amount that each school district is eligible to receive for that quarter. The sampling period is defined as the same three-month period comprising each quarter of the federal calendar.

To participate in the state-administered RMS, the steps outlined below are followed:

1. Identify total pool of time study participants
2. Identify total pool of time study moments
3. Randomly select moments and then randomly match each moment to a participant
4. Notify selected participants about their selection
5. Complete time study coding

8. Identify Total Pool of Time Study Participants

Prior to the beginning of each quarter, participating LEAs and ESUs submit a staff roster (Participant List) providing a comprehensive list of staff eligible to participate in the RMS time study.

This list may include vacant positions that are planned to be filled during the reporting quarter. If a vacant position is filled during the quarter, the individual will complete the time study (if sampled), and actual costs incurred for the position during the quarter are eligible to be reported. If a vacant position is not filled during the quarter, then any sampled time study moments are coded to Code 11 “Not Worked/Not Paid” and no costs are eligible to be reported. If a position becomes vacated during the quarter and is later filled with a direct replacement, the direct replacement will complete the time study (if sampled), and the proportional costs incurred for both the original participant and direct replacement are eligible to be reported. If the vacated position is not filled during the quarter, then any sampled time study moments are coded to Code 11 “Not Worked/Not Paid” and only those proportional costs eligible during the period staff received compensation can be reported.

The list of names is subsequently grouped into job categories (that describe their job function), and from that list all job categories are assigned into one of two “cost pools” as previously defined. Once the roster of eligible staff is submitted it cannot be updated or changed once the RMTS period begins.

9. Identify Total Pool of Time Study Moments

The sampling period is defined as the three-month period comprising each quarter of the state Fiscal Year calendar. The following are the quarters followed for the Administrative Claiming program and a time study is performed for each of the quarters, except for the June 1 - August 31 quarter (summer quarter):

• September 1 – November 31 • December 1 – February 28 • March 1 – May 31 • June 1 – August 31

The total pool of “moments” within the time study is represented by calculating the number of working days in the sample period, times the number of work hours of each day, times the number of minutes per hour, and times the number of participants within the time study. The total pool of moments for the quarter is reduced by the exclusion of weekends, holidays and hours during which employees are not scheduled to work. Standard working hours are determined by DHHS, provided to the contractor, and consistently applied across the LEAs and ESUs.

10. Randomly Select Moments and Randomly Match Each Moment to a Participant

Once compiled statewide, each cost pool is sampled to identify participants in the RMTS time study. The sample is selected from each statewide cost pool, along with the total number of eligible time study moments for the quarter. Using a statistically valid random sampling technique, the desired number of random moments is selected from the total pool of moments. Next, each randomly selected moment is matched up using a statistically valid random sampling technique, with an individual from the total pool of participants.

Each time the selection of a moment and the selection of a name occurs, both the minute and the name are returned to the overall sample pool to be available for selection again. In other words, the random selection process is done with replacement so that each moment and each person are available to be selected each time a selection occurs. This step guarantees the randomness of the selection process.

Each selected moment is defined as a specific one-minute unit of a specific day from the total pool of time study moments and is assigned to a specific time study participant. Each moment selected from the pool is included in the time study and coded according to the documentation submitted by the employee.

11. Sampling Requirements

In order to achieve statistical validity, maintain program efficiencies and reduce unnecessary district administrative burden an efficient sampling methodology will be used.

CMS policy permits a 5% precision level for random moment time study results that are used to claim MAC expenditures, as stated in the CMS May 2003 Medicaid School-Based Administrative Claiming Guide. However, CMS policy requires a higher 2% precision level for medical assistance (MAP) expenditures claimed under the cost based reporting methodology for its Direct Service Program. As a result, the following sampling methodology is defined for each Cost Pool.

12. Sampling Methodology - Cost Pool 1 (Direct Service & Administrative Providers)

Statistical calculations show that a minimum sample of 2401 completed moments each quarter, per cost pool, is adequate to obtain this precision when the total pool of moments is greater than 3,839,197. Additional moments are selected each quarter to account for any invalid moments. Invalid moments are moments not returned or inaccurately coded.

The following formula is used to calculate the number of moments sampled for each time study cost pool:

The following table shows the sample sizes necessary to assure statistical validity at a 95% confidence level and tolerable error level of 2%. Additional moments will be selected to account for unusable moments, as previously defined. An over sample of 15% will be used to account for unusable moments.

| N= | Sample Size Required | Sample Size plus 15% Oversample | | --- | --- | --- | | 100,000 | 2345 | 2697 | | 200,000 | 2373 | 2729 | | 300,000 | 2382 | 2739 | | 400,000 | 2387 | 2743 | | 500,000 | 2390 | 2745 | | 750,000 | 2393 | 2752 | | 1,000,000 | 2395 | 2754 | | 3,000,000 | 2399 | 2759 | | >3,839,197 | 2401 | 2761 |

13. Sampling Methodology - Cost Pool 2 (Administrative Services Providers Only)

CMS policy permits a 5% precision level for random moment time study results that are used to claim MAC expenditures, as stated in the CMS May 2003 Medicaid School-Based Administrative Claiming Guide. The RMTS sampling methodology for Cost Pool 2 must meet federal reporting and documentation requirements, and is designed to permit a level of precision of +/- 5% (five percent) with a 95% (ninety-five percent) confidence level for activities. Calculations show that a minimum sample of 385 completed moments each quarter is adequate to obtain this precision when the total pool of moments is greater than 222,639. Additional moments of a 15% oversample should be selected each quarter to account for any lost moments (observations that cannot be used for analysis, i.e., incomplete moments or moments selected for staff no longer at the district, etc.).

Moments not returned by the school district will not be included in the database unless the return rate for valid moments is less than 85%. If the statewide return rate of valid moments is less than 85%, all non-returned moments will be included and coded as non-Medicaid. To assure that districts are properly returning sample moments, districts’ return percentages for each quarter will be analyzed. If an individual district has non-returns greater than 15% and greater than five (5) sampled moments for a quarter, HHS may take appropriate action using sanctions, which may include but not be limited to conducting more frequent monitoring reviews, eliminating the school district’s claimed portion of federal funds, or ultimately, termination of the school district’s participation.

Nebraska requires a state-wide response for the time-study survey of at least 85%. Moments that have been inaccurately coded shall be returned to the district/ESU for correction and every effort shall be made to obtain the corrected valid moment from the district/ESU. Moments not returned or not accurately completed and subsequently resubmitted shall not be included in the data base. If the return rate of valid moments is less than 85%, non-returned moments shall be included and coded as non-allowable until an 85% compliance rate is obtained. To ensure that enough moments are received to have a statistically valid sample, a minimum of 15% over-sampling should be used. Districts/ESU must submit completed moments within five (5) working days after the sampled moment. To assure that districts/ESU’s are properly returning sample moments, return percentages for each quarter shall be analyzed (See Item 7 below for further Validation requirements).

The State shall be notified of any district/ESU that has non-returns greater than 15% and more than five (5) moments for a quarter. The State in turn will issue a warning in writing to the district/ESU requesting that a corrective action plan be submitted to the State within thirty (30) days of the warning letter. The plan should detail the district/ESU’s methodology for increasing its response rate. If the district/ESU has a non-response rate greater than 15% for two (2) successive time-study periods, it will not be able to participate for the entire fiscal year (Sep-Aug) and must return any payment made for the defaulted fiscal year.

14. Treatment of Summer Period

The summer period is distinguished from the regular school year and refers to the period between the end of one regular school year and the beginning of the next regular school year. In general, a time-study is developed and conducted with respect to a particular period and must represent and incorporate the actual activities performed during that period. The time- study mechanism and the associated application are then used to allocate the costs associated with the activities performed during the period.

Costs incurred during a summer period may relate to costs and activities associated with the regular school year and therefore, sometimes special treatment is necessary. The summer (break) period refers to the period between the end of one regular school year and the beginning of the next regular school year. Often, in the school setting, costs related to the regular school year are connected to the summer period. That is, salaries/benefits may continue to be paid to time-study participants during the months of the summer period even though the costs of these continuing salary payments during the summer represent and reflect activities actually performed during the regular school year.

The time-study methodology for addressing the summer period must reflect the practices of the applicable claiming unit related to the summer period. The treatment of continued salary and related costs that are actually paid during the summer but which reflect and represent activities actually performed during the regular school year must be distinguished from the treatment of salary and related costs that are paid during the summer and reflect activities actually performed during the summer. For example, a time-study performed during the summer period would not be appropriate to use for purposes of allocating those salary costs paid during the summer period if such costs represent activities actually performed during the regular school year. In that regard, time-studies performed during the regular school year would represent and be appropriate for allocating the costs of the continued salary payment from the regular school year that are paid during the summer.

As indicated, results of time-studies performed during the regular school year would be applied to allocate the associated salary costs paid during the summer. In general, this is acceptable if administrative activities are not actually performed during the summer break but salaries reflecting activities performed during the regular school year are prorated over the year and paid during the summer break. However, if activities are actually performed during the summer period, application of the results of time-studies from the regular school year would not accurately reflect the costs associated with the summer period activities. In those cases, time-studies would also need to be conducted with respect to summer periods.

In Nebraska, school staff members are often paid for a nine-month school year but their salaries paid over 12 months. Sampling during the 9 months, therefore, identifies activity related to salaries better than a sample over the 12-month period. In lieu of using the standard time-study concept during the fourth (summer – June, July, August) quarter, school districts may use an average of the time-study results from the preceding three (3) quarters. The fourth quarter encompasses the summer months when a systematic sampling would find few school staff at work. This sampling average will be applied to the fourth fiscal quarter’s financial information to formulate the claim.

15. Time-Study Documentation

As with all administrative costs that are related to time-study activities, there must be documentation of the costs for which FFP will be claimed under Medicaid. Documentation to be retained must support and include the following: sample universe determination, sample selection, sample results, sampling forms, cost data for each school district and summary sheets showing how each school district’s claim was compiled. All claims by the LEA’s and schools are summarized and submitted to DHHS for payment. The individual sample sheets may or may not be kept locally. Sometimes individual sheets are maintained locally while summary records are maintained at a central location.

[Nebraska] DHHS allows operational flexibility for validating the results of time-studies related to administrative activities. For example, administrative claims could be compared to parallel claims for direct services under Medicaid. However, regardless of the validation mechanism that is employed, appropriate documentation supporting claims must be maintained and available for audit purposes. DHHS and CMS work together to develop an acceptable validation mechanism.

16. Training for Staffing Time-study

All staff in the sample universe should be adequately trained before completing a sampled moment. Periodic staff education is essential for proper administration of the Medicaid EPSDT and NEBMAC programs. All district staff should become aware of the EPSDT program and its health benefits to eligible students through district-wide in-service awareness programs.

Without proper NEBMAC program training, data collected and used to generate billable charges will have little, if any, validity or reliability. Absent such, districts could not substantiate their charges and some or all funds paid would likely be disallowed and recouped. The procedures recommended herein and those which are to be included in the methodology are intended to assure the development of a complete, valid and reliable record of employee time and effort regarding program billings.

The objective of training staff for participation in the RMTS is to teach the:

1. Goals and overview of the NEBMAC program;
2. Instructions regarding the accurate completion of the RMTS time survey; and Importance of the accuracy of the participants’ documentation to the district’s overall effort.

It is important that the cost-pool staff realize what NEBMAC, outreach to children and wellness education means to them. Training should prepare the sampled participant to understand the purpose of the time-study and to be able to accurately document their activity during their sampled moment. Staff should know the difference between health related and other activities. Professional staff must understand the distinctions between the performance of administrative activities and direct medical services.

Time study participants are notified via email to participate in the time study and of their sampled moment. Sampled participants will be notified of their sampled moment no earlier than forty-eight (48) hours prior to their sampled moment. At the prescribed moment, each sampled participant is asked to record and submit his/her activity for that particular moment. The sampled moment has a three (3) day response window. After the three (3) day response time has expired, the participant’s login will not work and they will no longer be able to respond to the time study.

All staff training materials used by school districts must be approved by [Nebraska] DHHS prior to use for compliance with State methodology. Failure to do so may invalidate claims. Notification of training sessions must be made by the school district or consultant to DHHS in advance of training so that Agency staff may observe.

17. Monitoring Process

Each school district or its contractor/consultant must maintain separate audit files for each quarter billed. The following documentation is required:

• Completed RMTS surveys; • A copy of the summary of time-study compliance; • School location and costs paid for each group member in the cost-pool master list, employees and contracted personnel; • Upon request of the auditor, contracts of contracted employees; • Any computations or allocations used in reimbursement calculations and written explanations; • A detailed listing of all revenues offset by the claim by source; • Copies of training materials given to staff; • Names of attendees and instructors for the training session given for that quarter; • A completed quarterly claim; and • Organizational charts, job descriptions or other documents establishing supervisory relationships must be available for audit.

The above listed audit files should be retained by each school district for a period of five (5) years after the quarterly claim is filed with DHHS unless an ongoing audit or resolution of an audit exception in process. This data is essential to conducting periodic audits of billings. Lack of such documentation may lead to the disallowance of costs by DHHS and the school district or ESU could be forced to repay such costs.

18. Validation Process

In order to ensure that the time-study results are valid, the sampling methodology must be monitored for each participating school district and ESU. Yearly, sampling of claims of participating entities should be selected for review to verify time-study activities, statistics and claiming activities. Such reviews will include examination of calculations of time-study documents, processes and claim documents, and should involve 10% of the time study sample. DHHS employees or its agent may conduct these reviews. School districts will be notified in advance of any planned site visits in connection with reviews.

For each claim submitted for payment, DHHS also validates the claim calculations and the application of Medicaid Eligibility and indirect cost rates.

C. Offset of Revenues

Certain revenues must offset allocation costs in order to reduce the total amount of costs in which the federal government will participate. To the extent the funding sources have paid or would pay for the costs at issue, federal Medicaid funding is not available and the costs must be removed from total costs (See OMB 2 CFR Part 225, Attachment A, Part C., Item 4.a.). The following include some of the revenue-offset categories which must be applied in developing the net costs:

• All federal funds: • All state expenditures which have been previously matched by the federal government including but not limited to Medicaid funds for medical assistance such as the payment rate for services under fee-for-service; • Insurance and other fees collected from non-governmental sources must be offset against claims for Medicaid funds; • All applicable credits must be offset against claims for Medicaid funds. Applicable credits refer to those receipts or reduction of expenditure type transactions that offset or reduce expense items allocable to federal awards as direct or indirect costs; • A program may not claim any federal match for administrative activities if its total cost has already been paid by the revenue sources above. A government program may not be reimbursed in excess of its actual costs, i.e., make a profit. • The administrative costs incurred by DHHS to administer the School Based Admin program are: salaries, benefits, operating costs, and allocated costs (per the Nebraska Cost Allocation Plan). These costs are reported on the CMS-64.10 Base Line 29. • DHHS will refund 50% of that fee to CMS and will be reported on form CMS 64-10 Base, Line 19. • DHHS will subtract the amount received for the 3% fee from the total paid to the schools as a cost allocation adjustment and report the net amount CMS 64.10 Base form, Line 19. This will occur each quarter as part of the normal cost allocation adjustment process prior to running the final cost allocation module (distribution) in Enterprise One (NIS).

D. Cost Allocation Plans

Requirements for the development, documentation, submission, negotiation and approval of public assistance cost allocation plans are set forth in Subpart E of 45 CFR Part 95 and ASMB C-10. All administrative costs (direct and indirect) are normally charged to federal awards by implementing the public assistance cost allocation plan (CAP). OMB 2 CFR Part 225, Cost Principles for State, Local and Indian Tribal Governments - Attachment D - extends these requirements to all federal agencies whose programs, including Medicaid, are administered by a state public assistance agency. 2CFR Part 225 policy is that state public assistance agencies will develop, document and implement and the federal government will review, negotiate and approve public assistance CAP’s.

In accordance with the federal regulations indicated above and 2 CFR Part 225, a public assistance CAP must be amended and approved by the Division of Cost Allocation (DCA) within DHHS before FFP is available for administrative claims in the Medicaid program. In this regard, public assistance CAP’s must provide, in accordance with the approved interagency agreements, for reimbursement of the administrative activities performed in the school setting and for which claims will be made by the LEA’s, school districts and schools to DHHS The public assistance CAP must make explicit reference to the methodologies, claiming mechanisms, interagency agreements and other relevant issues that will be used by the LEA’s, school districts and schools for making such claims and appropriately allocating costs. CMS does not have direct authority for approval of the public assistance CAP’s. That is the purview of the DCA. However, CMS works directly with the DCA in the public assistance CAP review and approval process. Under this process the DCA will not approve such public assistance CAP’s without CMS review and approval of the methodologies referenced in the public assistance CAP. Therefore, referenced elements must be reviewed and approved by CMS before implementation of the school-based administrative claiming program and before the claiming of FFP.

See also Section IV.B Principle 11 titled “Review and Approval of Program and Codes by CMS.”

The school-based administrative claiming program must be supported by a system that has the capability to isolate the costs directly related to the support of the Medicaid program from all other costs incurred by the school and that will ultimately be claimed by DHHS as administration. Such costs must comply with the cost allocation principles described in 2 CFR Part 225 which requires that costs be “necessary and reasonable” and “allocable” to the Medicaid program. Claims for the school district’s indirect costs are only allowable when the entity has an approved indirect cost rate issued by the cognizant agency and costs are claimed in accordance with the rate

E. Administrative Claiming Implementation Plan

The implementation plan includes the following elements:

• Treatment of Indirect Costs : Indirect costs may be claimed at the restricted or non-restricted indirect cost rate approved by the cognizant agency responsible for approving such rates. With respect to school-based administrative costs, “cognizant agency” is the U.S. Department of Education or its delegate. In Nebraska, the cognizant agency is the Nebraska Department of Education. NDE’s School Finance and Organizational Services section annually calculates indirect cost rates for each local education agency (districts and Educational Service Units), and submits the cost allocation plan to the U.S. Department of Education for approval. Once approved, restricted and unrestricted indirect cost rates are available at http://www.education.ne.gov/fos/ASPX/IndirectCost/Default.aspx. The school district must certify that costs claimed as direct costs do not duplicate those costs reimbursed through application of the indirect cost rate.

• Certified Public Expenditures : Administrative payments for school-based services will be made utilizing certified public expenditures (CPE) to satisfy the state match requirements under Medicaid. There are sufficient local funds to match Title XIX expenditures and the funds are not already being used to match federal funds of other federal programs or being reimbursed by other federal grants.

• Description of Current Administrative Activities Paid by Medicaid : Administrative case management will usually not include the full development, implementation and monitoring of a care or treatment plan for individual students. Other contractors/providers of DHHS, including managed care plans, managed care organizations and public health nurses are responsible for the primary care planning and management in some areas of the state. School districts will be made aware of the existence of such contractors/providers in their areas and are expected to coordinate with them.

• Time-study Plan : The implementation plan includes details regarding the sampling methodology for selecting time-study participants including the types of job classifications eligible to be sampled, selection of time-study moments and provisions for applying a 95 percent or higher confidence level or some other statistically valid measure to the time-study.

F. Timely Filing Requirements :

Medicaid law requires that DHHS file a claim for FFP within a two-year period that begins on the first day of the calendar quarter immediately following the quarter in which the expenditure was made by the school district or ESU. Federal regulations indicate that a state agency's expenditure for administration is considered to have been made in the quarter the payment was actually made by DHHS. Therefore, we ask that school districts and ESU’s file their claims within fifteen (15) months of the end of the quarter activities are/were provided.

G. State Law Requirements

The OMB 2 CFR Part 200 - Super Circular states: “To be allowable under federal grants, costs must meet the following criteria . . . . be authorized or not prohibited under state or local laws and regulations.” Thus, FFP for school-based services and administrative outreach claims are not available if school districts and ESU’s are not in compliance with state statutes. If there is a question of whether the school district or ESU is in violation of state law, a legal opinion should be sought.

H. Provider Agreements

In order for a school or an ESU to participate as a provider of services and receive FFP through the Medicaid program for those services, it must have an intergovernmental agreement with the state. The basis and authority for this requirement can be found at Sections 1902(a)(4), 1902(a)(27), 1902(a)(57) and 1902(58) of the Act and implementing regulations at 42 CFR 431.107. Schools do not need to be Medicaid providers in order to participate in Medicaid administrative claiming but there are some administrative activities that schools will not be eligible to receive FFP for unless they have a provider agreement. For example, a school or claiming unit that has an agreement with DHHS to claim administrative costs can provide and receive FFP for, Medicaid outreach activities regardless of whether the school participates as a provider in the Medicaid program. However, if the school does not participate as a provider in the Medicaid program, it cannot bill Medicaid for the cost of direct medical services provided by school staff (e.g., physical therapists). Furthermore, since the Medicaid program would not reimburse for any of the services provided by the school due to its lack of a provider agreement, costs of administrative activities in support of those services such as referrals by the school would not be reimbursable under Medicaid as administration.

I. Transportation as Administration

School-based administration claimed in Nebraska does not include actual transportation costs.

APPENDIX A – General Federal Overview of the Medicaid and IDEA Programs and the Applicability of School-based Administrative Claiming to these Programs

A number of federal, state and local programs operate in the school setting, only some of which may focus on traditional education goals. Interaction and overlap among these programs often provide numerous benefits to children, although sometimes with an additional burden in administrative complexity on the part of program administrators. The following section contains a brief overview of the Medicaid program as it operates in the school environment and the Individuals with Disabilities Education Act (IDEA). These two (2) federal programs, Medicaid and IDEA, with distinct and separate statutory authorities, are closely linked in the school setting even though their underlying purposes and perspectives differ. In order to understand the procedures for claiming school-based administrative expenditures under Medicaid, it is important to consider both Medicaid and Education perspectives.

A. Medicaid

1. Medicaid’s Role In School-Based Health Services Programs

Schools have been at the forefront in developing and implementing programs to increase access to medical services for children. CMS has long recognized that school-based health services play an important role in ensuring that children and adolescents receive needed health care in a setting that is appropriate while ensuring that there is minimum disruption in the educational process.

In 1988, Medicaid's role in supporting school-based health care was greatly expanded by the enactment of the MCCA, P.L. 100-360. It clarified in Medicaid statute that the Medicaid program is primary to the IDEA program in paying for the costs of direct medical services provided to Medicaid-eligible children with special health care needs identified pursuant to IDEA. Each child eligible under IDEA must have an IEP or IFSP which includes a statement of the special education and related services to be provided to or on behalf of the child. These services include needed school-based services that are considered medical services by Medicaid that may be covered under the Medicaid program.

Many school-based health programs deliver a broad range of services that are covered by Medicaid affording access to care for children who might otherwise go without needed services. For Medicaid to cover school-based services they must be primarily medical and not educational in nature. The services must be provided by a qualified Medicaid provider to children in families that meet Medicaid income eligibility requirements and they must be considered medically necessary for the child. The services may include:

• routine and preventive screenings and examinations; • diagnosis and treatment of acute, uncomplicated problems; • monitoring and treatment of chronic medical conditions; and • provision of medical services to children with disabilities under IDEA.

Administrative activities in support of services that are not included in an IEP or IFSP and that are provided to Medicaid children in schools are usually not Medicaid coverable because most of these services are generally provided free of charge to non-Medicaid children. Such services include primary and preventive services provided by nurses or other qualified professionals in the school setting such as dispensing medication, attending to acute non-emergent problems (sore throat, earache, etc.), well-child examinations and vision and hearing screenings. (Free-Care and TPL are addressed in Section IV.B Principle 12. and Section V.J of the Guide.)

2. Early and Periodic Screening, Diagnosis and Treatment (EPSDT)

The Early and Periodic Screening, Diagnosis and Treatment (EPSDT) program is Medicaid’s comprehensive and preventive children’s health program that emphasizes the early assessment of children’s health care needs through periodic examinations. EPSDT is a unique benefit in Medicaid because the scope of required services can be broader than what is otherwise included under a state’s general Medicaid state plan. EPSDT is a required state plan service that by statute includes any necessary coverable services under Section 1905(a) of the Social Security ct (the Act) (42 U.S.C. 1396d) whether or not those services are covered under the state plan. While the EPSDT program may be known by other, more descriptive names in different states (i.e., Well Child Care, Health Check, KIDMED), basic elements are similar in order to meet federal requirements. Still, states have considerable discretion in administering their EPSDT programs as long as they comply with federal requirements. In many states schools play a large role in many EPSDT activities, particularly with respect to outreach, screening, diagnosis and treatment. In Nebraska, EPSDT services are referred to as “Health Check.”

a. EPSDT Screening

Schools often deliver screening services that comport with EPSDT requirements. Screenings include: a comprehensive health and developmental history, a comprehensive unclothed physical exam, appropriate immunizations and laboratory tests. Health education and anticipatory guidance are also an integral part of an initial or periodic screen.

b. EPSDT Treatment

The EPSDT program requires a state Medicaid agency to cover necessary health care, diagnostic services and treatment that is within the federal Medicaid framework to “correct and ameliorate” defects and physical and mental illnesses and conditions discovered by screening, whether or not those services are otherwise available under the state plan to individuals, age 21 and older. While EPSDT has tremendous potential for increasing health care services provided to the eligible population, certain restrictions apply. In order for Medicaid to pay for a medical service provided to a child or adolescent, any service must meet a number of federal coverage requirements. The services must be described under a service category referenced in Section 1905(a) of the Act (42 U.S.C. 1396d), it must be medically necessary and it must be provided by a qualified Medicaid provider. In the school, just as in any other setting, federal policies on FFP in the Medicaid program must be followed with respect to the 1988 legislation which revised Section 1903(c) of the Act (42 U.S.C. 1396b(c)) regarding IDEA, free-care exclusion rule and third party liability.

(Free-Care and third party liability are addressed in Section IV.B Principle 12 and Section V.J of the Guide.)

c. EPSDT Administrative Claiming

The EPSDT administrative requirements found in Section 1902(a)(43) of the Act (42 U.S.C. 1396a(a)(43)) are part of the legal basis and authority for obtaining FFP for administrative costs associated with health care provided in or by schools. The following administrative activities are a required part of any state’s EPSDT program:

• informing Medicaid eligible individuals about the availability of EPSDT services; • providing or arranging for the provision of EPSDT screening services; • arranging for (directly or through referral to appropriate providers or agencies) needed corrective and ameliorative treatment; • assisting families identifying and choosing Medicaid providers; and • conducting follow-up to ensure children receive needed diagnosis and treatment.

The EPSDT requirement to inform children and families of the availability of EPSDT services is done at the time of enrollment and periodically thereafter as necessary.

3. Children’s Health Insurance Program (CHIP)

The State Children's Health Insurance Program (CHIP) specified under Title XXI of the Act enables states to provide health insurance to children in families with incomes too high to qualify for the Medicaid program but too low to afford private health insurance. CHIP coverage is provided by states through separate Title XXI state child health programs, Title XXI Medicaid expansions or a combination of both. Nebraska’s CHIP program is a Medicaid expansion. All states have approved CHIP plans and receive enhanced federal matching payments for CHIP expenditures up to a fixed state CHIP allotment that varies on a federal fiscal year basis. States may spend up to 10 percent of their total annual CHIP expenditures (federal and state) on non-benefit activities including: outreach conducted to identify and enroll children in CHIP; administration costs; health services initiatives and other child health assistance.

Outreach activities related to a state’s separate Title XXI CHIP program are funded under the state's available Title XXI CHIP allotments. However, outreach activities provided with respect to a CHIP-related Medicaid expansion are funded at the state's option either from the state's CHIP allotment or from regular Medicaid funding. Joint outreach efforts for Medicaid and CHIP may similarly be matched by either Medicaid or CHIP. Under the provisions of OMB 2 CFR Part 225 and associated regulations, costs that are common to more than one (1) program are generally allocated to the related programs in accordance with the relative benefits received by each program. However, CHIP statute(s) provide for an exception to this general cost allocation principle, allowing states some flexibility in claiming FFP for outreach activities. Detailed guidance on these state options is available on the CMS CHIP web site:

http://www.insurekidsnow.gov/index.html

Nebraska’s outreach efforts are not administered through CHIP (Title XXI) but instead funded by its Title XIX (NMAP/Medicaid) program.

B. Individuals with Disabilities Education Act (IDEA)

1. Purpose of IDEA

The Individuals with Disabilities Education Improvement Act (IDEA) of 2004 (P.L. 108-446/20 USC 1400) is the most recent version of this important federal special education law. IDEA was passed to “assure that all children with disabilities have available to them… a free appropriate public education which emphasizes special education and related services designed to meet their individual needs.” Specific principles in IDEA include:

• Free Appropriate Public Education (FAPE); • Appropriate evaluation; • Individualized Family Service Plan (IFSP) for infants and toddlers (B-2); • Individual Education Program (IEP) for students with verified disabilities (3-21); • Least restrictive environment; • Parent and student participation in decision-making; and • Procedural safeguards.

In the context of IDEA, “Free Appropriate Public Education” means that special education and related services that meet the standards of the state education agency are provided to children with disabilities at public expense under public supervision and direction and without charge. The public school system must serve disabled children by responding to their individual needs, regardless of the nature or severity of their disabilities.

• “Special education” is defined at 34 Code of Federal Regulations (CFR) 300.26 to mean specially designed instruction which meets the unique needs of the child and includes instruction conducted in the classroom, in the home, in hospitals, in institutions, in other settings and instruction in physical education.

• “Related services” are defined at 34 CFR 300.34 as “transportation and such developmental, corrective and other supportive services as are required to assist a child with a disability to benefit from special education.” “Related Services include:

i. Counseling services; ii. Early identification and assessment of disabilities; iii. Interpreting services; iv. Medical services for diagnostic and evaluation purposes; v. Occupational therapy; vi. Orientation and mobility services; vii. Parent counseling and training; viii. Physical therapy; ix. Psychological services; x. Recreation; xi. Rehabilitation counseling services; xii. School health services; xiii. School nurse services; xiv. Social work services in schools; and xv. Speech-language pathology and audiology services.

Not all of the special education and related services required by the IDEA are within the scope of the federal Medicaid program. Only medically necessary IDEA services that are described in the definition of “medical assistance” can be covered as Medicaid services when furnished by qualified participating Medicaid providers.

IDEA authorizes federal funding to states for related services provided to children through a child’s Individualized Family Service Plan (IFSP) or Individual Education Program (IEP) including those that are referred to and covered as medical services under Medicaid. Section 411(k) (13) of the Medicare Catastrophic Coverage Act of 1988, P.L. 100-360, amended Section 1903(c) of the Act to permit Medicaid payment for medical services provided to children under IDEA through a child’s IFSP or IEP. This amendment was enacted to require Medicaid to be primary to the Department of Education for payment of the health-related services provided under IDEA. Medicaid covers services included in an IFSP or IEP under the following conditions:

• The services are medically necessary and included in a Medicaid covered category (speech therapy, physical therapy, etc.); • All other federal and state Medicaid regulations are followed including those for provider qualifications, comparability of services and the amount, duration and scope provisions; and • The services are included in the state’s plan or available under EPSDT. Further discussion of school based medical services can be found in the guidance document, “Medicaid and School Health: A Technical Assistance Guide,” issued by CMS in August 1997.

2. ChildFind

Part B, Section 612 (a)(3) of IDEA provides for the identification, location and evaluation of children with disabilities within the state and mandates that a “practical” method be developed and implemented to determine which children with disabilities should be provided services. A state is only eligible for funding under IDEA if the state demonstrates that it meets certain conditions including conducting “ChildFind” activities, as defined in IDEA. These “ChildFind” activities are undertaken to identify children in need of special education and related services. Medicaid is not responsible for covering or paying for “ChildFind” or other activities that fulfill education mandates. While ChildFind activities are not claimable as Medicaid administration, there are related activities such as Medicaid outreach which are allowable.

Activities performed for purposes of the Medicaid program such as informing potential eligible children and their families about Medicaid, how to access the program and facilitating the Medicaid application process are included as Medicaid outreach. In contrast, ChildFind is specifically mandated in IDEA and includes activities carried out for educational purposes. Therefore, distinction is made between the educational activities such as ChildFind and Medicaid outreach for purposes of claiming in Medicaid. (See Section IV.B Principle 10 for further information on ChildFind.)

3. Evaluation and Assessment Activities

Part B, Section 614 of IDEA outlines the evaluation process for determining if a child has a disability as defined in Section 602 and determining the educational needs of the child. This section focuses on appropriate evaluation principles and provides protection from unnecessary, costly or inappropriate assessment activities. The evaluation and assessment are conducted to determine if the child has a disability and if the child’s particular disability affects the student’s educational performance; evaluation and assessment must provide relevant information that directly assists the school in determining the educational needs of the child. Re-evaluation must be accomplished at least every three (3) years for an IEP. These evaluations are conducted, in part, to determine a child’s health related needs for purposes of the IEP. (See Section IV.B Principle 10 for further information on IEP-related medical evaluations and assessments.)

4. Individual Education Program (IEP)

For those Nebraska children identified and determined to be disabled in accordance with Section 602 of IDEA, an IEP must be developed by a team of individuals as defined in Section 614. In the case of a child with a disability, age Birth through two (2) years, under certain conditions, an Individualized Family Service Plan (IFSP) may be developed to serve as an IEP. The IEP is statutorily defined as a written statement for each child with a disability that, among other elements, includes:

• A statement of the child’s present levels of educational performance; • A statement of measurable annual goals including benchmarks or short term objectives; • A statement of the special education and related services and supplementary aids and services to be provided to the child or on behalf of the child and a statement of the program modifications or supports for school personnel that will be provided for the child; • An explanation of the extent, if any, to which the child will not participate with non-disabled children in the regular class and in the activities described above; • A statement of any individual modifications in the administration of state or district-wide assessments of student achievement needed for the child to participate in the assessment; • The projected date for the beginning of services and modifications and the anticipated frequency, location and duration of services and modifications; • For children age 14 or younger, if appropriate, a statement of transition service needs; • For children beginning at age 16 or younger, if appropriate, a statement of needed transition services for the student; • A statement of the child’s progress toward annual goals and how the child’s parents will be informed of the progress toward the annual goals; and • Transfer of rights statement.

The phases of the IEP process are generally described as follows:

a. Pre-IEP

Pre-IEP activities include “ChildFind” activities designed to identify children in need of evaluation and assessment activities performed to determine if the child has a disability as defined by Section 602 of the IDEA and to determine the educational needs of the child. There are no claimable administrative expenditures under Medicaid associated with these pre-IEP activities. Medicaid does not pay for the IEP team meetings or for costs related to attendance at those meetings by medical professionals. However, if a state has opted to include targeted case management in its Medicaid plan as a service, Medicaid may be able to pay for the activities of the child’s case manager/services coordinator.

b. Development of IEP

The development of an IEP is a requirement of IDEA with the primary purpose being to facilitate the child’s education. Medicaid does not pay for the administrative activities associated with the development of the IEP because it is an education requirement. Once the IEP is established and implemented, however, Medicaid may pay for administrative activities that are directly related to the provision of those Medicaid covered services identified in the IEP and are furnished to Medicaid eligible children.

The IEP is developed by a team of individuals, including:

• The child’s parents; • At least one of the child’s regular education teachers and/or one special education teacher or provider; • A representative of the school district who is knowledgeable about specific curriculum; • An individual who can interpret the instructional implications of evaluation results; • Other individuals, at the discretion of the parents or the school district who have knowledge or special expertise regarding the child; and • The child with the disability, whenever appropriate.

IDEA further specifies that in the development of the IEP, strengths of the child, concerns of the parents for enhancing the education of their child and the results of the initial or most recent evaluation of the child are to be considered. Special factors, such as behavior issues, language limitations, accommodations for visual or hearing impairments and the need for assistive technology devices/services must also be considered in the development of the IEP.

c. Review/Revision of IEP

The school district is mandated to review the IEP periodically but not less than annually and if needed, to revise the program to address any lack of expected progress toward individually defined goals or to address the results of a re-evaluation of the child. The IEP can be revised at any time if the child is not making expected progress or if new factors arise.

These activities are for the purpose of fulfilling education-related mandates under IDEA. As such, associated costs of these activities are not allowable as administrative costs under the Medicaid program.

A more detailed discussion of IEP’s and the IDEA can be found in Section IV.

d. Individualized Family Service Plan (IFSP)

By Statute, Nebraska is a “birth mandate state.” This means that school districts are responsible for the “special education” services required to meet the unique developmental needs of the infant or toddler from the point in time when the child’s developmental

disability is verified through processes prescribed in IDEA and further defined by the Nebraska Department of Education’s “Regulations and Standards for Special Education Programs (Title 92 Nebraska Administrative Code Chapter 51).

For each infant and toddler (under 3 years of age) determined to be disabled in accordance with Section 602 of IDEA, an IFSP must be developed in accordance with Section 636 of the Act. The IFSP shall be in writing and contain:

• A statement of the child’s present levels of physical development, cognitive development and adaptive development, based on objective criteria; • A statement of the family’s resources, priorities and concerns relating to enhancing the development of the family’s infant or toddler with a disability; • A statement of measurable results or outcomes expected to be achieved for the infant or toddler and the family; • A statement of the specific early intervention services based on peer-reviewed research to the extent practicable and necessary to meet the unique needs of the infant or toddler and the family; • A statement of the natural environments in which early intervention (Early Development Network in Nebraska) services will appropriately be provided; • Projected dates for initiation of services and anticipated length, duration and frequency of services; • Identification of the services coordinator who will be responsible for the implementation of the plan and coordination of other agencies and persons including transition services; and • Steps to be taken to support the transition of the toddler with a disability to preschool or other appropriate services.

The phases of the IFSP process are generally described as follows:

e. Pre-IFSP

Pre-IFSP activities include “ChildFind” activities designed to identify infants and toddlers in need of evaluation and assessment activities performed to determine if the child has a disability as defined by Section 602 of the IDEA and to determine the developmental needs of the infant or toddler and their family. There are no claimable administrative expenditures under Medicaid associated with these pre-IFSP activities. Medicaid does not pay for the IFSP team meetings or for costs related to attendance at those meetings by medical professionals. However, if a state has opted to include targeted case management in its Medicaid plan as a service, Medicaid may be able to pay for the activities of the child’s case manager/services coordinator.

f. Development of IFSP

For states like Nebraska who choose to participate, development of an IFSP is a requirement of IDEA with the primary purpose being to facilitate the infant or toddler’s development, to minimize their potential for developmental delay and to recognize the significant brain development that occurs during a child’s first three (3) years of life. Medicaid does not pay for the administrative activities associated with the development of the IFSP because it is an education requirement. Once the IFSP is established and implemented, however, Medicaid may pay for administrative activities that are directly related to the provision of those Medicaid covered services identified in the IFSP and are furnished to Medicaid eligible children.

The IFSP is a written plan developed by a multidisciplinary team including the parents as required by Section 636 of IDEA.

IDEA further specifies that in the development of the IFSP, strengths of the child, concerns of the parents for enhancing the development of their infant or toddler and the results of the initial or most recent evaluation of the child are to be considered. Special factors, such as behavior issues, language limitations, accommodations for visual or hearing impairments and the need for assistive technology devices/services must also be considered in the development of the IFSP.

g. Review/Revision of IFSP

The IFSP is to be evaluated once a year and the family shall be provided a review of the plan at six (6) month intervals or more often where appropriate based on the infant or toddler and family need(s). The IFSP can be revised at any time if the child is not making expected progress or if new factors arise.

These activities are for the purpose of fulfilling mandates under IDEA. As such, associated costs of these activities are not allowable as administrative costs under the Medicaid program.

APPENDIX B - CLAIM PROCESS/PROCEDURES

A. General

Claim preparation requires that the proper training has occurred of sampled staff that random moment time study (RMTS) surveys were completed correctly and the resulting data was accumulated without error. Salary and benefit information for those staff must be correct. The percentage of Medicaid enrolled and potentially eligible students must be accurate.

Claims are prepared once per quarter for that full quarter and must be submitted to [Nebraska] DHHS within one year after the end of each quarter. Claim quarters are defined as follows:

First (Fall quarter): September 1 to November 30 Second (Winter quarter):December 1, to February 28/29 Third (Spring quarter):March 1, to May 31 Fourth (Summer quarter):June 1, to August 31

B. Data Elements

1. Time-study Average: Percentage derived by dividing the amount of time determined in the time-study by the total work time for personnel in the sample cost-pool.
2. Total Personnel Related Costs: Total salaries, benefits and other allowable costs incurred during the quarter for those personnel in the cost-pool.
3. The federally approved cost allocation plan used to determine the non-restricted indirect cost rate, by which salaries and benefits are multiplied. The product of this reflects the “overhead” administrative expenses required to support the related personnel. NDE is the cognizant agency for indirect cost rates for all public school districts and ESU’s in Nebraska.
4. The Medicaid Eligibility Rate [MER] calculated for the school district or ESU.

C. Claim Calculation

Claim calculations will be formatted based on a claim template provided by DHHS’ vendor for the school districts and ESU’s. Submittal of the invoice and related information must contain all information required by DHHS.

History

• Effective 2020-10-04

Chapter 26 Ambulatory Surgical Center (asc) Services

Neb. Admin. Code tit. 471, ch. 26 Ambulatory Surgical Center (asc) Services {#sec-471-nac-26 omnilex-key=us-ne-regs-official--title-471--471 NAC 26}

26-001 Standards for Participation : NMAP covers facility services provided by ambulatory surgical centers in connection with certain surgical procedures. To participate in the Nebraska Medical Assistance Program, an ambulatory surgical center must:

1. Be certified as meeting the requirements for an ASC under Medicare;

2. Have an agreement with CMS under Medicare to participate as an ASC; and

3. Have an agreement with the Nebraska Department of Health and Human Services to participate in NMAP. NMAP covers ASC facility services for only the surgical procedures defined in 471 NAC 26-004. The ASC must accept the Department's payment for the facility services as payment in full for those services defined as ASC facility services in 471 NAC 26-002.

26-001.01 Definition of an ASC: An ASC is a distinct entity that operates exclusively to provide outpatient surgical services to patients. An ASC may be either:

1. Independent (not part of a provider of services or any other facility); or

2. Operated by a hospital (under the common ownership, licensure, or control of a hospital).

26-001.01A ASC's Operated by Hospitals: If an ASC is operated by a hospital, it may be covered under Medicare as an independent ASC or as a hospital-affiliated ambulatory surgical center (HAASC). The Department enrolls ASC's to participate in NMAP as they are enrolled to participate in Medicare. To be covered as a Medicare-participating ASC operated by a hospital, a facility must:

1. Elect to do so, and continued to be covered as an ASC unless CMS determines there is good cause to do otherwise;

2. Be a separately identifiable entity, physically, administratively, and financially independent and distinct from other operations of the hospital; and

3. Meet all Medicare's requirements for independent ASC's.

Facilities operated by a hospital as Medicare-participating ASC's are paid according to 471 NAC 26-005. Other HAASC's are paid according to 471 NAC 10-010.06.

26-001.02 Provider Agreement: The provider must complete and sign Form MC-19, "Medical Assistance Provider Agreement," (see 471-000-90) and submit it to the Department to be approved for provider enrollment.

26-002 Covered ASC Procedures : NMAP covers ASC facility services performed in connection with procedures on the list of covered ASC procedures in 471-000-409, state defined ASC Services code(s). These procedures are organized in several groups that refer to the facility payment amount available for each group. The ASC receives the same payment for each procedure within a particular group.

The list of covered ASC procedures indicates which procedures may be covered if performed in an ASC; NMAP does not require that these procedures must be performed in an ASC. The general rules regarding the medical necessity of a specific procedure for a specific client apply to ASC services as they do to all other services covered by NMAP.

26-003 Covered ASC Facility Services : ASC facility services are items and services provided by an ASC in connection with a covered surgical procedure defined in 471 NAC 26-002. These items and services are those that would otherwise be covered by NMAP if provided on a inpatient or outpatient basis in a hospital in connection with that surgical procedure.

The fee for ASC facility services includes payment for:

1. Nursing, technician, and related services;

2. Use of ASC facilities;

3. Drugs, biologicals, surgical dressings, splints, casts, and appliances and equipment directly related to the provision of a surgical procedure;

4. Diagnostic or therapeutic services or items directly related to the provision of a surgical procedure;

5. Administrative, record keeping, and housekeeping items and services;

6. Blood, blood plasma, platelets, etc.; and

7. Materials for anesthesia.

The fee for ASC facility services does not include payment for medical and other health services, such as physicians' services and prosthetic devices for which payment may be made under other NMAP payment plans, except for intraocular lenses. See 471 NAC 26-004, ASC Services Not Included in the ASC Facility Services Fee.

26-003.01 Nursing, Technician, and Related Services: The fee for ASC facility services includes payment for all services provided by nurses and technical personnel who are employees of the ASC in connection with covered procedures. In addition to nursing staff, this includes orderlies, technical personnel, and others involved in patient care.

26-003.02 Use of ASC Facilities: The fee for ASC facility services includes payment for operating and recovery rooms, patient preoperation areas, waiting rooms, and other areas used by the patient or offered for use by the patient's relatives in connection with covered procedures.

26-003.03 Drugs, Biologicals, Surgical Dressings, Supplies, Splints, Casts, Appliances, and Equipment: The fee for ASC facility services includes payment for all supplies and equipment commonly provided by the ASC in connection with covered procedures. Coverage of drugs and biologicals is limited to those which cannot be self-administered.

The following supplies and dressings are included in the ASC facility services fee:

1. Primary surgical dressings that are usually applied first by a physician in the ASC setting. These surgical dressings are therapeutic and protective coverings applied to lesions on the skin or openings to the skin required as a result of surgical procedures; and

2. Splints, casts, and other supplies, such as supplies required for the patient and ASC staff, that is, gowns, masks, drapes, hoses, scalpels, etc., whether disposable or reusable.

26-003.04 Diagnostic or Therapeutic Services and Items: The fee for ASC facility services includes payment for items and services provided by ASC staff in connection with covered procedures. With respect to diagnostic tests, many ASC's perform simple tests just before surgery, primarily urinalysis and blood hemoglobin or hemotocrit, which are generally included in their facility charges. To the extent that these simple tests are included in the ASC's facility charges, they are considered facility services. Under NMAP, diagnostic tests are not covered in laboratories independent of a physician's office, rural health clinic, or hospital unless the laboratory meets Medicare's requirements for independent laboratories; therefore, diagnostic tests performed by the ASC other than those generally included in the facility's charge are not included in the fee for ASC facility services. The ASC's laboratory may be certified as a independent lab by Medicare; in this case, the ASC may bill NMAP separately for the tests performed.

The ASC may make arrangements with an independent laboratory or other laboratory, such as a hospital laboratory, to perform diagnostic tests required before surgery; however, the necessary laboratory tests will generally have been done outside the ASC before surgery is scheduled because the tests results may determine whether the client's surgery should be performed on an outpatient basis.

26-003.05 Administrative. Record Keeping. and Housekeeping Items and Services: The fee for ASC facility services includes payment for the general administrative functions necessary to run the facility, such as scheduling, cleaning, utilities, and rent.

26-003.06 Blood and Blood Products: The fee for ASC facility services includes payment for blood and blood products. No separate or additional payment is made for blood and blood products.

26-003.07 Materials for Anesthesia: The fee for ASC facility services include payment for the anesthetic and any materials, disposable or reusable, necessary for its administration.

26-004 ASC Services Not Included in the ASC Facility Services Fee : NMAP makes a single payment (the fee for ASC facility services) to an ASC which covers "facility services" provided by the ASC in connection with a covered procedure. The ASC may provide a number of items and services covered by NMAP which are not included in the fee for ASC facility services. The ASC may be part of a medical complex that includes other entities, such as an independent laboratory, a supplier of durable medical equipment, ambulance services, or a physician's office, which NMAP covers separately. Items or services which are not included in the fee for ASC facility services are:

1. Physicians' services;

2. The sale or rental of durable medical equipment for use in the patient's home;

3. Prosthetic devices, that is, artificial legs, arms, and eyes;

4. Ambulance services;

5. Orthotic devices, that is, leg, arm, back, and neck braces; and

6. Services provided by an independent laboratory. The ASC may provide these services and bill NMAP for them in addition to the fee for ASC facility serivces. Refer to the appropriate chapter in Title 471 for coverage conditions and payment policies.

26-004.01 Physicians' Services: This category includes most covered services provided in ASC's which are not considered ASC facility services. Physicians' services include services of anesthesiologists administering or supervising the administration of anesthesia to ASC patients and the patient's recovery from the anesthesia. Physicians' services also include any routine pre- and post-operative services, such as office visits, consultations, diagnostic tests, removal of stitches, and changing of dressings. See 471 NAC 18-004.17, Surgery, and 471 NAC 18-006, Payment for Physicians' Services.

26-004.02 Durable Medical Equipment: The following items are not included in the fee for ASC facility services; when provided by the ASC facility in connection with a covered procedure, the ASC may bill for these services in addition to the ASC facility services fee:

1. Ace bandages, elastic stockings and support hose, Spence boots and other foot coverings, leotards, knee supports, surgical leggings, gauntlets, and pressure garments for the arms and hands, and which are generally used as secondary coverings;

2. Surgical dressings that are reapplied later by others, including the patient or a family member;

3. Recasting and resplinting, when provided on a date other than the date the surgical procedure was performed.

When these dressings and supplies are obtained by the patient on a physician's order from a supplier other than the ASC facility, they are covered under 471 NAC 7-000 ff.

26-004.03 Ambulance Services: Ambulance services are not included in the fee for ASC facility services. Ambulance services provided by the ASC are covered as ASC services only if provided in conjunction with a covered ASC procedure and only when any other form of transportation is contraindicated for the patient's condition. Licensure and other ambulance regulations are covered in 471 NAC 4-000.

26-004.04 Laboratory Services: Except for those laboratory services included in ASC facility services under 471 NAC 26-003.04, laboratory services are covered in 471 NAC 10-003.04 and 18-004.29.

26-005 Payment for ASC Services

26-005.01 Fee for ASC Facility Services: For services provided on or after January 1, 2008, NMAP will utilize the 2006 Medicare ambulatory surgical center group rates to reimburse for an ambulatory surgical center service. Reimbursement will be the surgical group rate specific to the procedure as established in 471-000-409.

If one covered ambulatory surgical procedure is provided in a single operative session, NMAP pays 100 percent of the applicable group rate. For example, excision of a benign lesion is a "group 1" procedure; therefore, NMAP would pay 100% of the "group 1" rate.

If more than one covered surgical procedure is provided in a single operative session, NMAP pays 100 percent of the applicable group rate for the procedure with the highest rate. NMAP pays for other covered ambulatory surgical procedures performed in the same operative session at 50 percent of the applicable group rate for each procedure. For example, hammertoe repair is a "group 4" procedure and tenotomy is a "group 1" procedure. Payment for these procedures performed in a single operative session in an ASC would be 100% of the "group 4" rate and 50% of the "group 1" rate.

26-005.02 (Reserved)

26-005.03 Payment for Services Not Included in the ASC Facility Services Fee: The fee for facility services does not include payment for physicians' services or other services not directly related to the performance of the surgical procedure. (See 471 NAC 26-004.) The ASC may bill for these services in addition to the fee for ASC facility services and will be paid according to the appropriate Medicaid payment plan.

26-005.04 Payment for State-Defined Services: Medicaid may cover payment for facility services provided in connection with certain state-defined services provided in an ASC. See 471 NAC 18-004.17E.

26-005.05 Non-Payment of Other Provider Preventable Conditions (OPPCs): Effective on or after the effective date of this regulation for facility services rendered by an ambulatory surgical center, payment will be denied for the following OPPCs:

1. Wrong surgical or other invasive procedure performed on a patient;

2. Wrong surgical or other invasive procedure performed on the wrong body part;

3. Wrong surgical or other invasive procedure performed on the wrong patient.

26-006 Billing Requirements

26-006.01 Required Forms: When billing Medicaid, the ASC must submit on the appropriate form or electronic format (see Claim Submission Table at 471-000-49).

All claims for ASC services must include the date of surgery and the physician's name and license number.

26-006.02 Procedure Codes: To claim the ASC facility fee, the ASC must use the appropriate HCPCS/CPT procedure codes as outlined in claim completion instructions (see 471-000-52) and see 471-000-409, state defined ASC Services code(s).

The ASC must use HCPCS/CPT procedure codes when billing for practitioner services and laboratory services. Regulations listed in 471 NAC 4-000 must be used for ambulance services. Regulations listed in 471 NAC 7-000 must be used for durable medical equipment and medical supplies.

History

• Effective 2013-05-18

Chapter 27 Non-Emergency Transportation (net) Services

Neb. Admin. Code tit. 471, ch. 27 Non-Emergency Transportation (net) Services {#sec-471-nac-27 omnilex-key=us-ne-regs-official--title-471--471 NAC 27}

TITLE 471 NEBRASKA MEDICAL ASSISTANCE PROGRAM SERVICES

CHAPTER 27 NON-EMERGENCY MEDICAL TRANSPORTATION (NE M T) SERVICES

001. SCOPE AND AUTHORITY. The regulations govern the services provided under Nebraska’s Medicaid program as defined by Nebraska Revised Statute §§ 68-901 et seq.

002. DEFINITIONS. The following definitions apply:

002.01 BASE RATES. Non-emergency medical transportation base rates include all services, equipment, and other costs, including: vehicle operating expenses, services of personnel, first five “loaded” miles of the trip, unloaded mileage, and usual waiting or standby time.

002.02 EXEMPT PROVIDER. Transportation carriers exempted from Nebraska Public Service Commission certification as defined in Neb. Rev. Stat. §§ 75-303 to 75-303.03.

002.03 FREE TRANSPORTATION. An appropriate mode of transportation that can be secured by the client without cost or charge, including the client’s personal vehicle or through access to a vehicle in the household that is owned by a legally responsible individual for the client.

002.04 INDIVIDUAL PROVIDER. An individual carrier who meets the requirements of Neb. Rev. Stat. § 75-303 (11), (12), or (13), has an approved service provider agreement with the Department and is chosen by the client.

002.05 LEGALLY RESPONSIBLE INDIVIDUAL. A parent or guardian of a minor child, or spouse.

002.06 LOADED MILEAGE. Miles traveled while the client is present in the vehicle. Loaded mileage is covered for non-emergency medical transports when travel exceeds six or more miles. The first five loaded miles are included in the payment for the base rate.

002.07 MODE. The method used to provide transportation services to clients. This includes personal vehicle owned by individual provider; fixed route public transportation; ambulatory sedan, van, and handi-bus; wheelchair-accessible van; and commercial airlines.

002.08 MOST APPROPRIATE. The least costly mode of transportation to meet a client’s medical needs that accommodates the client based on the client’s physical, cognitive, or developmental capabilities.

002.09 NON-EMERGENCY MEDICAL TRANSPORTATION (NEMT) BROKER. An entity under contract with a Heritage Health managed care organization provider to perform all administrative brokerage functions including, but not limited to establishing a transportation network; receiving non-emergency medical transportation (NEMT) service requests; verifying client program(s) eligibility; screening clients for mobility status and existing transportation resources; determining appropriateness and coverage of program services; approving and arranging for transport; notifying client of transportation arrangement; and facilitating provider payment for completed services.

002.10 NON-EMERGENCY MEDICAL TRANSPORTATION (NEMT) SERVICE PROVIDER. Non-emergency medical transportation (NEMT) services provided by an approved individual, exempt or public service commission (PSC) provider.

002.11 NON-EMERGENCY MEDICAL TRANSPORTATION (NEMT) SERVICE. Non-emergency medical transportation (NEMT) services are a ride, or mileage reimbursement for a ride, and escort or attendant services provided so that a Medicaid eligible client with no other transportation resources can receive Medicaid coverable services. By definition, non-emergency medical transportation (NEMT) services do not include transportation provided on an emergency basis, such as trips to the emergency room.

002.12 NO SHOW. A trip that is not cancelled where the client or non-emergency medical transportation (NEMT) provider does not arrive as scheduled; or a scheduled trip that is not cancelled prior to the service when either the client or the non-emergency medical transportation (NEMT) provider fails to arrive.

002.13 PUBLIC SERVICE COMMISSION (PSC) CERTIFIED CARRIER. Transportation providers requiring Nebraska Public Service Commission certification as defined in Neb. Rev. Stat. § 75-302 including the following carriers:

002.13(A) COMMON CARRIER. Any person who or which undertakes to transport passengers or household goods for the general public in intrastate commerce by motor vehicle for hire, whether over regular or irregular routes, upon the highways of this state.

002.13(B) CONTRACT CARRIER. Any motor carrier which transports passengers or household goods for hire other than as a common carrier designed to meet the distinct needs of each individual customer or a specifically designated class of customers without any limitation as to the number of customers it can serve within the class.

002.14 UNLOADED MILEAGE. Miles traveled when a client is not present in the vehicle. All unloaded mileage is included in the payment for the base rate.

002.15 URGENT. A serious, but not life threatening, illness or injury. Urgent care is determined by the client’s medical care provider. An appointment must be considered urgent if the medical service provider grants an appointment within 48 hours of the client’s request. An inpatient or outpatient hospital discharge must be considered an urgent trip.

002.16 WAIT TIME. Periods of time that a non-emergency medical transportation (NEMT) provider spends waiting for the client prior to or in between the provision of covered non-emergency medical transportation (NEMT) services.

003. COVERED SERVICES. Medicaid covers the most appropriate non-emergency medical transportation (NEMT) services necessary to obtain Nebraska Medicaid reimbursed services when one of the following criteria is met:

(A) Client does not own or does not have access to a working licensed vehicle;

(B) Client does not have a current valid driver's license;

(C) Client is unable to drive due to a documented physical, cognitive, or developmental limitation;

(D) Client is unable to travel or wait by himself or herself due to a documented physical, cognitive, or developmental limitation; or

(E) Client is unable to secure free transportation as defined in this chapter.

003.01 NON-EMERGENCY MEDICAL TRANSPORTATION (NEMT) SERVICES PROVIDED FOR CLIENTS RESIDING IN NURSING FACILITIES OR INTERMEDIATE CARE FACILIITIES FOR PERSONS WITH DEVELOPMENTAL DISABILITIES (ICF/DD’S) WHEN MEDICAID IS THE PRIMARY INSURANCE. Non-emergency medical transportation (NEMT) services for clients residing in nursing facilities or intermediate care facilities for persons with developmental disabilities (ICF/DD) may be covered under this chapter for facility discharge transportation to a private residence within boundaries of the State of Nebraska.

003.02 EARLY AND PERIODIC SCREENING, DIAGNOSIS AND TREATMENT (EPSDT) SERVICES. All transportation services for medically necessary early and periodic screening, diagnosis, and treatment (EPSDT) covered services will be provided without regard to service limitations defined within this chapter, and with prior authorization.

003.03 PROVIDER LOCATION. Non-emergency medical transportation (NEMT) services are available to the nearest Nebraska Medicaid coverable services within a 20-mile radius of the client’s residence, able to meet the client’s medical needs, and willing to accept the client as a patient, unless otherwise exempted or approved by the Department.

004. NON-COVERED SERVICES. The following non-emergency medical transportation (NEMT) services are not covered by Nebraska Medicaid:

(A) Transportation to obtain services not coverable by Nebraska Medicaid;

(B) Transportation for clients residing in nursing facilities or intermediate care facilities for persons with developmental disabilities (ICF/DD), except for circumstances when facility discharge transportation to a private residence within boundaries of the State of Nebraska;

(C) Transportation of family members to visit a hospitalized or institutionalized member;

(D) Transportation to a durable medical equipment (DME) provider that provides a delivery service that can be accessed at no cost to the client, in addition to the delivery of durable medical equipment (DME) products in lieu of transporting the client;

(E) Transportation for Medicaid covered services provided in the client’s home such as personal care, home health, etc.;

(F) Transportation to a pharmacy that provides a delivery service that can be accessed at no delivery cost to the client, with the exception of a new prescription requiring immediate use not otherwise reasonably accessible to the client; in addition to the delivery of pharmacy products in lieu of transporting the client;

(G) Transportation to a hospital emergency room;

(H) Client-provided transportation utilizing his or her own personal vehicle;

(I) Wait times;

(J) Services provided by Department staff or a legally responsible individual for the client; and

(K) No shows.

005. AUTHORIZATION PROCEDURES. Authorization for non-emergency medical transportation (NEMT) services must be requested for a scheduled trip at least three business days in advance, with the exception of an unscheduled trip for urgent medical care as defined in this Chapter. The authorization will be requested through the non-emergency medical transportation (NEMT) brokerage contracted by the Heritage Health managed care organization or if fee-for-service (FFS), through the Customer Service Center according to the most appropriate mode of transportation for the service provided to the client.

005.01 MINOR CHILDREN. A minor child under age 13 may not be transported by a non-emergency medical transportation (NEMT) provider without supervision by a legally responsible individual or an adult designated by a legally responsible individual.

005.02 ADDITIONAL PASSENGERS. The transportation for one legally responsible individual, or an adult designated by a legally responsible individual, may be authorized to accompany a minor child under age 19 as an additional passenger. Transportation for a child under age 13, as an additional passenger, may be authorized to accompany their legally responsible individual, or an adult designated by the legally responsible individual. This may be authorized when the legally responsible individual, or adult designated by the legally responsible individual, is the client or when they are authorized to accompany a minor client under age 19. The transportation for a personal assistance services or waiver provider may be authorized to accompany a client as an additional passenger. The transportation for one additional passenger may be authorized to accompany a disabled or aged client.

006. PAYMENT FOR SERVICES.

006.01 CONDITIONS FOR PAYMENT. The provider may bill Medicaid only when:

(A) The transportation is furnished by a Medicaid enrolled provider to whom a direct vender payment can be made; and

(B) The client is actually in the vehicle.

007. PROVIDER PARTICIPATION. To participate in the Nebraska Medicaid Program, providers of non-emergency medical transportation (NEMT) services must fully meet all applicable local, state, and federal laws and regulations governing the provision of their services.

007.01 DRIVER QUALIFICATIONS. Providers must ensure drivers:

(A) Be age 19 or older;

(B) Possess a current and valid driver’s license with no more than three points assessed against his or her Nebraska driver’s license within the past two years, or meet a comparable standard in the state in which he or she is licensed to drive; and

(C) Not had his or her driver or chauffeur’s license revoked within past three years.

008. BACKGROUND CHECKS. Records of screening results must be maintained by these carriers and providers and must be made available to the Department upon request. The following background check requirements apply:

(A) Individual Providers: If the provider is an individual, prior to enrollment and annually, the Department will:

(i) Conduct the Nebraska State Patrol Sex Offender Registry screening;

(ii) Conduct the Criminal History Check; and

(iii) Notify the provider when and how to conduct the Nebraska Adult and Child Abuse and Neglect Central Registry screening.

(B) Public Service Commission (PSC) and Exempt Providers: Public service commission (PSC) certified carriers and exempt providers must perform the following screenings on all drivers, whether employees or independent contractors prior to being allowed to provider transportation to Nebraska Medicaid clients:

(i) Nebraska State Patrol Sex Offender Registry;

(ii) Criminal History Check; and

(iii) Nebraska Adult and Child Abuse and Neglect Central Registry.

008.01 NEBRASKA ADULT AND CHILD ABUSE AND NEGLECT CENTRAL REGISTRY. A Nebraska Adult and Child Abuse and Neglect Central Registry check must be completed for each potential driver prior to providing services and annually thereafter. Any person whose result is “record found” must not be enrolled or allowed to provide transportation to Nebraska Medicaid clients.

008.02 NEBRASKA STATE PATROL SEX OFFENDER REGISTRY CHECKS. A Nebraska State Patrol Sex Offender Registry check must be completed for each potential driver prior to providing services and annually thereafter. Any person whose name appears on the Nebraska State Patrol Sex Offender Registry must not be enrolled or allowed to provide transportation to Nebraska Medicaid clients.

008.03 CRIMINAL HISTORY CHECKS. Provider staff must ensure criminal history checks are completed for each potential driver prior to providing services and annually thereafter. Any person whose result includes the driver being the respondent of a protection order, crimes against a child or vulnerable adult, drug-related crimes, or crimes that if repeated could harm a Medicaid client, must not be enrolled, or allowed to provide transportation to Nebraska Medicaid clients.

History

• Effective 2024-11-12

Chapter 28 Presumptive Eligibility

Neb. Admin. Code tit. 471, ch. 28 Presumptive Eligibility {#sec-471-nac-28 omnilex-key=us-ne-regs-official--title-471--471 NAC 28}

28-001 Presumptive Eligibility for Pregnant Women : Under Section 1920 of the Social Security Act, Medicaid covers ambulatory prenatal care provided by an enrolled Medicaid provider to a pregnant woman during a presumptive eligibility period determined by a qualified provider. A pregnant woman is eligible for only one presumptive eligibility period per pregnancy.

Ambulatory prenatal care is defined as ambulatory services related to the pregnancy excluding inpatient hospital services, nursing home services, labor and delivery services, and services furnished to deliver or remove an embryo/fetus from the mother or services following such a procedure.

28-001.01 Definition of a Qualified Provider: Only a qualified provider is allowed to make the presumptive eligibility determination. A qualified provider must meet the following four criteria:

1. Have a current provider agreement with Medicaid;

2. Provide services of the type provided by one of the following:

a. An outpatient hospital;

b. A rural health clinic; or

c. A clinic under the direction of a physician, without regard to whether the clinic itself is administered by a physician;

3. Meet one of the following requirements:

a. Receive funds under one of the following:

(1) The Migrant Health Centers or Community Health Centers (Sections 329, 330, or 340, of the Public Health Service Act);

(2) The Maternal and Child Health Services Block Grant Program (Title V of the Social Security Act); or

(3) Title V of the Indian Health Care Improvement Act;

b. Participate in a program established under one of the following:

(1) The Special Supplemental Food Program for Women, Infants, and Children (Section 17 or the Child Nutrition Act of 1966); or

(2) The Commodity Supplemental Food Program (Section 4(a) of the Agriculture and Consumer Protection Act of 1973);

c. Participate in a State perinatal program; or

d. Is itself the Indian Health Service or a health program or facility operated by a tribe or tribal organization under the Indian Self-Determination Act (P.L. 93-638); and

4. Have been specifically designated in writing by the Division of Medicaid and Long-Term Care as a qualified provider for the purposes of determining presumptive eligibility.

The provider shall immediately notify the Division of Medicaid and Long-Term Care in writing should they no longer meet the required criteria to be a qualified provider. The provider shall discontinue making presumptive eligibility determinations when the requirements for being a qualified provider are no longer met.

28-001.02 Provider Approval: A provider who meets the requirements of 471 NAC 28-001.01 may request approval as a qualified provider for presumptive eligibility determinations from the Medicaid Division. The provider shall submit a written request for approval as a qualified provider to the Administrator of the Medicaid Division. The written request must identify the requirements of 471 NAC 28-001.01 the provider meets as well as how the provider will check active or pending Medicaid status for potential presumptively eligible pregnant women. The Medicaid Division shall coordinate with the Economic Assistance Division and the local Department of Health and Human Services (DHHS) office for the training of the qualified provider. The provider must be trained by the Medicaid and Economic Assistance Division staff, or staff approved by the Medicaid and Economic Assistant Division, before approval as a qualified provider is given. Final approval of the trained qualified provider is made in writing by the Medicaid Division. The designation of a qualified provider may be terminated by the Medicaid Division upon written 30-day notice to the qualified provider.

28-001.03 Presumptive Eligibility Determination: A pregnant woman may apply at a qualified provider’s office (see 471 NAC 28-001.01) for ambulatory prenatal services. The provider makes a presumptive determination of the woman's eligibility based only on declared income and citizenship/eligible alien status. Income of the woman and spouse (if he is in the home) is counted. Income of the responsible parent(s) of a pregnant minor is counted unless the pregnant woman is an emancipated minor. The provider does not investigate resources or other eligibility requirements. See 477 NAC 1-004 for definition of emancipated minor. For income levels, see 471-000-202.

28-001.04 Responsibilities of the Qualified Provider: The qualified provider shall complete the following actions during the process of making a presumptive eligibility determination:

1. Check for any current or pending Medicaid eligibility prior to completing a presumptive eligibility determination;

2. Check for any past presumptive eligibility period during the client's current pregnancy. A pregnant woman may receive only one period of presumptive eligibility per pregnancy;

3. Inform the woman at the time the determination is made:

a. The copy of the presumptive eligibility application is the client's proof of coverage and is a Medicaid application;

b. She is required to provide verification and documentation as requested by DHHS;

c. Presumptive eligibility ends when DHHS makes a determination of eligibility for medical assistance or at the end of the 45-day presumptive period; and

4. Forward a copy of the presumptive eligibility application, along with the attestation form if applicable, to the local DHHS office within five working days after making a presumptive eligibility determination.

5. If the woman is not presumptively eligible, inform her in writing:

a. Of the reason for her ineligibility; and

b. That she may file an application for the Nebraska Medical Assistance Program (also known as medical assistance or Medicaid) at the local DHHS office.

6. A presumptive application approved in error will be closed by DHHS upon discovery.

28-001.05 Appeal Rights: The standard notice and appeal rights apply for a woman who has been denied continuous medical assistance (see 465 NAC 2-001). There are no appeal rights with regard to the denial of presumptive eligibility.

28-002 (Reserved)

28-003 Presumptive Eligibility for Women with Cancer : Under Section 1920B of the Social Security Act, the Nebraska Medical Assistance Program (NMAP) covers services provided by an enrolled NMAP provider to a woman during a presumptive eligibility period when the woman has been screened by the Every Woman Matters Program and found to have breast or cervical cancer. Presumptive eligibility must be determined by a qualified entity.

Beginning September 1, 2001, women determined presumptively eligible will be eligible for the full scope of services under the State Plan during the presumptive eligibility period. A woman may qualify for presumptive eligibility each time a qualified provider finds her to meet the presumptive eligibility requirements.

28-003.01 Definition of a Qualified Entity: Only a qualified entity is allowed to make the presumptive eligibility determination. A qualified provider must meet the following criteria:

1. Is eligible for payments under the Medicaid State Plan and provides items and services covered by the NMAP or is eligible for payments as an administrative contractor under the State Medicaid plan, and

2. Is determined to be capable for making presumptive eligibility determinations and has been specifically designated in writing by the Medicaid Division as a qualified entity for the purpose of determining presumptive eligibility in accordance with the requirements listed and any other limitations issued by the Center for Medicare and Medicaid Services (CMS).

The provider must immediately notify the Medicaid Division in writing should they no longer meet the required criteria to be a qualified provider. The provider shall discontinue making presumptive eligibility determinations when the requirements for being a qualified provider are no longer met.

28-003.02 Provider Approval: An entity who meets the requirements of 471 NAC 28-003.01 may request approval as a qualified entity for presumptive eligibility determinations from the Medicaid Division. The entity must submit a written request for approval as a qualified entity to the Administrator of the Medicaid Division. The written request must identify the requirements of 471 NAC 28-003.01 the provider meets as well as how the provider will check active or pending Medicaid status for potential presumptively eligible women with either breast or cervical cancer. The Medicaid Division shall coordinate with the Economic Assistance Division and the local Department of Health and Human Services (DHHS) office for the training of the qualified entity. The Medicaid Division makes final approval of the trained qualified entity in writing. The entity must be trained by the Medicaid and Economic Assistance Division staff, or staff approved by the Medicaid and Economic Assistance Division, before approval as a qualified entity is given. The Medicaid Division, upon written 30-day notice to the qualified provider, may terminate the designation of a qualified entity.

28-003.03 Presumptive Eligibility Determination: A woman in need of treatment for certain breast or cervical cancer conditions may apply for presumptive eligibility for Medicaid- covered services at a qualified provider’s site. The qualified entity shall make a presumptive eligibility determination based only on the eligibility requirements in 469 NAC 9-000 which state that a woman must:

1. Be screened for breast and cervical cancer by Every Woman Matters;

2. Be found to need treatment for breast and/or cervical cancer, including a pre-cancerous condition or early stage cancer;

3. Be uninsured, not have creditable coverage or be covered by Medicaid;

4. Be a Nebraska Resident.

The qualified entity does not investigate resources or other eligibility requirements. The DHHS must determine eligibility for medical assistance within 45 days of the woman’s application for medical assistance.

28-003.04 Responsibilities of the Qualified Entity: During the process of making a presumptive eligibility determination the qualified entity must:

1. Check for any current or pending Medicaid eligibility prior to completing a presumptive eligibility determination;

2. Inform the woman at the time the determination is made that:

a. The copy of the presumptive eligibility application is the client’s proof of coverage;

b. She is required to follow through with the eligibility process by applying for Medicaid no later than the last day of the month following the month during which the presumptive eligibility determination is made.

c. The presumptive eligibility ends when a final determination is made by DHHS or if the woman does not apply for Medicaid, the last day of the month following the month during which the entity makes the presumptive eligibility determination.

3. Forward a copy of the presumptive eligibility application to the DHHS office within five working days after making a presumptive eligibility determination.

4. If the woman is not presumptively eligible, inform her (or the individual acting on her behalf ) in writing:

a. Of the reason for ineligibility; and

b. That she may file an application for medical assistance at the local DHHS office.

28-003.05 Appeal Rights: The standard notice and appeal rights apply for a woman who has been denied continuous medical assistance. There are no appeal rights with regard to the denial of presumptive eligibility.

History

• Effective 2013-09-29

Chapter 29 Federally-Qualified Health Centers (fqhc's)

Neb. Admin. Code tit. 471, ch. 29 Federally-Qualified Health Centers (fqhc's) {#sec-471-nac-29 omnilex-key=us-ne-regs-official--title-471--471 NAC 29}

29-001 Standards for Participation : To be considered a Federally-Qualified Health Center (FQHC) for the Nebraska Medical Assistance Program, as allowed by section 6404 of P.L. 101-239, a health center must furnish proof that the United States Public Health Service has determined that it is qualified under Sections 329, 330, or 340 of the Public Health Service Act, or that it qualifies by meeting other requirements established by the Secretary of the Federal Health and Human Services.

29-002 Services Provided for Clients Enrolled in the Nebraska Health Connection (NHC) : Certain NMAP clients are required to participate in the Nebraska Medicaid Managed Care Program known as the Nebraska Health Connection (NHC). See 471-000-122 for a listing of the NHC plans.

29-002.01 Health Maintenance Organization (HMO) Plans: The NHC HMO plans are required to provide, at a minimum, coverage of services as described in this Chapter. The prior authorization requirements, payment limitations, and billing instructions outlined in this Chapter do not apply to services provided to clients enrolled in an NHC HMO plan with the following exceptions:

1. Medical Transplants: As defined under 471 NAC 18-004.40, transplants continue to require prior authorization by NMAP and are reimbursed on a fee-for-service basis, outside the HMO's capitation payment;

2. Abortions: As currently defined, abortions continue to require prior authorization by NMAP and are included in the capitation fee for the HMO; and

3. Family Planning Services: Family planning services do not require a referral from a primary care physician (PCP). As defined in 471 NAC 18-004.26, the client must be able to obtain family planning services upon request and from a provider of choice who is enrolled in NMAP. Family planning services are reimbursed by the HMO, regardless of whether the service is provided by a PCP enrolled with the HMO or a family planning provider outside the HMO.

Services provided to clients enrolled in an NHC HMO plan are not billed to NMAP. The provider shall provide services only under arrangement with the HMO.

29-002.02 Primary Care Case Management (PCCM) Plans: All NMAP regulations apply to services provided to NHC clients enrolled in a PCCM plan. For services that require prior authorization under 471 NAC 18-004.01, the provider must obtain prior authorization from the PCCM plan under the directions for prior authorization of the PCCM plan with the following exceptions:

1. Medical Transplants: As define under 471 NAC 18-004.40, transplants are subject to prior authorization by NMAP; and

2. Abortions: As currently defined, abortions require prior authorization by NMAP.

29-002.02A Referral Management: When medically necessary services that cannot be provided by the PCP are needed for the client, the PCP must authorize the services to be provided by the approved provider as needed with the following exceptions:

1. Visual Care Services: All surgical procedures provided by an optometrist or ophthalmologist require approval from the PCCM plan. Providers must contact the client's PCCM primary care physician before providing surgical services. Non-surgical procedure provided by an optometrist or ophthalmologist do not require referral/approval from the PCP; however, when an optometrist or ophthalmologist diagnoses, monitors, or treats a condition, except routine refractive conditions, the practitioner shall send a written summary of the client's condition and treatment/follow-up provided, planned, or required to the client's PCP.

2. Dental Services: Dentists or oral surgeons providing medically necessary services not covered under 471 NAC 6-000 must bill that service on Form CMS-1500 or electronically using the standard Health Care Claim: Professional transaction (ASC X12N 837), using HCPCS/CPT procedure codes. These services require referral/ authorization from the client's PCP. The provider must contact the PCP before providing these services. If a client requires hospitalization for dental treatment or for medical and surgical services billed on Form CMS-1500 or electronically using the standard Health Care Claim: Professional transaction (ASC X12N 837), the provider must contact the PCP for referral/authorization.

3. Family Planning Services: Family planning services do not require a referral from the PCP. As defined in 471 NAC 18-004.26, the client must be able to receive family planning services upon request and from a provider of choice who is enrolled in NMAP.

29-002.03 Mental Health and Substance Abuse Services Mental health and substance abuse services (MH/SA) are provided by the MH/SA managed care plan for all NHC clients. This plan includes the Client Assistance Program (CAP). Clients may access five services annually with any CAP-enrolled provider without prior authorization. All other MH/SA services must be prior authorized by the Plan.

29-003 Payment for Services Provided by FQHCs : (NMAP) makes payment for services provided by federally-qualified health centers (FQHCs) as defined in section 1905(a)(2)(C) of the Social Security Act NMAP will pay for services provided by FQHCs under a prospective payment system (PPS) that is in compliance with Section 1902(bb) of the Social Security Act. The Department assures that payment to an FQHC will result in payment to the center of an amount which is at least equal to the Prospective Payment System rate.

29-003.01 Definitions: The following definitions apply in this chapter.

Encounter means a face-to-face visit between a Medicaid-eligible patient and a physician, physician assistant, nurse practitioner, nurse midwife, specialized nurse practitioner, visiting nurse, clinical psychologist, or clinical social worker during which an FQHC service is rendered. Encounters with more than one health professional and multiple encounters with the same health professional which take place on the same day and at a single location constitute a single visit, except for cases in which the patient, subsequent to the first encounter, suffers an illness or injury requiring additional diagnosis or treatment.

Encounter Rate means the all-inclusive PPS rate that the Department reimburses the FQHC for an encounter.

Encounter Payments means PPS rate paid to the FQHC by the Department multiplied by the number of encounters billed.

Medicare Cost Report means the report filed by each provider with its Medicare intermediary as required in the Medicare Rural Health Clinic and Federal Qualified Health Center Manual.

Prospective Payment System (PPS) means the payment system where in the reimbursement rate is paid for services provided.

29-004 Prospective Payment System

29-004.01 Prospective Payment System Base Rates: The Prospective Payment System base rate will be computed as follows:

1. Combine reasonable costs from the FQHC fiscal year 1999 and 2000 cost reports; and

2. Divide the costs by the Total Adjusted Visits from the two fiscal year cost reports (Form HCFA-222-92 Worksheet C, Part 1, Line 6; or Form HCFA-2552-96 Worksheet M-3, Line 6).

Beginning October 1, 2001, the PPS base rate will be updated annually based on the Medicare Economic Index (MEI).

29-004.02 Rates for New Providers: The Department will establish rates for a new FQHC entering the program after 1999 as follows:

1. For the initial year, the interim rate will be the average PPS rate of all FQHCs in Nebraska. The interim rate will be retroactively settled based on the FQHC’s initial cost report.

2. The FQHC’s individual PPS base rate will be computed later, using its initial cost report.

3. The PPS base rate will be updated annually based on the Medicare Economic Index (MEI).

29-004.03 FQHC Managed Care Payments: FQHCs that provide services under a contract with a Medicaid managed care entity (MCE) will receive quarterly state supplemental payments for the cost of furnishing such services that are an estimate of the difference between the payment the FQHC receives from the MCE(s) and the payments the FQHC would have received under the PPS methodology.

29-004.03A At the end of each FQHC fiscal year, the Department will compare:

1. The total amount of supplemental and MCE payments received by the FQHC; to

2. The amount that the actual number of visits provided under the FQHC’s contract with the MCE(s) would have yielded under the PPS methodology.

The Department will pay the FQHC the difference between item 1 and item 2 if the PPS amount exceeds the total amount of supplemental and MCE payments. The FQHC must refund the difference between item 1 and item 2 if the PPS payment is less than the total amount of the supplemental and MCE payments.

29-004.04 Non-FQHC Services: For non-FQHC services, NMAP will pay according to the Nebraska Medicaid Practitioners Fee Schedule.

29-004.05 Payment for Telehealth Services: Payment for telehealth services will be the Medicaid rate for the comparable in-person service. FQHC core services provided via telehealth technologies are not covered under the encounter rate.

29-004.05A Payment for Telehealth Transmission Costs: Payment for telehealth transmission costs related to non-core services will be the lower of:

1. The provider’s submitted charge; or

2. The maximum allowable amount.

The Department will pay for transmission costs for line charges when directly related to a covered telehealth service. The provider must be in compliance with the standards for real time, two way interactive audiovisual transmissions (see 471 NAC 1-006).

29-005 Cost Reports : Providers participating in the NMAP as FQHCs must submit an annual cost report to the Department.

The Medicare cost report form CMS-222-92 can be found in the Provider Reimbursement Manual-Part-2 (Pub. 15-2), Chapter 29 located at http://www.cms.hhs.gov/manuals/PBM/list.asp on the CMS website.

Each FQHC must report and supply the Department with necessary documentation, cost reports, and any other documentation when requested.

29-006 Billing for FQHC Services : FQHCs must bill for their services on Form CMS-1450 (see 471-000-51) or electronically using the standard Health Care Claim: Institutional transaction (ASC X12N 837). FQHCs must use the appropriate HCPCS/CPT procedure codes and revenue codes when billing for services.

FQHCs must bill for HEALTH CHECKS (Early and Periodic Screening, Diagnosis, and Treatment-EPSDT-Exams) on Form CMS-1500 (see 471-000-58) or electronically using the standard Health Care Claim: Professional transaction (ASC X12N 837).

FQHCs must bill all laboratory/radiology services and other non-FQHC services on the form CMS-1500 (see 471-000-58) or electronically using the standard health care claim; Professional transaction (ASC X12N 837) using the non-FQHC number.

History

• Effective 2010-03-10

Chapter 30 Health Insurance Premium Payment Program

Neb. Admin. Code tit. 471, ch. 30 Health Insurance Premium Payment Program {#sec-471-nac-30 omnilex-key=us-ne-regs-official--title-471--471 NAC 30}

001. SCOPE AND AUTHORITY . The regulations govern the services provided under Nebraska’s Medicaid program as defined by Nebraska Revised Statute (Neb. Rev. Stat.) §§ 68-901 to 68-991 (the Medical Assistance Act). The Health Insurance Premium Payment (HIPP) Program is authorized under §§1905 and 1906 of the Social Security Act.

002. DEFINITIONS . The following definitions apply:

002.01 COST EFFECTIVENESS. A determination, made by the Department, that payment for coverage under a group health plan or individual market health plan will be less than the amount of expenditures under the Nebraska Medicaid State Plan that Medicaid would have made to provide comparable coverage for the client.

002.02 GROUP HEALTH PLAN. Any plan of, or contributed to by, an employer (including a self-insured plan) to provide health care (directly or otherwise) to the employer's employees, former employees, or the families of employees or former employees. A group health plan must meet S. 5000(b)(1) of the Internal Revenue Code of 1986, and includes continuation coverage pursuant to Title XXII of the Public Health Services Act, S. 4980B of the Internal Revenue Code of 1986, or Title VI of the Employee Retirement Income Security Act of 1974.

002.03 INDIVIDUAL MARKET HEALTH PLAN. Individual market is the market for health insurance coverage offered to individuals other than in connection with a group health plan. For purposes of the Health Insurance Premium Payment (HIPP) Program, individual market policies include health plans that comply with the requirements of the Patient Protection and Affordable Care Act of 2010 (ACA) and may include policies that do not meet all Affordable Care Act (ACA) requirements but are still found to provide comprehensive health coverage as determined by the Department.

003. PARTICIPATION IN THE HEALTH INSURANCE PREMIUM PAYMENT (HIPP) PROGRAM .

003.01 VOLUNTARY PARTICIPATION IN HEALTH INSURANCE PREMIUM PAYMENT (HIPP). Participation in the Health Insurance Premium Payment (HIPP) Program is voluntary. For Medicaid eligible clients, enrollment in the Health Insurance Premium Payment (HIPP) Program does not change the client’s eligibility for benefits through the state plan or cost sharing obligations under the state plan.

003.02 PARTICIPATION DETERMINATION FOR HEALTH INSURANCE PREMIUMPAYMENT (HIPP).

003.02(A) REQUIRED DOCUMENTATION. The Department may request any documentation from the client that it deems to be necessary to determine whether the client’s enrollment in an available group health plan or individual market health plan is cost effective. Documentation that must be submitted includes, but is not limited to:

(i) Signed application for enrollment in the Health Insurance Premium Payment (HIPP) Program;

(ii) Summary of covered benefits from the group health plan or individual market health plan;

(iii) If applicable, verification of the client’s ongoing medical diagnosis. Verification must be provided by an appropriate physician or entity;

(iv) Completed verification form for employer sponsored insurance; and

(v) Monthly proof of health insurance premium payments.

003.03 EFFECTIVE DATE OF PARTICIPATION IN THE HEALTH INSURANCE PREMIUM PAYMENT (HIPP) PROGRAM. The effective date for Health Insurance Premium Payment (HIPP) participation is the first day of the month that the following criteria are met:

(A) The client is enrolled in a group health plan or individual market health plan;

(B) All documentation necessary for Medicaid to determine cost effectiveness has been submitted; and

(C) The Department has determined that the client’s participation in Health Insurance Premium Payment (HIPP) would be cost effective.

003.04 COST-EFFECTIVENESS DETERMINATION. The Department determines the cost-effectiveness for payment of qualifying group health insurance or individual market health insurance premiums.

003.04(A) COST-EFFECTIVE MEDICAL CONDITIONS. Any Medicaid-eligible client who has an existing, ongoing, medically confirmed medical condition determined by the Department to be considered a cost-effective condition, is deemed to meet the cost-effective criteria.

003.04(B) COST-EFFECTIVENESS CALCULATION. When the criteria of 471 Nebraska Administrative Code (NAC) 30-003.03(A) are not met, cost-effectiveness will be calculated as follows:

(i) Determine the annual anticipated cost for Medicaid services generally covered by the private health insurance based on the client’s age, sex, and eligibility category;

(ii) Total the results of each of the following calculations:

(1) The portion of the group health insurance or individual market health insurance premium payable by the Health Insurance Premium Payment (HIPP) program;

(2) A predetermined annual administration cost per participant; and

(3) The expected cost to Medicaid for any deductibles, coinsurance, or copayments.

(iii) Subtract the result of (ii) from the result of (i);

(iv) If the result is greater than or equal to $10, the policy would be determined cost effective; and

(v) If the result is less than $10, the policy would not be considered cost effective.

003.04(C) SUPPLEMENTAL INFORMATION. When the criteria of 471 NAC 30-003.04(A) and 471 NAC 30-004.03(B) are not met, specific information relating to the individual circumstances of the Medicaid-eligible client may be provided. On a case-by-case basis and at the sole discretion of the Department, a determination of cost effectiveness can be made if sufficient evidence is provided to demonstrate savings to Medicaid.

003.04(D) EXCLUDED CASES. The Department will not make a determination of cost effectiveness in the following circumstances:

(i) The client is eligible for or enrolled in Medicare;

(ii) Payment of health insurance premiums have been fully reimbursed or offset by a third party, including, but not limited to:

(1) An employer; or

(2) An individual court-ordered to provide medical support.

(iii) The recipient is only eligible for a medically needy, spend-down, program; or

(iv) The group health insurance or individual market health insurance only provides catastrophic, limited benefit, limited duration, or indemnity coverage.

003.04(E) MULTIPLE POLICIES. When more than one group or individual market health insurance policy is available, the Department shall pay only for the most cost-effective policy.

003.04(E)(i) EXCEPTION FOR SUPPLEMENTAL POLICIES. At the sole discretion of the Department, in the circumstance when an additional supplemental policy is available and that policy is found to provide coverage that does not duplicate coverage included in the primary health insurance plan, the Department may include both the primary health plan and supplemental policy in its cost-effectiveness calculation. If the Department finds that paying the costs described in 471 NAC 30-003.04 for both the primary and supplemental health policies is more cost effective than paying solely for the costs of the primary health policy, the Department may pay for the costs of both the primary and supplemental health policies.

003.04(F) REDETERMINATIONS.

003.04(F)(i) ANNUAL REDETERMINATION. The Department conducts a redetermination of participation annually for all clients enrolled in the Health Insurance Premium Payment (HIPP) Program. This redetermination includes:

(1) Verification of eligibility for Medicaid; and

(2) Completion of the cost-effective calculation as outlined in 471 NAC 30-004.03(A) through 30-004.03(C).

003.04(F)(ii) CHANGES IN CIRCUMSTANCES. A redetermination of participation may be conducted at any point if:

(1) The monthly premium of the group health insurance or individual market health insurance increases by more than $50;

(2) There is a change in eligibility category or status for Medicaid;

(3) The services offered by the group health insurance or individual market health insurance decrease;

(4) There is a change in the deductible, co-insurance, or any other cost-sharing provisions of the group health policy or individual market health policy; or

(5) There is reason to believe a change has occurred which may affect participation for Health Insurance Premium Payment (HIPP) enrollment.

The client has an affirmative obligation to report any change in circumstances.

003.05 TERMINATION OF HEALTH INSURANCE PREMUIM PAYMENT (HIPP) PARTICIPATION. Failure to provide requested documentation in accordance with 471 NAC 30-003.02(A), or failure to meet Health Insurance Premium Payment (HIPP) enrollment participation criteria as outlined in 471 NAC 30-004.01 and 30-004.03, may result in termination of participation in the Health Insurance Premium Payment (HIPP) Program.

004. REIMBURSEMENTS . Medicaid covers reimbursement of premiums for Medicaid-eligible enrollees in a cost effective group health plan or individual market health plan. Medicaid also covers payment of all deductibles, coinsurance, and other cost sharing obligations under the group health plan or individual market health plan that are for services covered under the Medicaid State Plan.

Reimbursements will be made directly to the policyholder as a reimbursement for the group health insurance or individual market health insurance premiums. The client or policyholder must submit accompanying documentation within sixty days of the date paid showing the premium payment has been made.

004.01 FAMILY MEMBERS. If a family member who is not eligible for Medicaid must be enrolled in the group health plan or individual market health plan to obtain coverage under the group health plan or individual market health plan for the Medicaid-eligible client, Medicaid covers payment for the group health plan premiums for the family member who is not eligible for Medicaid.

004.02 DEDUCTIBLES, COINSURANCE, AND OTHER COST SHARING. The Department will pay deductibles, co-insurance, and cost sharing obligations up to the Medicaid allowable amounts directly to the enrolled Medicaid provider. The provider must submit a claim to the Department in accordance with claim submission and payment guidelines outlined in 471 NAC Chapters 2 and 3, as well as any submission and payment guidelines included within each service specific NAC Title 471 Chapter directly. Payment will be made directly to the provider in an amount up to, but not exceeding, the Medicaid allowable amount less any payment made to the provider by the group health plan or individual market health plan. The provider must accept Medicaid payment as payment in full, and cannot bill the client for the difference between the Medicaid payment and the billed amount.

Prior to submitting a claim to the Department for payment, the provider must complete the provider enrollment process outlined in 471 NAC Chapter 2 as well as any enrollment requirements included within each service specific NAC Title 471 Chapter.

004.02(A) FAMILY MEMBERS. Medicaid does not cover deductibles, coinsurance, and other cost sharing obligations under the group health plan or individual market health plan for any family member who is not eligible for Medicaid.

004.03 SERVICES COVERED BY MEDICAID. A client's enrollment in a group health plan or individual market health plan does not change the client's eligibility for benefits under Medicaid. If services covered under Medicaid are not covered by the group health plan or individual market health plan, the client may obtain these services from Medicaid-enrolled providers. Coverage of, and payment for those services is made according 471 NAC Chapters 1, 2, and 3, as well as well as any coverage and payment requirements included within each service specific NAC Title 471 Chapter. If a client is enrolled in Managed Care to obtain services, the coverage and subsequent payment for those services will be in accordance with the Managed Care entities’ coverage and payment guidelines.

004.04 SERVICES NOT COVERED BY MEDICAID. Medicaid does not pay for the deductibles, coinsurance, and other cost sharing obligations for services covered under the client’s group health plan or individual market health plan that are not covered under the Nebraska Medicaid State Plan.

004.05 MEDICARE ENROLLMENT. If the client is also eligible for Medicare but is not enrolled in Medicare, Medicaid does not pay for the premiums or other cost sharing obligations to the group health plan or individual market health insurance.

005. CLIENTS RIGHT TO APPEAL . The Health Insurance Premium Payment (HIPP) Program is intended to serve as a cost saving measure for Medicaid, and does not confer any additional benefits upon the client. Accordingly, the client does not have the right to appeal an adverse decision regarding enrollment or participation in the Health Insurance Premium Payment (HIPP) Program.

History

• Effective 2019-07-01

Chapter 31 Services in an Intermediate Care Facility for Individuals with Developmental Disabilities (icf/Dd)

Neb. Admin. Code tit. 471, ch. 31 Services in an Intermediate Care Facility for Individuals with Developmental Disabilities (icf/Dd) {#sec-471-nac-31 omnilex-key=us-ne-regs-official--title-471--471 NAC 31}

001. SCOPE AND AUTHORITY . The regulations govern the services provided under Nebraska’s Medicaid program as defined by Neb. Rev. Stat. §§ 68-901 to et seq.

002. DEFINITIONS . The following definitions apply:

002.01 ACTIVE TREATMENT. A continuous treatment plan which includes aggressive, consistent implementation of a program of specialized and generic training, treatment, health services, and related services that meet the requirements of 42 Code of Federal Regulations (CFR) 483.440(a).

002.02 ADMISSION DATE. The date the facility determines to admit the client to the facility. The determination must occur within 24 hours of the client’s arrival at the facility.

002.03 ALTERNATE LEVELS OF CARE. Non-institutional living arrangements providing less care than a nursing facility (NF) or an intermediate care facility for individuals with developmental disabilities (ICF/DD) ) and more care than independent living, such as adult family home, domiciliary facility, residential care facility, group home, center for the developmentally disabled, or other community living situations.

002.04 BED HOLDING. Per diem payment made to an intermediate care facility for individuals with developmental disabilities (ICF/DD) to hold a bed when a client is hospitalized or on therapeutic leave.

002.05 BENEFIT FROM ACTIVE TREATMENT. Demonstrable progress in reducing barriers to less restrictive alternatives.

002.06 CLIENT. An individual who has been determined eligible for the Nebraska Medicaid Program.

002.07 COMMUNITY-BASED DEVELOPMENTAL DISABILITY SERVICES. An array of specialized services, including vocational, pre-vocational, residential, and service coordination, provided outside an institutional setting.

002.08 COMPREHENSIVE FUNCTIONAL ASSESSMENT. A report or a series of reports synthesizing the results of relevant evaluations of the client's abilities and deficits to determine needs. These reports, or assessments, must be made in the following areas: developmental skills, behavioral skills, social skills, health and nutritional status, and other assessments based on the client’s needs.

002.09 DEVELOPMENTAL DISABILITY (DD). Developmental disability means a severe, chronic disability, including an intellectual disability, other than mental illness, which:

(1) Is attributable to a mental or physical impairment unless the impairment is solely attributable to a severe emotional disturbance or persistent mental illness;

(2) Is manifested before the age of twenty-two years;

(3) Is likely to continue indefinitely;

(4) Results in substantial functional limitations in one of each of the following areas of adaptive functioning:

(i) Conceptual skills, including language, literacy, money, time, number concepts, and self-direction;

(ii) Social skills, including interpersonal skills, social responsibility, self-esteem, gullibility, wariness, social problem solving, and the ability to follow laws and rules and to avoid being victimized; and

(iii) Practical skills, including activities of daily living, personal care, occupational skills, healthcare, mobility, and the capacity for independent living; and

(5) Reflects the individual’s need for a combination and sequence of special, interdisciplinary, or generic services, individualized supports, or other forms of assistance which are of lifelong or extended duration and are individually planned and coordinated.

002.09(A) INDIVIDUALS NINE AND YOUNGER. An individual from birth through the age of nine years inclusive, who has a substantial developmental delay or specific congenital or acquired condition, may be considered to have a developmental disability without meeting three or more of the major life activities described in subdivision of this section if the individual, without services and support, has a high probability of meeting those criteria later in life.

002.10 DISCHARGE PLAN. A plan developed by the client's interdisciplinary team (IDT) at the time of admission as part of the individual program plan (IPP), reviewed quarterly and revised as needed, which identifies:

(A) The rationale for the client's current level of care;

(B) The types of services the client would require in a less restrictive alternative; and

(C) A summary of alternatives explored for the client through the Department of Health and Human Services Developmental Disabilities Division, Service Coordination (DDD SC) over the past year as in 42 CFR 456.380.

002.11 DUAL DIAGNOSIS. An individual diagnosed with a developmental disability or related condition along with a mental illness disorder.

002.12 HABILITATIVE TRAINING. Training in new skills and behaviors necessary to facilitate independent functioning.

002.13 INDEPENDENT QIDP (QUALIFIED INTELLECTUAL DISABILITY PROFESSIONAL) ASSESSMENT. A functional evaluation to determine the client's present skills with recommendations for training, services, and level of care.

002.14 INDIVIDUAL PROGRAM PLAN (IPP). A document or documents developed by the interdisciplinary team (IDT) which includes services and supports needed by the client.

002.15 INDIVIDUALIZED EDUCATIONAL PLAN (IEP). A written statement for a child with a verified disability that specifies the special education and related services necessary to assure that child a free and appropriate education. The development of the individualized educational plan (IEP) is the responsibility of the school district in which the child is receiving educational services.

002.16 INPATIENT DAYS. The number of days of care covered for inpatient intermediate care facility for individuals with developmental disabilities (ICF/DD) services is always in units of full days. A day begins at midnight and ends 24 hours later. The midnight-to-midnight method is to be used in counting days of care for Medicaid reporting purposes, even if the intermediate care facility for individuals with developmental disabilities (ICF/DD) uses a different definition of a day for statistical or other purposes.

002.16(A) PART OF DAY. Except for death on the day of admission, a part of a day on the day of discharge or death is not counted as a day. If inpatient admission and death occur on the same day, the day is considered a day of admission and counted as one inpatient day.

002.17 INTELLECTUAL DISABILITY (ID). An individual with significantly sub-average, general intellectual functioning existing concurrently with deficits in adaptive behavior. An intelligence quotient of seventy or below on a reliably administered intelligence quotient test is presumptive evidence of intellectual disability.

002.18 INTERDISCIPLINARY TEAM (IDT). A group of persons representing the professions, disciplines, or service areas which are relevant to identifying the client's needs, and coordinating and designing training programs and services to meet these needs. Team membership varies according to individual needs, but must always include a qualified intellectual disability professional (QIDP) and a person(s) responsible to assure the client's rights are protected. The interdisciplinary team (IDT) must include the client and the client's legal representative(s).

002.19 INTERMEDIATE CARE FACILITY FOR INDIVIDUALS WITH DEVELOPMENTAL DISABILITIES (ICF/DD). A facility where shelter, food, and active treatment are provided for a period of more than twenty-four consecutive hours to four or more persons residing at such facility who have an Intellectual Disability or related condition.

002.20 LEAST RESTRICTIVE ALTERNATIVE. The most appropriate living environment which meets the client's needs in the most normalizing manner.

002.21 LEVEL OF CARE (LOC). A category of living arrangement. Levels of care funded by Medicaid include nursing facility (NF), intermediate care facility for individuals with developmental disabilities (ICF/DD), acute hospital, and institution for mental disease (IMD).

002.22 MAINTENANCE THERAPY. Therapy to maintain the client at their current level and to prevent loss or deterioration of present abilities.

002.23 MEDICAL CARE PLAN. A plan developed by the physician when the physician determines the client requires 24-hour nursing care or the client suffers from an acute illness requiring 24-hour nursing care.

002.24 MENTAL ILLNESS. A mental disorder according to the most current edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM).

002.25 NEED LEVEL. A classification system which identifies clients as high need, moderate need, or low need, which is:

(A) Based on the amount of staff time required to meet the client's needs; and

(B) Determined by intermediate care facility for individuals with developmental disabilities (ICF/DD) staff.

002.26 NURSING FACILITY (NF). A facility, or a distinct part of a facility, as defined in, and operating in, accordance with 471 Nebraska Administrative Code (NAC) 12.

002.27 PHYSICIAN'S CERTIFICATION. Physician's determination specifying the type of services the client requires.

002.28 PLAN OF CARE. A plan to provide care and interventions to a person according to that person’s needs.

002.29 PRE-ADMISSION EVALUATION. An interdisciplinary process to determine:

(1) Specific needs of the client;

(2) The least restrictive alternative which meets the client's needs;

(3) Availability of the least restrictive alternative;

(4) The intermediate care facility for individuals with developmental disabilities (ICF/DD)'s ability to meet the client's needs; and

(5) If admitted, a written plan of services for the first 30 days.

002.29(A) ADMISSION DECISION. This process results in the intermediate care facility for individuals with developmental disabilities (ICF/DD)'s decision on admitting the client.

002.30 POST-ADMISSION EVALUATION. The initial Individual program plan developed and implemented by the interdisciplinary team within 30 days of the client’s admission to the facility. The post-admission evaluation is based on the results and recommendations of the functional assessments completed during the client’s initial 30 days residing at the facility.

002.31 PRIOR AUTHORIZATION. Determination of necessity for intermediate care facility for individuals with developmental disabilities (ICF/DD) level of care and authorization for payment.

002.33 QUALIFIED INTELLECTUAL DISABILITIES PROFESSIONAL (QIDP). A member of the client’s interdisciplinary team who is responsible for coordinating and monitoring the client’s active treatment program. The qualified intellectual disabilities professional (QIDP) must meet the federal qualifications found at 42 CFR 483.430(a) through 483.430(a)(2)(iii) and 42 CFR 483.430(b)(5) through 483.430(b)(5)(x).

002.34 RELATED CONDITION. A severe, chronic disability which meets the following conditions:

(A) It is attributable to:

(i) Cerebral palsy or epilepsy; or

(ii) Any other condition, other than mental illness, found to be closely related to intellectual disability because this condition results in impairment of general intellectual functioning or adaptive behavior similar to that of persons with intellectual disability, and requires treatment or services similar to those required for these persons;

(B) It is manifested before the person reaches age 22;

(C) It is likely to continue indefinitely;

(D) In the case of a child under three years of age, results in at least one developmental delay;

(E) In the case of a person three years of age or older, results in substantial functional limitations in three or more of the following areas of major life activity:

(i) Self-care;

(ii) Understanding and use of language;

(iii) Learning;

(iv) Mobility;

(v) Self-direction; or

(vi) Capacity for independent living; and

(F) Reflects the individual's need for a combination and sequence of special, interdisciplinary, or generic care, treatment, or other services which are life-long or of an extended duration and are individually planned and coordinated.

002.35 SUBSTANTIAL FUNCTIONAL LIMITATION. A demonstrated interference in the capacity or ability to perform activities appropriate given the individual’s stage of development.

002.36 THERAPEUTIC LEAVE. Therapeutically indicated overnight home visits with relatives and friends or visits to participate in therapeutic or habilitative programs.

002.37 UTILIZATION REVIEW. Review of Medicaid-eligible clients residing in intermediate care facility for individuals with developmental disabilities (ICF/DD) facilities to determine the client’s need for intermediate care facility for individuals with developmental disabilities (ICF/DD) level of care.

003. PROVIDER REQUIREMENTS .

003.01 GENERAL PROVIDER REQUIREMENTS. To participate in the Nebraska Medical Assistance Program (Medicaid), providers of intermediate care facility for individuals with developmental disabilities (ICF/DD) services must comply with all applicable participation requirements codified in 471 NAC 2 and 3. In the event which provider participation requirements in 471 NAC 2 and 3 conflict with requirements outlined in this chapter, the individual provider participation requirements in this chapter govern.

003.02 SPECIFIC PROVIDER REQUIREMENTS. To participate in Medicaid, an intermediate care facility for individuals with developmental disabilities (ICF/DD) must:

(1) Meet all related requirements for participation in Medicaid as required by state and federal law and regulation;

(2) Be certified as a Title XIX intermediate care facility for individuals with intellectual disabilities (ICF/IID) per federal regulations and licensed as an intermediate care facility for individuals with developmental disabilities (ICF/DD) by the Nebraska Department of Health and Human Services, Division of Public Health or, for an out-of-state facility, by that state's survey agency;

(3) Provide licensed nurses sufficient to care for clients' health needs, as defined in 42 CFR 483.460(c) and (d);

(4) Provide active treatment as defined in this chapter, and 42 CFR 483.440 - 483.450; and

(5) Have a current Medicaid provider agreement with the Department of Health and Human Services, Division of Medicaid and Long-Term Care.

003.02(A) AGENCY COOPERATION. All intermediate care facility for individuals with developmental disabilities (ICF/DD) facilities must provide staff of the federal Department of Health and Human Services, and Medicaid with the data, forms, and cooperation necessary to admit, plan for, evaluate the needs of, and make determinations on the appropriate care level for each individual eligible for Medicaid as required by federal and state Medicaid regulations.

003.02(B) FREEDOM OF CHOICE. Each intermediate care facility for individuals with developmental disabilities (ICF/DD) must ensure that any client may exercise their freedom of choice in obtaining Medicaid-covered services from any provider qualified to perform the services.

003.02(C) ROOM AND BED ASSIGNMENTS. The facility must ensure any changes made in the client’s room or bed assignment is documented in the client’s individual program plan (IPP). This record must show the dates and reasons for all changes in accordance with 42 CFR 442.404.

003.02(D) DISCHARGE. The intermediate care facility for individuals with developmental disabilities (ICF/DD) must ensure any client identified to permanently move from the facility is discharged according to requirements in this section. If the client moves to a separately licensed and certified intermediate care facility for individuals with developmental disabilities (ICF/DD), the same discharge requirements must be followed. The client must be admitted to the receiving intermediate care facility for individuals with developmental disabilities (ICF/DD).

003.02(D)(i) DISCHARGE PLANNING. The intermediate care facility for individuals with developmental disabilities (ICF/DD) must include discharge planning procedures for all Nebraska Medicaid clients in the individual program plan (IPP). The discharge planning procedures must be reviewed and updated (if needed) by the client’s interdisciplinary team (IDT) at least annually. The procedures must include:

(1) Which intermediate care facility for individuals with developmental disabilities (ICF/DD) staff person is responsible for discharge planning; and

(2) The interdisciplinary team (IDT)’s determination of the level of care the client needs or may need upon discharge, including programming, medical, nutritional, psychological or psychiatric, and supervision needs.

003.02(D)(ii) DISCHARGE TO ALTERNATIVE SETTING. If it is determined that a client does not meet level of care requirements and the client’s health and habilitative needs could more appropriately be met in another setting, the facility must follow the steps as outlined in this chapter.

003.02(D)(iii) DISCHARGE PROCESS. When a client is to be discharged, the intermediate care facility for individuals with developmental disabilities (ICF/DD) facility must ensure:

(a) The following is documented in the client’s individual program plan (IPP):

(i) Notification of the discharge to the client as well as to the family or legal representative;

(ii) The justification for the discharge;

(iii) The type of service or level of care the client is being discharged to;

(iv) The date the client is discharged; and

(v) The discharge plan which must include activities to ensure the client is adequately prepared for the discharge and the receiving facility is provided current information related to the client’s social and programming history, current developmental skills and skill deficits, current training needs, and medical, nursing and nutritional status;

(b) All adaptive equipment and supplies specifically purchased for the client move with the client; and

(c) Medicaid is notified of the discharge within 10 days of discharge, to include the type of service setting the client was discharged to.

003.02(D)(iii)(1) NOTICE. Should the client’s interdisciplinary team (IDT) decide to discharge the client without plans to admit to another service provider, the facility must notify the Department of Health and Human Services’ Developmental Disabilities Division, Service Coordination (DDD SC) within two working days of the interdisciplinary team (IDT)’s decision in order to aid the client and their legal representative to secure alternative services.

003.02(D)(iv) CLIENT DEATH. Within 10 days after a client has expired, the intermediate care facility for individuals with developmental disabilities (ICF/DD) must notify Medicaid of the date of death.

004. SERVICE REQUIREMENTS .

004.01 GENERAL REQUIREMENTS.

004.01(A) MEDICAL NECESSITY. Intermediate care facility for individuals with developmental disabilities (ICF/DD) services must meet the medical necessity requirements in 471 NAC 1, and each client must be determined to meet level of care criteria outlined in this chapter.

004.01(B) PRIOR AUTHORIZATION. Medicaid pays for intermediate care facility for individuals with developmental disabilities (ICF/DD) services only when prior authorized. Each admission must be separately prior authorized.

004.01(C) ADMISSION PROCESS. For all clients seeking Medicaid payment for intermediate care facility for individuals with developmental disabilities (ICF/DD) services, the facility must complete a pre-admission evaluation to determine if the client is Medicaid eligible or has applied for Medicaid, has been diagnosed with an intellectual disability or related condition and whether the facility can provide services to meet the client’s needs. In addition, the facility must determine that the client needs and will benefit from active treatment. The facility must conduct or obtain the following as part of the pre-admission evaluation:

(1) Current and comprehensive physician’s examination;

(2) A current dental examination completed within 12 months before admission or within one month after the date of admission;

(3) Current and comprehensive functional assessments conducted on the day of and no more than three months prior to the admission;

(4) Psychological evaluation which includes the client’s diagnoses, must be completed on or no more than three months prior to admission;

(5) The most recent individual program plan and if school age, the most recent individual education plan. Must have been implemented within the previous twelve months;

(6) Current, within the previous twelve months, habilitative training records;

(7) Current medical records;

(8) Physician certification for the client’s need of intermediate care facility for individuals with developmental disabilities (ICF/DD) level of care. Must be signed by the physician;

(9) Physician plan of care, as required by 42 CFR 456.380; and

(10) Independent qualified intellectual disabilities professional (QIDP) assessment.

004.01(C)(i) EVALUATIONS. Evaluations conducted must meet requirements found at 42 CFR 456.370(c). All evaluations, assessments, and records obtained must be current with the client’s needs at the time of the admission process as required at 42 CFR 456.370(a) and (b).

004.01(C)(ii) ADMISSION DETERMINATION. The facility will review the pre-admission evaluation and hold a pre-admission meeting with the client, guardian, and interdisciplinary team (IDT) to determine admission. Personnel from outside the facility that previously provided services to the client should be encouraged to attend, as well. The purpose of the pre-admission meeting is to:

(a) Summarize in writing the findings from the individual functional assessments;

(b) Determine the client's needs without regard to the intermediate care facility for individuals with developmental disabilities (ICF/DD)'s ability to meet those needs;

(c) Determine whether or not the intermediate care facility for individuals with developmental disabilities (ICF/DD) level of care is appropriate and meets the client’s needs. If the interdisciplinary team (IDT) determines that intermediate care facility for individuals with developmental disabilities (ICF/DD) services are not appropriate to meet the client’s needs, the intermediate care facility for individuals with developmental disabilities (ICF/DD) must refer the client and legal guardian to the Department of Health and Human Services’ Developmental Disabilities Division, Service Coordination (DDD SC) to determine the availability of alternative services;

(d) Determine if the client will be admitted to the intermediate care facility for individuals with developmental disabilities (ICF/DD); and

(e) Develop the pre-admission plan if the client is to be admitted.

004.01(C)(ii)(1) ALTERNATIVES. The intermediate care facility for individuals with developmental disabilities (ICF/DD), Medicaid, the client, family, guardian, attending physician, and intermediate care facility for individuals with developmental disabilities (ICF/DD)'s interdisciplinary team (IDT) staff must cooperatively explore alternatives available through Medicaid programs based on the client's total needs.

004.01(C)(iii) PRE-ADMISSION PLAN. The pre-admission plan is the individual program plan (IPP) for the first 30 days after the client is admitted to the intermediate care facility for individuals with developmental disabilities (ICF/DD). The plan must:

(1) Include the client’s name, date of birth, and guardianship status;

(2) Document the interdisciplinary team (IDT)’s rationale for admitting the client;

(3) Identify additional needed evaluations;

(4) Identify the client’s skills and skill deficits;

(5) Identify baselines which are conducted to determine training needs;

(6) Identify the client’s current medical and nutritional status;

(7) Specify the care, services, and referral for additional evaluations to be provided for the first 30 days or until the post-admission evaluation is established;

(8) Include programs and services to be continued from other programs; and

(9) Include a plan to explore alternative, less restrictive services on an ongoing basis.

004.01(C)(iv) PHYSICIAN'S ADMISSION HISTORY AND PHYSICAL. When the client is admitted to the intermediate care facility for individuals with developmental disabilities (ICF/DD), the facility must ensure that:

(1) The client has a physical examination within 48 hours, two working days, after admission, unless an examination was performed within thirty days before admission; and

(2) The history and physical is documented on Form DM-5 or attached to Form DM-5.

004.01(C)(v) PHYSICIAN'S INITIAL CERTIFICATION (FORM DM-5 OR FORM MC-9NF). The physician's certification on Form DM-5, Form MC-9NF, or Nursing Facility Level Of Care Determination Form, must be signed within the following time frame:

(a) For clients already eligible for Medicaid at the time of admission, Form DM-5, Form MC-9NF, or Nursing Facility Level Of Care Determination Form must be signed and dated within 30 days before the date of admission, or within 48 hours (two working days) after the date of admission; or

(b) For clients not already determined to be eligible for Medicaid at the time of admission, Form DM-5, Form MC-9NF or Nursing Facility Level Of Care Determination Form must be signed and dated within 30 days before or within 48 hours (two working days) after the date the client's eligibility is determined.

004.01(C)(v)(1) ELIGIBILITY DETERMINATION. The date of eligibility for intermediate care facility for individuals with developmental disabilities (ICF/DD) services is defined as the actual date the eligibility determination is made not necessarily the effective date of Medicaid eligibility. The following circumstances impact Medicaid coverage of intermediate care facility for individuals with developmental disabilities (ICF/DD) services:

(a) If Form DM-5, Form MC-9NF, or Nursing Facility Level of Care Determination Form, is signed and dated more than 30 days before the date of eligibility determination, the facility must provide Medicaid with a new or updated Form DM-5, Form MC-9NF, or Nursing Facility Level of Care Determination Form before Medicaid authorizes payment to the facility;

(b) If Form DM-5, Form MC-9NF, or the Nursing Facility Level of Care Determination Form is signed and dated more than 48 hours two working days after admission or eligibility determination, the earliest that payment to the facility could be effective is the date Form DM-5, Form MC-9NF, or the Nursing Facility Level Of Care Determination Form, is signed and dated. Holidays and weekends are not counted if they fall within the 48-hour time period; and

(c) If the date of Form DM-5, Form MC-9NF, or the Nursing Facility Level of Care Determination Form falls within the required time frame, Medicaid may authorize payment to be effective on the date of admission or the medical eligibility effective date.

004.01(C)(v)(2) SIGNATURE REQUIREMENTS. Form DM-5 must be signed and dated by a physician, if a physician signature stamp is used, the physician must initial the stamped signature. Physician's assistant or registered nurse signature or initials are not acceptable.

004.01(C)(v)(3) RECORD RETENTION. Forms DM-5, MC-9NF, or the Nursing Facility Level of Care Determination Form must be maintained in the client's medical record in the facility where the client resides.

004.01(C)(vi) EMERGENCY ADMISSIONS. In the case of an emergency admission, the intermediate care facility for individuals with developmental disabilities (ICF/DD) facility will follow the admission process according to this chapter. The facility must hold the pre-admission meeting on the day the client enters the facility and will document the reason for the admission. However, the facility is given seven calendar days to complete the needed assessments to verify the client’s need for intermediate care facility for individuals with developmental disabilities (ICF/DD) level of care, health and nutritional needs, skills and skill deficits and training needs.

004.01(C)(vii) ADMISSION NOTIFICATION. The intermediate care facility for individuals with developmental disabilities (ICF/DD) must notify Medicaid within 10 days of admitting a client into the intermediate care facility for individuals with developmental disabilities (ICF/DD).

004.01(D) LEVEL OF CARE.

004.01(D)(i) INTERMEDIATE CARE FACILITY FOR INDIVIDUALS WITH DEVELOPMENTAL DISABILITIES (ICF/DD) LEVEL OF CARE CRITERIA. Medicaid applies the following criteria to determine the appropriateness of intermediate care facility for individuals with developmental disabilities (ICF/DD) services on admission and at each subsequent review:

(1) The individual has a diagnosis of an intellectual disability or a related condition, which has been confirmed by prior diagnostic evaluations and standardized tests and sources independent of the intermediate care facility for individuals with developmental disabilities (ICF/DD); and

(2) The individual can benefit from active treatment as defined in 42 CFR 483.440(a) and 471 NAC 31-002. In addition, the following criteria apply:

(a) The individual has a related condition and the independent qualified intellectual disabilities professional (QIDP) assessment identifies the related condition has resulted in substantial functional limitations in three or more of the following areas of major life skills: self-care, receptive and expressive language, learning, mobility, self-direction, or capacity for independent living. These substantial functional limitations indicate that the individual needs a combination of individually planned and coordinated special interdisciplinary care, a continuous active treatment program, treatment, and other services which are lifelong or of extended duration;

(b) A Medicaid-eligible individual has a dual diagnosis of developmental disability or a related condition and a mental illness. The developmental disability or related condition has been verified as the primary diagnosis by both an independent qualified intellectual disabilities professional (QIDP) and a mental health professional in which their scope of practice allows them to diagnose mental illness:

(i) Historically there is evidence of missed developmental stages, due to developmental disability or a related condition;

(ii) There is remission in the mental illness and it does not interfere with intellectual functioning and participation in training programs; and

(iii) The diagnosis of developmental disability or a related condition takes precedence over the diagnosis of mental illness; and

(c) When the individual does not have substantial functional limitations in self-care skills, the individual must have substantial functional limitations in at least the life skill area for capacity for independent living along with two other life skill areas.

004.01(D)(ii) APPROVAL OF THE INTERMEDIATE CARE FACILITY FOR INDIVIDUALS WITH DEVELOPMENTAL DISABILITIES (ICF/DD) LEVEL OF CARE. The intermediate care facility for individuals with developmental disabilities (ICF/DD), after determining to admit the client, must submit the following to the Medicaid review team to request approval for Medicaid payment of intermediate care facility for individuals with developmental disabilities (ICF/DD) level of care for the client:

(a) Completed Form MC-9NF, or Nursing Facility Level of Care Determination Form;

(b) The physician's examination or completed Form DM-5. The physician who conducted the examination must sign and date Form DM-5 with the physician's determination of level of care indicated. If the physician’s examination is submitted instead of Form DM-5, it must include a clear indication that the physician conducting the examination certifies the client requires intermediate care facility for individuals with developmental disabilities (ICF/DD) level of care;

(c) A current dental examination, completed within 12 months before admission or within one month after the date of admission;

(d) Completed Form DM-5-DD-LTC as instructed in Appendix 471-000-5;

(e) The independent qualified intellectual disabilities professional (QIDP) assessment;

(f) The individual program plan (IPP) and individualized educational plan (IEP), if school-aged, from the previous provider;

(g) Mental health evaluation performed by a mental health professional;

(h) The pre-admission evaluation; and

(i) For out-of-state intermediate care facility for individuals with developmental disabilities (ICF/DD) verification that the client’s needs cannot be met by a Nebraska provider. Exceptions may be made by the department in its own discretion for this requirement.

004.01(D)(ii)(1) ONSITE OBSERVATIONS. When Medicaid receives all required documentation, Medicaid reviews all submitted documentation and determines whether the intermediate care facility for individuals with developmental disabilities (ICF/DD) level of care is appropriate. In the event Medicaid determines the documentation available for review does not provide adequate information to make a determination of whether the intermediate care facility for individuals with developmental disabilities (ICF/DD) level of care is appropriate, Medicaid may conduct onsite observations of the client at the facility, interview facility staff, or request additional information from the intermediate care facility for individuals with developmental disabilities (ICF/DD) facility. If additional information is needed, the intermediate care facility for individuals with developmental disabilities (ICF/DD) must provide the necessary information upon the request of Medicaid. Medicaid will notify the intermediate care facility for individuals with developmental disabilities (ICF/DD) of any decision, and will notify the client as well as the parent or guardian of an adverse decision.

004.01(D)(iii) INAPPROPRIATE LEVEL OF CARE. On admission, and at each subsequent review, the facility must ensure which services provided in the intermediate care facility for individuals with developmental disabilities (ICF/DD) are the least restrictive alternative. The following do not meet criteria for intermediate care facility for individuals with developmental disabilities (ICF/DD) services:

(a) Mental illness is the primary barrier to independent living within a normalized environment; or

(b) The intermediate care facility for individuals with developmental disabilities (ICF/DD) level of care is not the least restrictive alternative, including when the client:

(i) Exhibits skills and needs comparable to those of persons with similar needs living independently or semi-independently in the community;

(ii) Exhibits skills and needs comparable to those of persons at nursing facility (NF) level of care; or

(iii) Is able to function with little supervision or in the absence of a continuous active treatment program.

004.01(D)(iii)(1) INITIAL REVIEW. For those clients who, at the time of initial review, are found to be inappropriate for intermediate care facility for individuals with developmental disabilities (ICF/DD) care, Medicaid limits Medicaid coverage to a maximum of 30 days, beginning with the day Medicaid determines that the level of care is inappropriate.

004.01(D)(iii)(2) CLIENT RESIDING AT THE FACILITY. For those clients who, while residing at an intermediate care facility for individuals with developmental disabilities (ICF/DD), are found to be inappropriate for intermediate care facility for individuals with developmental disabilities (ICF/DD) care in accordance with the provisions of this chapter below, Medicaid limits Medicaid coverage to a maximum of 60 days, beginning with the day the recommendation becomes final.

004.01(D)(iii)(2)(a) DEPARTMENT RECOMMENDATION. After Medicaid reviews the client’s health, habilitative, and social needs and determines the client no longer meets criteria for intermediate care facility for individuals with developmental disabilities (ICF/DD) level of care according to this chapter, the following process will take place:

(i) Medicaid will send a notification letter to the client's attending physician and the intermediate care facility for individuals with developmental disabilities (ICF/DD)'s qualified intellectual disabilities professional (QIDP) giving them an opportunity to respond. Based on the responses, Medicaid may take the following actions:

(1) If appropriate justification for continued intermediate care facility for individuals with developmental disabilities (ICF/DD) care is provided within the time frames specified in the letter of notification, the recommendation may be withdrawn; or

(2) In the absence of appropriate or timely justification, the recommendation becomes final;

(ii) Once the responses of the attending physician and intermediate care facility for individuals with developmental disabilities (ICF/DD) qualified intellectual disabilities professional (QIDP) have been reviewed, Medicaid will send written notification of the decision to the intermediate care facility for individuals with developmental disabilities (ICF/DD), the attending physician, and the intermediate care facility for individuals with developmental disabilities (ICF/DD)’s qualified intellectual disabilities professional (QIDP); and

(iii) If the recommendation is upheld, the intermediate care facility for individuals with developmental disabilities (ICF/DD) must document a specific and appropriate discharge plan in compliance with 42 CFR 483.440(b) to assist the client in preparing for alternate arrangements.

004.01(D)(iii)(2)(b) INTERMEDIATE CARE FACILITY FOR INDIVIDUALS WITH DEVELOPMENTAL DISABILITIES (ICF/DD) RECOMMENDATION. Intermediate care facility for individuals with developmental disabilities (ICF/DD) staff must submit requests for a change of level of care between reviews to Medicaid in writing along with supporting documentation. If the client needs to be discharged to an alternative setting:

(i) The intermediate care facility for individuals with developmental disabilities (ICF/DD) must notify the individual, family or legal guardian, and the Department of Health and Human Services’ Developmental Disabilities Division, Service Coordination (DDD SC) recommendation; of the

(ii) The intermediate care facility for individuals with developmental disabilities (ICF/DD) must assist the client, family, or legal guardian in seeking appropriate alternatives;

(iii) The intermediate care facility for individuals with developmental disabilities (ICF/DD) must document which other alternatives were explored and the responses;

(iv) The present intermediate care facility for individuals with developmental disabilities (ICF/DD) must provide services to meet the needs of the client and must refer to appropriate agencies for services until the expiration of the 60 day coverage period or until an appropriate alternative is available, whichever comes first;

(v) The intermediate care facility for individuals with developmental disabilities (ICF/DD), and others involved, must make available to the Medicaid review team the documentation of active exploration for appropriate alternatives; and

(vi) Upon receipt of all the necessary information, the intermediate care facility for individuals with developmental disabilities (ICF/DD) must document a specific and appropriate discharge plan in compliance with 42 CFR 483.440(b) to assist the client in preparing for alternate arrangements.

004.01(D)(iii)(2)(c) ADDITIONAL RECOMMENDATIONS. In the event that any State or Federal survey or certification agency determines a client no longer needs or benefits from intermediate care facility for individuals with developmental disabilities (ICF/DD) services, Medicaid will follow the process outlined in 471 NAC 31-004.01(D)(iii)(2)(a).

004.01(D)(iv) INTERMEDIATE CARE FACILITY FOR INDIVIDUALS WITH DEVELOPMENTAL DISABILITIES (ICF/DD) LEVEL OF CARE CONTINUANCE. A client who currently resides in an intermediate care facility for individuals with developmental disabilities (ICF/DD) who has been determined inappropriate for that level of care may be approved by the Medicaid review team to continue at the intermediate care facility for individuals with developmental disabilities (ICF/DD) level of care, for a limited period of time. The continuance may be approved when the intermediate care facility for individuals with developmental disabilities (ICF/DD) presents written documentation of its ongoing efforts to obtain an appropriate alternative living situation for the client.

004.01(E) OUT-OF-STATE SERVICES. Medicaid covers out-of-state intermediate care facility for individuals with developmental disabilities (ICF/DD) services in accordance with 471 NAC 1. Evidence must be provided that the client’s needs cannot be met by providers in Nebraska. Out-of-State services may also be permitted by department discretion in cases where the client’s current living situation is bordering an out-of-state community where an appropriate provider is located.

004.01(F) INDEPENDENT QUALIFIED INTELLECTUAL DISABILITIES PROFESSIONAL (QIDP) ASSESSMENT. The intermediate care facility for individuals with developmental disabilities (ICF/DD) facility must ensure an independent qualified intellectual disabilities professional (QIDP) assessment is completed for all clients during the admission process. The facility is responsible for securing the qualified intellectual disabilities professional (QIDP), including payment for such services. An individual program plan (IPP) is acceptable in lieu of the independent qualified intellectual disabilities professional (QIDP) assessment as long as the individual program plan (IPP) provides accurate and current information regarding the client’s strengths and needs. The Individual Program Plan (IPP) cannot have an implementation date of more than 12 months prior to the client’s admission to the facility. The facility must ensure:

(1) The qualified intellectual disabilities professional (QIDP) is not associated with the facility in any manner;

(2) The qualified intellectual disabilities professional (QIDP) meets requirements at 42 CFR 480.430 to be considered a qualified intellectual disabilities professional (QIDP);

(3) The qualified intellectual disabilities professional (QIDP) assessment is completed no later than the date of and, no more than three months prior to, the client’s admission to the facility; and

(4) The independent qualified intellectual disabilities professional (QIDP) completes the assessment in accordance with requirements at 471 NAC 31-004.01(F)(i).

004.01(F)(i) QUALIFIED INTELLECTUAL DISABILITIES PROFESSIONAL (QIDP) ASSESSMENT PROCESS. To ensure completion of an accurate, comprehensive assessment, the qualified intellectual disabilities professional (QIDP) must:

(1) Interview and conduct observations of the client in their living environment, and vocational environment, if possible;

(2) Conduct a functional and complete assessment of skills, using an appropriate standardized assessment tool, in order to identify the client's present skills and skill-deficit areas;

(3) Review records to verify the diagnosis of an intellectual disability or related condition, including the most recent psychological assessment, as well as medical records;

(4) Review of available, relevant client records, including medical and programming records, to aid in determining the client’s skills, skill-deficits, training needs, and possible assessment needs;

(5) Submit a written report to the facility which summarizes the results of the qualified intellectual disabilities professional (QIDP) assessment. The written report must include the following:

(a) The client’s name, age, and date of birth;

(b) The client’s current address or place of residence;

(c) The client’s guardianship status;

(d) The client’s current diagnosis and physical disabilities;

(e) Sources of information gathered to complete the assessment;

(f) Any independent assessments or evaluations conducted as part of the assessment process;

(g) Date(s) the assessment was conducted, as well as the date of the written report;

(h) A narrative summarizing the client’s skills and skill-deficits, including use of adaptive equipment, with regard to:

(i) Self-care;

(ii) Communication, receptive and expressive;

(iii) Learning abilities;

(iv) Mobility;

(v) Self-direction, adaptive skills, including but not limited to behavior, social skills and decision-making skills;

(vi) Independent living skills, including but not limited to money-handling, daily household tasks, and community access;

(vii) Vocational skills; and

(viii) Recommendations for each skill area for training, treatment needs, further assessment and evaluation needs, needed adaptive equipment, and possible needs for additional services. The recommendations must be determined without regard to the availability of services;

(j) Summary of progress, or lack of progress, in previous service settings;

(k) The qualified intellectual disabilities professional (QIDP)’s determination of the type of service setting needed to meet the client’s treatment needs. This determination must not identify a specific facility or provider; and

(l) The qualified intellectual disabilities professional (QIDP)’s name, signature, and address.

004.01(G) INDIVIDUAL PROGRAM PLAN (IPP). Within 30 days of a client’s admission to the intermediate care facility for individuals with developmental disabilities (ICF/DD), the interdisciplinary team (IDT) must prepare an individual program plan (IPP). The individual program plan (IPP) must specify long-term goals, short-term objectives, and services to address prioritized needs in a continuum of development; outlining projected progressive, sequential, steps and the developmental consequences, outcomes, of training programs and services. Additionally, the individual program plan (IPP) must address therapeutic leave. Long-term goals and short-term objectives for all formal training to be provided are based on identified needs. Objectives must be person-centered, stated in specific, observable, and measurable terms so the level of skill acquisition can be assessed. The long-term goal must be the culmination of its short-term objectives. Each client's individual program plan (IPP), functional assessments, and nursing plan of care must be made available to all relevant staff and the interdisciplinary team (IDT). As soon as the interdisciplinary team (IDT) has formulated a client's individual program plan (IPP), each client must receive a continuous active treatment program consisting of needed interventions and services in sufficient number and frequency to support the achievement of the objectives identified in the individual program plan (IPP).

004.01(G)(i) REVIEW AND REVISION OF THE INDIVIDUAL PROGRAM PLAN (IPP). The interdisciplinary team (IDT) must review each individual program plan (IPP) at least quarterly, and revise each individual program plan (IPP) as needed. At least annually, the Interdisciplinary Team (IDT) reviews and updates each client's individual program plan (IPP), including ongoing exploration of alternatives. Each interdisciplinary team (IDT) member's assessment must be completed before this annual review. The revisions of the individual program plan (IPP) are based on current needs as identified by the comprehensive functional assessments and the client's response to training, as required by 42 CFR 456.380(c) and 483.440. The qualified intellectual disabilities professional (QIDP) and other interdisciplinary team (IDT) members must each routinely review aspects of the client's active treatment process to determine if the client's needs are effectively addressed and if revisions are needed.

004.01(H) BED HOLDING. Medicaid covers a reserved bed in an intermediate care facility for individuals with developmental disabilities (ICF/DD) during a client's absence, due to hospitalization for an acute condition, and for therapeutically indicated home visits. Coverage of bed holding is subject to the following conditions:

(1) A held bed must be vacant and counted in the census. The census must not exceed licensed capacity;

(2) Hospital bed holding is limited to reimbursement for 15 days per hospitalization;

(3) Therapeutic leave bed holding is limited to reimbursement for 36 days per calendar year, even if the client has a stay in more than one intermediate care facility for individuals with developmental disabilities (ICF/DD) during the calendar year. Bed holding days are prorated when a client is admitted after January 1; and

(4) Facility staff must work with the client as well as parent or guardian to plan the use of the allowed 36 days of therapeutic leave for the calendar year.

004.01(H)(i) SPECIAL LIMIT. When the limitation for therapeutic leave interferes with an approved therapeutic or habilitative program, the intermediate care facility for individuals with developmental disabilities (ICF/DD) may submit a request for special limits of up to an additional six days per calendar year to Medicaid. Requests for special limits must include:

(1) The number of leave days requested;

(2) The need for additional therapeutic bed holding days;

(3) The physician's orders; and

(4) The individual program plan (IPP).

004.02 COVERED SERVICES.

004.02(A) ANNUAL PHYSICAL EXAMINATION. Medicaid requires that all individuals eligible for Medicaid residing in long-term care facilities have an annual physical examination. The physician or other medical professional, operating within their scope of practice according to State law and based on their authority to prescribe continued treatment, determines the extent of the examination for individuals eligible for Medicaid based on medical necessity. For the annual physical exam, a CBC and urinalysis will not be considered "routine" and is reimbursed based on the medical practitioner's orders. The results of the examination must be recorded in the individual's medical record.

004.02(B) HEALTH CARE SERVICES. The intermediate care facility for individuals with developmental disabilities (ICF/DD) must ensure that intermediate care facility for individuals with developmental disabilities (ICF/DD) clients receive appropriate health care services. If appropriate health care services cannot be provided by facility staff, the care must be contracted from providers who are licensed or certified as applicable.

004.02(B)(i) PHYSICIAN SERVICES.

004.02(B)(i)(1) PHYSICIAN'S OVERALL PLAN OF CARE. Before admission to an intermediate care facility for individuals with developmental disabilities (ICF/DD), or before authorization for payment, a physician must establish a written plan of care for each client. The client’s interdisciplinary team must review the client's plan of care at least every 90 days. The plan of care must include:

(a) Diagnoses, symptoms, complaints, and complications indicating the need for admission;

(b) A description of the functional level of the client;

(c) Objectives;

(d) Any orders for:

(i) Medications;

(ii) Treatments;

(iii) Restorative and rehabilitative services;

(iv) Activities;

(v) Therapies;

(vi) Social services;

(vii) Diet; and

(viii) Special procedures designed to meet the objectives of the plan of care;

(e) Plans for continuing care, including review of and modification of the plan of care;

(f) A determination of whether the client needs a medical care plan; and

(g) Plans for discharge.

004.02(B)(i)(2) STANDARDS FOR PHYSICIAN SERVICES. The facility must ensure the availability of physician services 24 hours a day. The physician must develop, in coordination with licensed nursing personnel, a medical care plan for a client if the physician determines the individual requires 24-hour licensed nursing care. This plan must be integrated in the individual program plan. To the extent permitted by state law, the facility may utilize physician assistants and nurse practitioners to provide physician services as described in this section. The facility must provide or obtain preventive and general medical care, as well as annual physical examinations, of each client that at a minimum include the following:

(a) Evaluation of vision and hearing;

(b) Immunizations, using as a guide the recommendations of the Public Health Service Advisory Committee on Immunization Practices or of the Committee on the Control of Infectious Diseases of the American Academy of Pediatrics;

(c) Routine screening laboratory examinations, as determined necessary by the physician, and special studies when needed; and

(d) Tuberculosis control, appropriate to the facility's population, and in accordance with the recommendations of the Nebraska Department of Health and Human Services Regulation and Licensure.

004.02(B)(i)(3) PHYSICIAN PARTICIPATION IN THE INDIVIDUAL PROGRAM PLAN. A physician must participate in:

(a) The establishment of each newly admitted client's initial individual program plan as required by 42 CFR 456.380; and

(b) If appropriate, the review and update of an individual program plan as part of the interdisciplinary team (IDT) process either in person or through written report to the interdisciplinary team (IDT).

004.02(B)(i)(4) RECERTIFICATION. The physician, the physician's assistant or nurse practitioner, must recertify in writing the client's continued need for the intermediate care facility for individuals with developmental disabilities (ICF/DD) level of care at least once every 365 days, and at any time the client requires a different level of care. The extended recertification period in no way indicates that one year is the appropriate length of stay for a client in an intermediate care facility for individuals with developmental disabilities (ICF/DD). The interdisciplinary team responsible for the client's care determines the client's length of stay.

004.02(B)(i)(4)(a) DELEGATION. The physician's assistant, or nurse practitioner, may recertify the client's need under the general supervision of a physician when the physician formally delegates this function to the physician's assistant or nurse practitioner.

004.02(B)(i)(4)(b) SIGNATURE. The physician, the physician's assistant, or nurse practitioner must sign, or signature stamp and initial, and date the recertification clearly identifying the medical professional as a physician, physician's assistant, or nurse practitioner. Electronic signatures will also be accepted.

004.02(B)(i)(4)(c) RECORDS. Facility staff must maintain the recertification in the client's medical record in the facility where the client resides.

004.02(B)(i)(4)(d) RECORD RETENTION. The physician must record recertifications accomplished by on-site visits to the facility in the client's medical record. The physician is paid according to 471 NAC 18 for a nursing home visit. The physician must use the appropriate procedure codes when billing Medicaid for this service.

004.02(B)(ii) NURSING SERVICES.

004.02(B)(ii)(1) STANDARDS FOR NURSING SERVICES. The facility must provide clients with nursing services in accordance with their needs. These services must include:

(a) Participation in the pre-admission evaluation and in the development, review, and update of an individual program plan as part of the interdisciplinary team (IDT) process;

(b) The development, with a physician, of a medical care plan of treatment for a client when the physician has determined that a client requires such a plan;

(c) For those clients certified as not needing a medical care plan, a review of their health status which must:

(i) Be by direct physical examination;

(ii) Be by a licensed nurse;

(iii) Be on a quarterly or more frequent basis depending on need;

(iv) Be recorded in the record; and

(v) Result in any necessary action (including referral to a physician to address health problems;

(d) Other nursing care as prescribed by the physician or as identified by needs;

(e) Implementing, with other members of the interdisciplinary team (IDT), appropriate protective and preventive health measures which include, but are not limited to:

(i) Training clients and staff as needed in appropriate health and hygiene methods;

(ii) Control of communicable diseases and infections, including the instructions of other personnel in methods of infection control; and

(iii) Training direct care staff in detecting signs and symptoms of illness or dysfunction, first aid for accidents or illness, and basic skills required to meet the health needs of the clients; and

(f) The nursing plan of care as part of the individual program plan (IPP) must be revised as necessary, but reviewed at least quarterly.

004.02(B)(ii)(2) STANDARDS FOR NURSING STAFF. Nurses providing services in the facility must have a current license to practice in the state. The facility must employ, or arrange for, licensed nursing services sufficient to care for client’s health needs, including those clients with medical care plans.

004.02(B)(ii)(2)(a) ADDITIONAL REQUIREMENTS. The facility must utilize registered nurses as appropriate and required by state law, to perform the health services specified in this section. If the facility utilizes only licensed practical or vocational nurses to provide health services, it must have a formal written arrangement with a registered nurse to be available for verbal or onsite consultation to the licensed practical or vocational nurse. Non-licensed nursing personnel who work with clients under a medical care plan must do so under the supervision of licensed nursing personnel.

004.02(B)(iii) DENTAL CARE. All intermediate care facility for individuals with developmental disabilities (ICF/DD) clients must have a dental evaluation:

(a) Within 12 months before admission or within one month after admission; and

(b) At least annually thereafter.

004.02(B)(iii)(1) STANDARDS FOR DENTAL SERVICES. The facility must provide, or make arrangements for, comprehensive diagnostic and treatment services for each client from qualified personnel. This includes licensed dentists and dental hygienists either through organized dental services in-house or through arrangement. If appropriate, dental professionals must participate, in the development, review, and update of an individual program plan as part of the interdisciplinary team (IDT) process either in person or through written report to the interdisciplinary team (IDT). The facility must provide education and training in the maintenance of oral health.

004.02(B)(iii)(2) COMPREHENSIVE DENTAL DIAGNOSTIC SERVICES. Comprehensive dental diagnostic services include:

(a) A complete extraoral and intraoral examination, using all diagnostic aids necessary to properly evaluate the client's oral condition, not later than one month after admission to the facility, unless the examination was completed within 12 months before admission;

(b) Periodic examination and diagnosis performed at least annually, including radiographs, when indicated and detection of manifestations of systemic disease; and

(c) A review of the results of examination and entry of the results in the client's dental record.

004.02(B)(iii)(3) COMPREHENSIVE DENTAL TREATMENT. The facility must ensure comprehensive dental treatment services which include:

(a) The availability for emergency dental treatment on a 24-hour-a-day basis by a licensed dentist; and

(b) Dental care needed for relief of pain and infections, restoration of teeth, and maintenance of dental health.

004.02(B)(iii)(4) DOCUMENTATION OF DENTAL SERVICES. If the facility maintains an in-house dental service, the facility must keep a permanent dental record for each client, with a dental summary maintained in the client's living unit. If the facility does not maintain an in-house dental service, the facility must obtain a dental summary of the results of dental visits and maintain the summary in the client's medical record.

004.02(C) ITEMS COVERED PER DIEM PAYMENTS. The following items are included in the per diem payment made by Medicaid to the intermediate care facility for individuals with developmental disabilities (ICF/DD).

004.02(C)(i) ROUTINE SERVICES. Routine intermediate care facility for individuals with developmental disabilities (ICF/DD) services include regular room, dietary, and nursing services; social services and active treatment program as required by any applicable federal and state certification standards; minor medical supplies; oxygen and oxygen equipment; the use of equipment and facilities; and other routine services. Examples of items which routine services may include are:

(1) All general nursing services, including administration of oxygen and related medications; collection of all laboratory specimens as ordered by the physician, such as blood and urine; hand-feeding; incontinency care; tray service; normal personal hygiene which includes bathing, skin care, hair care, excluding professional barber and beauty services, nail care, shaving, and oral hygiene; enema;

(2) Active treatment: The facility must provide a continuous active treatment program, as determined necessary by each client's interdisciplinary team, including physical therapy, occupational therapy, speech therapy, recreational therapy, and pre-vocational services and related supplies to include, but not limited to, augmentative communication devices with related equipment and software, as described in each client's Individual Plan of Care;

(3) Items which are furnished routinely and relatively uniformly to all residents. These items include gowns, linens, water pitchers, basins, and bedpans;

(4) Items stocked at nursing stations on each floor or in each home in gross supply and distributed or used individually, including alcohol, applicators, cotton balls, Band Aids, incontinency care products, oxygen and oxygen equipment, colostomy supplies, catheters, irrigation equipment, tape, needles, syringes, I.V. equipment, supports, hydrogen peroxide, over the counter enemas, tests, tongue depressors, hearing aid batteries, facial tissue, personal hygiene items;

(5) Items which are used by individual residents, but are reusable and expected to be available, such as; ice bags, bed rails, canes, crutches, walkers, standard wheelchairs, gerichairs, traction equipment, alternating pressure pad and pump, and all other durable medical equipment not listed in 471 NAC 31-004.03(A)(ii);

(6) Nutritional supplements and supplies used for oral, enteral, or parenteral, feeding;

(7) Laundry services, including personal clothing;

(8) Cost of providing basic cable television service, including applicable installation charge, to individual rooms. This is not a mandatory service; and

(9) Repair of medically necessary facility owned and purchased durable medical equipment and their maintenance.

004.02(C)(ii) INJECTIONS. The resident's physician must prescribe all injections. Payment is not authorized for the administration of injections, since giving injections is considered a part of routine nursing care and covered by the long-term care facility's reimbursement. Payment is authorized to the drug provider for drugs used in approved injections. Syringes and needles are necessary medical supplies and are included in the per diem rate.

004.02(C)(iii) TRANSPORTATION. The facility is responsible for ensuring that all clients receive appropriate medical care. The facility must provide transportation to client services which are reimbursed by Medicaid including, but not limited to, medical and dental services. The reasonable cost of maintaining and operating a vehicle for patient transportation is an allowable cost and is reimbursable under the long-term care reimbursement plan.

004.03 NON-COVERED SERVICES.

004.03(A) ITEMS NOT INCLUDED IN PER DIEM RATES. Medicaid may cover services provided in an intermediate care facility for individuals with developmental disabilities (ICF/DD) which are not included in the per diem payment outlined in 471 NAC 31-004.02(C). Coverage of additional items and services is provided in accordance with each specific NAC Title 471 Chapter.

004.03(A)(i) PAYMENTS TO INTERMEDIATE CARE FACILITY FOR INDIVIDUALS WITH DEVELOPMENTAL DISABILITIES (ICF/DD) PROVIDER SEPARATE FROM THE PER DIEM RATE. Items for which payment may be made to intermediate care facility for individuals with developmental disabilities (ICF/DD) providers and are not considered part of the facility’s Medicaid per diem are listed below. To be covered, the client’s condition must meet the criteria for coverage for the item as outlined in 471 NAC 7.

(1) Non-standard wheelchairs and wheelchair accessories, options, and components, including power operated vehicles;

(2) Air fluidized bed units and low air loss bed units; and

(3) Negative pressure wound therapy.

004.03(A)(ii) PAYMENTS TO OTHER PROVIDERS. Items for which payment may be authorized to non-intermediate care facility for individuals with developmental disabilities (ICF/DD) providers and are not considered part of the facility's Medicaid per diem are listed below. To be covered, the client's condition must meet the criteria for coverage for the item as outlined in the appropriate Medicaid provider chapter. The provider of the service may be required to request prior authorization of payment for the service.

(1) Legend drugs, over the counter drugs and compounded prescriptions, including intravenous solutions and dilutants;

(2) Personal appliances and devices, if recommended in writing by a physician, such as eye glasses, hearing aids;

(3) Orthoses as defined in 471 NAC 7;

(4) Prostheses as defined in 471 NAC 7; and

(5) Ambulance services required to transport a client to obtain and after receiving Medicaid-covered medical care which meets the definitions in 471 NAC 4.

004.03(A)(ii)(5)(a) AMBULANCE SERVICES MEDICAL NECESSITY. To be covered, ambulance services must be medically necessary and reasonable. Medical necessity is established when the client's condition is such that use of any other method of transportation is contraindicated. In any case in which some means of transportation other than an ambulance could be used without endangering the client's health, whether or not such other transportation is actually available, Medicaid does not make payment for ambulance service.

004.03(A)(ii)(5)(b) NON-EMERGENCY AMBULANCE SERVICES. Non-emergency ambulance transports to a physician or practitioner's office, clinic, or therapy center are covered when the client is bed confined before, during and after transport and when the services cannot or cannot reasonably be expected to be provided at the client's residence (including the intermediate care facility for individuals with developmental disabilities (ICF/DD)).

005. BILLING AND PAYMENT FOR INTERMEDIATE CARE FACILITY FOR INDIVIDUALS WITH DEVELOPMENTAL DISABILITIES (ICF/DD) SERVICES .

005.01 BILLING.

005.01(A) GENERAL BILLING REQUIREMENTS. Providers must comply with all applicable billing requirements codified in 471 NAC 3. In the event individual billing requirements in 471 NAC 3 conflict with billing requirements outlined in this chapter, the individual billing requirements in this chapter govern.

005.01(B) SPECIFIC BILLING REQUIREMENTS.

005.01(B)(i) REPORTING BED HOLDING DAYS. Intermediate care facility for individuals with developmental disabilities (ICF/DD) must report bed holding days on the appropriate claim. The appropriate bed holding days are reported as outlined in claim submission instructions; the “nursing facility days” are adjusted to the actual number of days the client was present in the intermediate care facility for individuals with developmental disabilities (ICF/DD) at midnight.

005.01(B)(ii) BILLING FOR THE ANNUAL PHYSICAL EXAMINATION. If the annual physical examination is performed solely to meet the Medicaid requirement, the physician must use the appropriate Healthcare Common Procedure Coding System code and submit the claim to Medicaid. If the physical examination is performed for diagnosis or treatment of a specific symptom, illness, or injury and the individual has Medicare or other third party coverage, the physician must submit the claim through the usual Medicare or other third party process.

005.02 PAYMENT.

005.02(A) GENERAL PAYMENT REQUIREMENTS. Nebraska Medicaid will reimburse the provider for services rendered in accordance with the applicable payment regulations codified in 471 NAC 3. In the event individual payment regulations in 471 NAC 3 conflict with payment regulations outlined in this chapter, the individual payment regulations in this chapter govern.

005.02(B) SPECIFIC PAYMENT REQUIREMENTS. Medicaid will pay for intermediate care facility for individuals with developmental disabilities (ICF/DD) services only when prior authorized.

005.02(B)(i) INITIAL CERTIFICATION. Medicaid must approve payment to an intermediate care facility for individuals with developmental disabilities (ICF/DD) for services rendered to an eligible client beginning on the date:

(1) The client is formally admitted to the intermediate care facility for individuals with developmental disabilities (ICF/DD) following the admission evaluation process;

(2) The client's eligibility for Medicaid is effective, if later than the admission date; or

(3) The date Form DM-5 is signed and dated, if Form DM-5 is signed and dated more than 48 hours (two working days) after admission or the date eligibility is determined. If the physician’s examination is submitted instead of Form DM-5, the date the physician’s examination is signed and dated, if this execution is more than 48 hours (two working days) after admission or the date eligibility is determined. If Form DM-5 is signed and dated more than 30 days before admission, or the date eligibility is determined, Medicaid will not approve payment unless a new or updated Form DM-5 is obtained.

005.02(B)(ii) DEATH ON DAY OF ADMISSION. If a client is admitted to an intermediate care facility for individuals with developmental disabilities (ICF/DD) and dies before midnight on the same day, Medicaid allows payment for one day of care.

005.03 INTERMEDIATE CARE FACILITY FOR INDIVIDUALS WITH DEVELOPMENTAL DISABILITIES (ICF/DD) RATE REQUIREMENTS.

005.03(A) REPORTING REQUIREMENTS AND RECORD RETENTION. Providers must submit cost and statistical data on Form FA-66, Long-Term Care Cost Report, and Form FA-66 Intermediate Care Facility For Individuals With Developmental Disabilities (ICF/DD), Long-Term Care Cost Report Supplement. Data must be compiled on the basis of generally accepted accounting principles and the accrual method of accounting for the report period. If conflicts occur between generally accepted accounting principles and requirements of this regulation, the requirements of this regulation prevail. Financial and statistical records for the period covered by the cost report must be accurate and sufficiently detailed to substantiate the data reported. All records must be readily available upon request by Medicaid for verification of the reported data. I f records are not accurate, sufficiently detailed, or readily available, Medicaid may correct, reduce, or eliminate data. Providers are notified of changes.

005.03(A)(i) TIMELINE. Each facility must complete the required schedules and submit the original, signed Report to Medicaid within 90 days of the close of the reporting period, when a change in ownership or management occurs, or when terminated from participation in Medicaid. Under extenuating circumstances, an extension not to exceed 45 days may be permitted. Requests for extensions must be made in writing before the date the cost report is due.

005.03(A)(ii) FAILURE TO PROVIDE. When a provider fails to file a cost report prior to expiration of 90 days from the close of the reporting period, Medicaid will suspend payment. At the time the suspension is imposed, Medicaid will send a letter informing the provider that if a cost report is not filed, all payments made since the end of the cost report period are deemed overpayments. The provider must continue to care for residents and maintain levels of care if Medicaid suspends payment.

005.03(A)(iii) LEGAL ACTION. If the provider takes no action to comply with the obligation, Medicaid may refer the case for legal action.

005.03(A)(iv) SUMS DUE. If a cost report has not been filed, the sum of the following is due:

(1) All payments made during the rate period to which the cost report applies;

(2) All payments made subsequent to the accounting rate period to which the cost report applies; and

(3) Costs incurred by Medicaid in attempting to secure reports and payments.

005.03(A)(v) AUDIT. If the provider later submits an acceptable cost report, Medicaid will undertake the necessary audit activities. Providers will receive all funds due to them reflected under the properly submitted cost reports less any costs incurred by Medicaid as a result of late filing.

005.03(A)(vi) RETENTION OF RECORDS. Providers must retain financial records, supporting documents, statistical records, and all other pertinent records related to the cost report for a minimum of five years after the end of the report period or until an audit started within the five years is finalized, whichever is later. Records relating to the acquisition and disposal of fixed assets must be retained for a minimum of five years after the assets are no longer in use by the provider. Medicaid retains all cost reports for at least five years after receipt from the provider.

005.03(A)(vii) OTHER SERVICES. Facilities providing any services other than certified intermediate care facility for individuals with developmental disabilities (ICF/DD) services must report all costs separately, based on separate cost center records. As an alternative to separate cost center records and for shared costs, the provider may use a reasonable allocation basis documented with the appropriate statistics. All allocation bases must be approved by Medicaid before the report period. Any Medicare certified facility must not report costs for a level of care to Medicaid which have been reported for a different level of care on a Medicare cost report.

005.03(B) AUDITS. Medicaid will perform an initial desk audit on all cost reports. Payment rates are determined after the initial desk audit is completed. Subsequent desk audits or a periodic field audit may also be performed for each cost report. Performance of a desk audit includes the review of information submitted, and may require additional information to be submitted by the provider. Performance of a field audit requires an onsite visit to the provider to review information.

005.03(B)(i) SUBSEQUENT AUDITS. Selection of subsequent desk audits and field audits are made as determined necessary by Medicaid to maintain the integrity of the program. Medicaid may retain an outside independent public accounting firm, licensed to do business in Nebraska or the state where the financial records are maintained, to perform the audits. Audit reports must be completed on all field audits and desk audits. All audit reports are retained by Medicaid for at least three years following the completion and finalization of the audit.

005.03(B)(ii) INITIAL AUDITS. An initial desk audit is completed on all cost reports. Payment rates are determined after the initial desk audit is completed.

005.03(B)(iii) SUBSEQUENT AUDITS. All cost reports, including those previously desk audited but excluding those previously field audited, are subject to subsequent desk audits. To initiate a subsequent desk audit, Medicaid sends a notification letter to the provider identifying the primary period(s) and subject(s) to be desk audited. The provider must deliver copies of schedules, summaries, or other records requested by Medicaid as part of any desk audit.

005.03(B)(iv) FIELD AUDITS. All cost reports, including those previously desk-audited but excluding those previously field-audited, are subject to field audit by Medicaid. The primary period(s) to be field-audited are indicated in a confirmation letter, which is mailed to the facility before the start of the field work. A field audit may be expanded to include any period that has not previously been subjected to a field audit. The scope of each field audit is determined by Medicaid. The provider must deliver to the site of the field audit, or an alternative site agreed to by the provider and Medicaid, any records requested by Medicaid as part of a field audit.

005.03(C) SETTLEMENT AND RATE ADJUSTMENTS. When an audit has been completed on a cost report, Medicaid will determine if an adjustment to the rate is required. If necessary, a settlement amount is determined. Payment, or arrangements for payment, of the settlement amount, by either Medicaid or the provider, must be made within 45 days of the settlement notice unless an administrative appeal filed within the appeal period is also filed within the 45-day repayment period. Administrative appeals filed after the 45-day payment period will not stay repayment of the settlement amount. The filing of an administrative appeal will not stay repayments to Medicaid for audit adjustments not included in the appeal request. If an audit is completed during the applicable rate period, Medicaid will adjust the rate for payments made after the audit completion.

005.03(C)(i) FINAL ADJUSTMENT. Medicaid will determine a final adjustment to the rate and settlement amount after the audit is final and all appeal options have been exhausted. Payment for any final settlement must be made within 30 days. If payment is not made, Medicaid will immediately begin recovery from future facility payments until the amount due is recovered.

005.03(C)(ii) REPORT. Medicaid will report an overpayment to the federal government on the appropriate form no later than the second quarter following the quarter in which the overpayment was found.

005.03(D) APPEAL PROCESS. Final administrative decision or inaction in the allowable cost determination process is subject to administrative appeal. The provider may request an appeal in writing from the Director of Medicaid within 90 days of the decision or inaction. The request for an appeal must include identification of the specific adjustments or determinations being appealed and basis or explanation of each item. After the Director issues a determination in regard to the administrative appeal, Medicaid will notify the facility of the final settlement amount. Repayment of the settlement amount must be made within 30 days of the date of the letter of notification.

005.03(E) ADMINISTRATIVE FINALITY. Administrative decision or inaction in the allowable cost determination process for any provider, which is otherwise final, may be reopened by Medicaid within three years of the date of notice of the decision or inaction. "Reopening" means an action taken by the Director of Medicaid to reexamine or question the correctness of a determination or decision that is otherwise final. The Director is the sole authority in deciding whether to reopen. A provider does not have the right to appeal a finding by the Director that a reopening or correction of a determination or decision is not warranted. The action may be taken:

(i) On the initiative of Medicaid within the three-year period;

(ii) In response to a written request from a provider or other entity within the three-year period. Whether the Director will reopen a determination, which is otherwise final, depends on whether new and material evidence has been submitted, a clear and obvious error has been made, or the determination is found to be inconsistent with the law, regulations and rulings, or general instructions; or

(iii) Any time fraud or abuse is suspected.

005.03(F) SANCTIONS. See 471 NAC 2.

005.03(G) CHANGE OF HOLDER OF PROVIDER AGREEMENT. A holder of a provider agreement receiving payments under this section must notify Medicaid 60 days before any change or termination regarding the holder of the provider agreement. If any known settlement is due Medicaid by that provider, payment must be made immediately. If the provider is subject to recapture of depreciation on the anticipated sale or if an audit is in process, the provider is required to provide a guarantee of repayment of Medicaid's estimated settlement either by payment of that amount to Medicaid, providing evidence that another provider receiving payments under this section has assumed liability, or by surety bond for payment. All estimated or final amounts, regardless of appeal status, must be paid before the transfer of ownership.

005.03(G)(i) UNPAID SETTLEMENT. Medicaid will not enter into a provider agreement with a new provider if there is an unpaid settlement payable to Medicaid by a prior provider of services at the same facility unless the new provider has assumed liability for the unpaid amount. Parties to a facility provider change may receive information about unpaid settlement amounts owed to Medicaid by making a written request.

005.03(H) ADDITIONAL PAYMENT TO NON-STATE-OPERATED INTERMEDIATE CARE FACILITY FOR PERSONS WITH DEVELOPMENTAL DISABILITIES (ICF/DD) PROVIDERS. In accordance with Neb. Rev. Stat. § 68-1804(3)(d), non-state-operated intermediate care facility for individuals with developmental disabilities (ICF/DD) providers may be eligible to participate in an additional distribution. For fiscal years 2011-12, 2012-13, and 2013-14, Medicaid determines the amount available in the intermediate care facility for individuals with developmental disabilities (ICF/DD) Reimbursement Protection Fund. Following the distributions of the payments identified in Neb. Rev. Stat. § 68-1804(3)(a-c), the amount remaining in the Fund, not to exceed a total of $600,000, is distributed to non-State-operated intermediate care facility for individuals with developmental disabilities (ICF/DD) providers.

006. UTILIZATION REVIEW . Utilization reviews (UR) of Nebraska Medicaid clients residing in an intermediate care facility for individuals with developmental disabilities (ICF/DD) are conducted by the Medicaid review team to determine if clients continue to meet intermediate care facility for individuals with developmental disabilities (ICF/DD) level of care. The utilization review (UR) also evaluates the effectiveness of services provided to clients by intermediate care facilities for individuals with developmental disabilities (ICF/DD). Utilization reviews (UR) will occur at least every six months. The intermediate care facility for individuals with developmental disabilities (ICF/DD) must retain documentation of the utilization review (UR) in the client’s permanent record.

006.01 MEDICAID REVIEW TEAM.

006.01(A) MEDICAID REVIEW TEAM RESPONSIBILITIES. The Medicaid review team will:

(1) With input from facility staff as needed, establish a utilization review (UR) schedule for each intermediate care facility for individuals with developmental disabilities (ICF/DD);

(2) Notify the facility of the utilization review (UR) at least 30 days prior to the review;

(3) Provide the facility a listing of the clients that are reviewed;

(4) Provide direction to the facility regarding forms and records required for the review;

(5) Determine whether each client is approved for a continued stay for a maximum of six months or does not meet criteria for a continued stay. When a continued stay is not approved, follow the appropriate procedures; and

(6) Notify the facility of the results of the utilization review (UR).

006.01(A)(i) EXPANSION OF REVIEW PROCESS. The Medicaid review team has the authority to expand the review process as needed and may include the review of additional client records, and interviews with clients and facility staff. In the event the Medicaid review team determines the documentation available for review does not provide adequate information to make a determination of whether the intermediate care facility for individuals with developmental disabilities (ICF/DD) level of care is appropriate, the Medicaid review team may conduct onsite observations and interview with the client at the facility, interview facility staff, and request additional information from the intermediate care facility for individuals with developmental disabilities (ICF/DD).

006.01(B) INTERMEDIATE CARE FACILITY FOR INDIVIDUALS WITH DEVELOPMENTAL DISABILITIES (ICF/DD). Within 10 days following receipt of the utilization review results the intermediate care facility for individuals with developmental disabilities (ICF/DD) must respond to the department in writing, and must include the following information:

(1) A complete plan of correction that addresses all identified findings and recommendations;

(2) Changes in level of care;

(3) Each individual recommendations and the examples of problems; and

(4) Projected dates of completion on each of the above.

006.01(B)(i) FAILURE TO RESPOND. If the facility fails to submit a timely and/or appropriate response, the Department may take administrative sanctions or any of the following actions.

(a) The Department may suspend Title XIX reimbursement for a client or the entire reimbursement for the facility; or

(b) Clients may be transferred to another facility.

006.01(C) COMPOSITION OF THE MEDICAID REVIEW TEAM. The Medicaid review team must include a Medicaid reviewer who is knowledgeable in working with individuals with developmental disabilities and related conditions. The team may also include any of the following:

(1) A physician;

(2) A registered nurse; and

(3) Other professional personnel as needed based on the review process.

006.01(C)(i) PHYSICIAN. The Department is the final authority for findings, patient care recommendations, and official action.

006.01(C)(ii) REGISTERED NURSE. The registered nurse may consult and participate in the utilization review (UR) process, should there be potential issues related to nursing or medical services.

006.01(C)(iii) OTHER PROFESSIONAL PERSONNEL. Other professional personnel may consult and participate in the utilization review (UR) process, based on their expertise related to services in which the Medicaid review team identified possible issues.

007. HOSPICE SERVICES .

007.01 DEFINITION OF HOSPICE. Hospice or hospice services must meet the definition outlined in 471 NAC 36.

007.02 STANDARDS FOR PARTICIPATION. To participate in Medicaid, a hospice must be a public agency or private organization, or a subdivision of either, primarily engaged in providing care to terminally ill individuals and is certified for participation in Medicare as a hospice.

007.02(A) PROVIDER ENROLLMENT. To complete the provider enrollment process for adult clients, the hospice must meet the following conditions:

(i) The hospice must have a signed, written, non-resident-specific contract with the intermediate care facility for individuals with developmental disabilities (ICF/DD); and

(ii) The hospice must complete and submit a Nebraska Medicaid provider agreement in its entirety to Medicaid for each contracted intermediate care facility for individuals with developmental disabilities (ICF/DD).

007.03 PRIOR AUTHORIZATION PROCESS. The following must be completed before Medicaid authorizes payment to the hospice for board and room:

(A) The hospice must request prior authorization for payment by paper or electronically. If requesting prior authorization by paper, the hospice must provide Medicaid all records listed below:

(i) Form MC-9NF, or Nursing Facility Level of Care Determination Form;

(ii) Physician’s order for hospice services, including rationale for the need of hospice services including certification of terminal illness;

(iii) Hospice plan of care, including the responsibilities of the intermediate care facility for individuals with developmental disabilities (ICF/DD) as part of the hospice services;

(iv) List of hospice covered medications and pharmacy notification;

(v) List of hospice covered medical appliances, supplies, and therapies; and

(vi) The hospice must obtain prior authorization for the actual hospice service when Medicaid is the primary payer.

007.04 BILLING AND PAYMENT FOR HOSPICE BOARD AND ROOM.

007.04(A) BILLING. Hospice providers must bill Medicaid on the appropriate claim form or electronic format.

007.04(B) PAYMENT OF BOARD AND ROOM TO THE HOSPICE PROVIDER. Medicaid pays the hospice for the client's board and room in the intermediate care facility for individuals with developmental disabilities (ICF/DD) facility when the following conditions are met:

(1) The hospice and the facility must have a written agreement under which the hospice is responsible for the professional management of the client's hospice care;

(2) The client must be eligible for Medicaid benefits;

(3) The client must have elected to receive the Medicare or Medicaid hospice benefit;

(4) The client must reside in a Medicaid-certified bed in the intermediate care facility for individuals with developmental disabilities (ICF/DD) facility;

(5) The client's medical needs must meet the Medicaid criteria and be approved for intermediate care facility for individuals with developmental disabilities (ICF/DD) level of care;

(6) Prior authorization requirements must be met; and

(7) The client is an adult.

007.04(B)(i) FACILITY AND HOSPICE CONTRACT. The hospice must make payment to the intermediate care facility for individuals with developmental disabilities (ICF/DD) facility for the client's board and room according to the contract between the facility and the hospice.

007.04(B)(ii) PER DIEM LIMITATION. The provider must not bill Medicaid for any provider service related to the terminal illness that is included in the Medicare hospice benefit or services covered under the Medicaid intermediate care facility for individuals with developmental disabilities (ICF/DD) per diem.

007.04(B)(iii) CHILD LIMITATION. Nebraska Medicaid does not pay the hospice for the client’s board and room expense in the intermediate care facility for individuals with developmental disabilities (ICF/DD) if the client is a child.

History

• Effective 2021-12-26

Chapter 32 Children’s Mental Health and Substance Use Treatment Services

Neb. Admin. Code tit. 471, ch. 32 Children’s Mental Health and Substance Use Treatment Services {#sec-471-nac-32 omnilex-key=us-ne-regs-official--title-471--471 NAC 32}

TITLE 471 NEBRASKA MEDICAL ASSISTANCE PROGRAM SERVICES

CHAPTER 32 CHILDREN’S MENTAL HEALTH AND SUBSTANCE USE DISORDER TREATMENT SERVICES

001. SCOPE AND AUTHORITY. These regulations govern services provided under the Medical Assistance Act, Nebraska Revised Statute (Neb. Rev. Stat.) §§ 68-901 et seq.

002. DEFINITIONS. The following definitions apply.

002.01 ANNUAL SUPERVISION OF NEBRASKA MEDICAID ELIGIBLE BENEFICIARIES. Annual supervision includes a review of a beneficiary’s treatment plan and progress notes, specific case discussion, and assessment of the beneficiary. This review should be completed annually or as often as is medically necessary.

002.02 APPLIED BEHAVIOR ANALYSIS (ABA). Applied behavior analysis (ABA) is a type of therapy that uses behavior modification principles to treat functional impairments due to maladaptive behaviors in individuals with autism spectrum disorder (ASD) or developmental or intellectual disabilities.

002.03 CHILD PARENT PSYCHOTHERAPY. Child parent psychotherapy is an evidence-based service provided to children from birth to age five, who have experienced at least one traumatic event and, as a result, are experiencing behavior, attachment, or mental health problems, including post-traumatic stress disorder.

002.04 COMMUNITY TREATMENT AIDE SERVICES (CTA). Community treatment aide (CTA) services are supportive and psychoeducational interventions designed to assist the beneficiary and parents or primary caregivers to learn and rehearse the specific strategies and techniques that can decrease the severity of, or eliminate, symptoms and behaviors associated with the beneficiary’s mental illness that create significant impairments in functioning.

002.05 CRISIS OUTPATIENT. Crisis outpatient individual or family therapy is an immediate, short-term treatment service provided to a beneficiary with urgent psychotherapy needs.

002.06 FAMILY PSYCHOTHERAPY. Family psychotherapy is a treatment session in which an identified beneficiary and the beneficiary’s nuclear or extended family interact with a practitioner for the purpose of improving the functioning of the family system and decrease or eliminate the mental health symptoms experienced by the family.

002.07 FAMILY SUBSTANCE USE DISORDER COUNSELING. Family substance use disorder counseling is a treatment session between an identified beneficiary and the beneficiary’s nuclear or extended family and a licensed practitioner.

002.08 FUNCTIONAL FAMILY THERAPY (FFT). Functional family therapy (FFT) provides clinical assessment and treatment for the beneficiary and their family to improve communication, problem solving and conflict management in order to reduce problematic behavior of the beneficiary.

002.09 GROUP PSYCHOTHERAPY. Group psychotherapy is a treatment session between a beneficiary and a licensed practitioner in the context of a group setting of three to 12 beneficiaries.

002.10 GROUP SUBSTANCE USE DISORDER COUNSELING. Group substance use disorder counseling is a counseling session during which a practitioner directs interactions between three to 12 beneficiaries who have a substance use disorder diagnosis for the purpose of all beneficiaries achieving abstinence from alcohol and drug use.

002.11 INDIVIDUAL PSYCHOTHERAPY. Individual psychotherapy is an active treatment session between a beneficiary and an appropriately licensed practitioner for the purpose of improving the mental health symptoms that are significantly impairing the beneficiary’s functioning in at least one life domain.

002.12 INDIVIDUAL SUBSTANCE USE DISORDER COUNSELING. Individual substance use disorder counseling is a counseling session between a beneficiary and a licensed practitioner for a primary substance use disorder.

002.13 INPATIENT HOSPITAL SERVICES FOR BENEFICIARIES AGE 20 OR YOUNGER IN INSTITUTIONS FOR MENTAL DISEASE (IMD). Services provided under the direction of a psychiatrist for the care and treatment of beneficiaries age 20 and younger in an institution for mental disease (IMD) that meets the requirements of federal regulations.

002.14 INSPECTION OF CARE TEAM. Nebraska Medicaid or designee's inspection of care team for institutions of mental disease (IMD), consisting of a psychiatrist knowledgeable about institutions for mental disease (IMD), a qualified registered nurse (RN), and other appropriate personnel as necessary who conduct inspection of care reviews under federal regulations and this regulations.

002.15 INSTITUTION FOR MENTAL DISEASE (IMD). An institution for mental disease (IMD) is defined as an entity that primarily provides inpatient treatment for beneficiaries with mental diseases and is credentialed according to federal regulations.

002.16 INTERDISCIPLINARY TEAM. The team responsible for developing each beneficiary's individual plan of care.

002.17 MEDICAL NECESSITY. Medical necessity is defined as the need for treatment services which are necessary to diagnose, treat, cure, or prevent regression of significant functional impairments resulting from symptoms of a mental health or substance use disorder diagnosis. Treatment services must:

(A) Be provided in the least restrictive level of care that is appropriate to meet the needs of the beneficiary;

(B) Be supported by evidence that the treatment improves symptoms and functioning for the individual beneficiary’s mental health or substance use disorder diagnosis;

(C) Be reasonably expected to improve the beneficiary’s condition or prevent further regression so that the services will no longer be necessary; and

(D) Be required for reasons other than primarily for the convenience of the beneficiary or the provider.

002.18 MEDICAL REVIEW ORGANIZATION. A review body contracted by Nebraska Medicaid, responsible for pre-admission certification and concurrent and retrospective reviews of care.

002.19 MEDICATION MANAGEMENT. Medication management is the service provided by a physician, physician assistant (PA), or advanced practice registered nurse (APRN) focused on the monitoring and prescribing of psychopharmacologic agents.

002.20 OUTPATIENT. An outpatient is defined as a person who has not been admitted as an inpatient but is registered on the hospital records as an outpatient and receives services rather than supplies alone. If a beneficiary receives 24 or more hours of continuous outpatient care, that beneficiary is defined as an inpatient regardless of the hour of admission, whether they used a bed and whether they remained in the hospital past midnight or the census-taking hour, and all inpatient prior-authorization requirements apply.

002.21 PARENT CHILD INTERACTION THERAPY. Parent child interaction therapy is aservice provided to children age two to 12 that places emphasis on improving the quality of the parent-child relationship and changing parent-child interaction patterns.

002.22 PSYCHOLOGICAL TESTING. Psychological testing is the administration and interpretation of standardized tests used to assess a beneficiary’s psychological or cognitive functioning. It assists in gaining an understanding of a beneficiary’s diagnostic presentation and informs the appropriate course of treatment.

002.23 SELF-CARE SERVICES. Self-care services are services supervised by a registered nurse (RN) or occupational therapist (OT) who is oriented toward activities of daily living and personal hygiene.

002.24 SEX OFFENDER RISK ASSESSMENT. A sex offender risk assessment is a structured evaluation for the purpose of recommending whether sex offender specific treatment is necessary, the most appropriate intensity, frequency and type(s) of sex offender treatment and to recommend safety parameters, including the level of supervision and monitoring needed during treatment.

002.25 TREATMENT PLAN. The treatment plan is a written, comprehensive plan of care to address mental health and substance use disorder symptoms identified in the initial diagnostic interview.

003. GENERAL REQUIREMENTS.

003.01 ELIGIBILITY. A beneficiary is eligible for mental health or substance use treatment services, or both, set forth in this chapter when:

(A) The beneficiary has a diagnosis of a mental health or substance use disorder;

(B) The mental health or substance use disorder results in functional impairment that substantially interferes with or limits the beneficiary’s role or functioning within their family, school, or community. Coexisting conditions must be carefully evaluated in order to identify the functional impairments resulting from the mental health or substance use disorder diagnosis and those resulting from the coexisting condition. In the evaluation of coexisting conditions, evidence of the conditions will not automatically result in denial of eligibility; and

(C) The services meet medical necessity criteria.

003.02 FAMILY COMPONENT. Unless otherwise prohibited, providers must involve the family in assessment, treatment planning, updating of the treatment plan, therapy and transition, and discharge planning. Providers must schedule meetings and sessions in a flexible manner to accommodate a family’s schedule, including weekends and evenings. Family involvement, or lack thereof, must be documented in the clinical record. Parental or caregiver involvement in treatment is essential and evidence-based practices, which include parents or caregivers in therapy are the expectation for treatment.

003.03 CULTURAL COMPETENCE. Providers must be culturally competent. This includes awareness, acceptance, and respect of differences and continuing self-assessment regarding culture.

003.04 INITIAL DIAGNOSTIC INTERVIEW. The initial diagnostic interview is required prior to initiation of treatment services and must include a history, mental status, and a disposition and may include communication with family or other sources. If circumstances require, family members, guardians, or other supports may be interviewed to supplement the interview of the beneficiary. Except that beneficiaries receiving acute inpatient hospital services, crisis services, or substance use disorder services subject to the requirements of this chapter are not required to receive an initial diagnostic interview before services are initiated.

003.04(A) PROVIDER AGREEMENT. Providers of the acute services must facilitate or perform the initial diagnostic interview. Providers of crisis intervention services must facilitate the referral to or provide the initial diagnostic interview if it has not already occurred. For providers of substance use disorder services, if a co-occurring mental health condition is known or suspected, the clinician will refer the beneficiary for an initial diagnostic interview.

003.05 PRACTITIONERS REQUIRING SUPERVISION. A practitioner who is not eligible to practice independently and who provides mental health or substance use treatment services, or both, must be supervised by a supervising practitioner. A supervising practitioner must be a:

(A)Provisionally licensed mental health practitioner (LMHP);

(B)Registered nurse (RN);

(C)Provisionally licensed psychologist; or

(D)Provisional licensed alcohol and drug counselor (LADC).

003.05(i) SUPERVISING PRACTITIONER. A supervising practitioner must be:

(1)A licensed physician who has a Doctor of Medicine (M.D.) or a Doctor of Osteopathic Medicine degree ( D.O.) and has completed a psychiatric residency or similar training program and preferably is board certified in psychiatry or addiction medicine, for any level of mental health or substance use services;

(2)A licensed psychologist who has a Doctor of Philosophy (Ph.D) or Doctor of Psychology degree ( Psy.D.) for any level of mental health or substance use services except psychiatric residential treatment facility (PRTF);

(3)A licensed independent mental health practitioner (LIMHP) for outpatient services, intensive outpatient, and community treatment aide (CTA) services only; and

(4) A licensed advanced practice registered nurse (APRN) who has proof of a current certification from an approved certification program in a psychiatric or mental health specialty for any level of mental health or substance use services except psychiatric residential treatment facility (PRTF).

003.05(ii) RESPONSIBILITIES OF A SUPERVISING PRACTITIONER. A supervising practitioner must :

(1)Approve and supervise the beneficiary’s assessment and treatment plan. This requires facilitation of an assessment in order to develop, approve, and supervise the beneficiary’s assessment and treatment plan;

(2)Direct patient care by reviewing and approving beneficiary specific treatment plans and progress notes within the timelines specified for each level of care, not to exceed 90 days; and

(3)Assure treatment provided meets standards of care.

003.05(iii) REIMBURSEMENT FOR SUPERVISION. Assessments and other services provided by the supervising practitioner, directly to the beneficiary, are reimbursable. Supervision is not reimbursable either by the supervising practitioner or the practitioner who is being supervised.

003.06 PROVIDER ENROLLMENT. All providers of mental health and substance use treatment services must submit a completed medical assistance provider agreement to Nebraska Medicaid for approval. A separate application must be submitted for each particular mental health and substance use treatment service.

003.06(A) NEBRASKA HEALTH CONNECTION ENROLLMENT. In order to be reimbursed for providing services to beneficiaries in Nebraska Health Connection, providers must be credentialed by and under contract with the Nebraska Medicaid managed care behavioral health contractor.

003.07 ACTIVE TREATMENT. Treatment must be provided in an interactive environment with the beneficiary present, and must be focused on reducing or controlling the beneficiary's mental health and substance use disorder symptoms that cause functional impairments and promoting the beneficiary's movement to less restrictive treatment in the most time efficient manner consistent with sound clinical practice.

003.08 TREATMENT PLANS. The treatment plan must include transition and discharge planning and must be amended as needed as treatment progresses. The treatment plan must:

(A)Be individualized to the beneficiary;

(B)Include the specific symptoms or skills to be addressed;

(C)Provide clear and realistic goals;

(D)Include treatment objectives services, strategies, and methods of intervention to be implemented;

(E)Describe the methods for evaluating both the beneficiary's progress and the performance of the practitioner facilitating the intervention; and

(F)Estimate the length of time or number of sessions necessary to complete the treatment goals.

003.09 TRANSITION AND DISCHARGE PLANNING. Providers must begin and document transition and discharge planning at the time of admission or onset of treatment and continue to update the documentation throughout the treatment episode.

003.10 COORDINATION OF CARE. Providers must coordinate services for beneficiaries who receive services from more than one mental health and substance use provider .

003.11 CLINICAL RECORDS. Each provider must maintain a legible clinical record for each beneficiary that includes a complete record of all the treatment services rendered. The clinical record must contain documentation sufficient to justify reimbursement and must allow an individual not familiar with the beneficiary to evaluate the course of treatment. Failure to have sufficient documentation to justify the level of reimbursement may result in recoupment of payments made for services lacking the documentation.

003.11(A) PROGRESS NOTES. Progress notes must identify the beneficiary name, the name and title of the practitioner, and the date of service. The progress note must also identify the type of therapy, beginning and end date, and time of the service delivered.

003.11(B) RECORD RETENTION. Clinical records must be maintained for a minimum of seven years in a secure location.

003.11(C) CONFIDENTIALITY OF RECORDS. Each provider must ensure the confidentiality of clinical data in accordance with state and federal law.

003.12 LOCATION OF COMMUNITY BASED SERVICES. Community based mental health and substance use treatment services must be provided in the beneficiary’s home or a professional environment conducive to beneficiary confidentiality and privacy.

003.13 QUALITY ASSURANCE, UTILIZATION REVIEW AND INSPECTION OF CARE. Providers must fully cooperate with any reviews conducted by Nebraska Medicaid or a Nebraska Medicaid designee to determine the quality of care and services provided. Providers must have access to a copy of any final inspection of care report.

003.13(A) RESPONSE TO INSPECTION OF CARE REPORTS. Within 15 days following the receipt of the inspection of care report, the provider must respond in writing and submit a plan of correction for any identified findings and recommendations. The provider may request an extension of time to respond if needed.

003.14 PAYMENT. Payment for services must be based upon rates established by Nebraska Medicaid, as described further throughout this chapter, and may be increased or decreased based on legislative appropriations or budget directives from the Nebraska Legislature. Providers may be required to report their costs on an annual basis or as needed.

003.15 INSTITUTION FOR MENTAL DISEASE (IMD). Services provided to beneficiaries residing in an institution for mental disease (IMD) must not be reimbursable by Nebraska Medicaid except as provided in the regulations on psychiatric residential treatment facilities (PRTF).

004. OUTPATIENT MENTAL HEALTH AND SUBSTANCE USE DISORDER TREATMENT SERVICES.

004.01 COVERED OUTPATIENT MENTAL HEALTH AND SUBSTANCE USE DISORDER TREATMENT SERVICES. Covered services include:

(A)Crisis outpatient services;

(B)The initial diagnostic interview;

(C)Psychological testing;

(D)Individual psychotherapy;

(E)Group psychotherapy;

(F)Family psychotherapy;

(G)Parent child interaction therapy ;

(H)Child-parent psychotherapy ;

(I)Individual substance use disorder counseling;

(J)Group substance use disorder counseling;

(K)Family substance use disorder counseling;

(L)Conferences;

(M)Community treatment aide;

(N)Medication management;

(O)Sex offender risk assessment;

(P) Annual supervision of Nebraska Medicaid eligible beneficiaries by a psychologist or a licensed independent mental health professional (LIMHP);

(Q) Functional family therapy (FFT); and

(R) Applied behavior analysis (ABA).

004.02 NON-COVERED TREATMENT SERVICES. Services not covered include, but are not limited to:

(A)Biofeedback services;

(B)Treatment that is primarily supportive, social or educational in nature;

C)Treatment for prevention, maintenance, socialization, or skill building;

(D)Behavior modification and planning;

(E)Eye movement desensitization and reprocessing ; and

(F)Art, play, or music therapy.

004.03 OUTPATIENT SERVICES PROVIDERS. Outpatient services must be provided by licensed practitioners whose scope of practice includes mental health or substance use disorder services, or both.

004.04 CRISIS OUTPATIENT SERVICES. The provider of crisis outpatient services must develop a short-term plan and must identify ongoing treatment services if services appear to be medically necessary following stabilization. If services are to continue, the provider must perform or arrange for an assessment and develop a treatment plan if one has not already been completed.

004.04(A) SESSION MAXIMUM. A beneficiary is eligible to receive crisis outpatient services of no more than five sessions per episode of crisis, or three occurrences requiring mobile crisis intervention in a 90-day time period.

004.05 INITIAL DIAGNOSTIC INTERVIEW. An initial diagnostic interview as set forth in this chapter .

004.06 PSYCHOLOGICAL TESTING. Testing services must be administered and scored by a licensed psychologist or, under the supervision of a licensed psychologist, by a provisionally licensed psychologist, a licensed psychological assistant or a licensed psychological associate. All interpretation must be done by the licensed psychologist.

004.06(A) PRIOR AUTHORIZATION. Psychological testing must be prior authorized. Before psychological testing, the beneficiary must be assessed to determine the need for and extent of the psychological testing. Testing may be authorized at the onset of treatment when it is necessary for reaching a diagnosis or helps resolve specific treatment planning questions, or both. It may also occur later in treatment if the beneficiary’s condition has not progressed and there is no clear explanation for the lack of improvement. Psychological testing that is available in schools is not covered by Nebraska Medicaid.

004.07 INDIVIDUAL PSYCHOTHERAPY. The treatment plan must identify the diagnosis that is the focus of treatment, the specific target symptoms, the goals, the frequency, and the estimated duration of the service and must be individualized according to the beneficiary’s needs and the identified symptoms experienced by the beneficiary. Services must be treatment focused and not rehabilitative or habilitative in nature.

004.08 GROUP PSYCHOTHERAPY. Group psychotherapy must be provided as an active treatment service for a primary psychiatric disorder in which identified treatment goals, frequency and duration of service are a part of the beneficiary's active treatment plan and there is reasonable expectation that group psychotherapy will improve the beneficiary's psychiatric symptoms so that therapy will no longer be needed.

004.09 FAMILY PSYCHOTHERAPY. Depending on the clinical appropriateness, it is expected that all members of the family residing in the same household as the beneficiary participate in family therapy. Others significant to the beneficiary or the family may also be in attendance at family psychotherapy if their attendance will be meaningful in improving family functioning.

004.10 PARENT-CHILD INTERACTION THERAPY (PCIT). Parent-child interaction therapy (PCIT) is used to treat clinically significant disruptive behaviors due to the child’s primary mental health disorder.

004.10(A) SERVICE IDENTIFICATION BASED ON NEED. The goals, frequency, and duration of the service must be identified in the child’s treatment plan and must vary according to the child’s individual needs and the identified symptoms experienced by the child. Services must be treatment focused and not rehabilitative or habilitative in nature. Young children should receive parent-child interaction therapy (PCIT) services only after a recent appropriate medical evaluation to rule out conditions of a general medical nature.

004.10(B) REASONABLE EXPECTATION OF IMPROVEMENT. There must be a reasonable expectation that parent-child interaction therapy (PCIT) will improve the child’s psychiatric symptoms so that the services will no longer be necessary.

004.10(C) NON-COVERED TREATMENT SERVICES. Services not following the parent-child interaction therapy (PCIT) evidence-based treatment model or performed by an individual not appropriately trained in parent-child interaction therapy (PCIT) are not covered.

004.11 CHILD-PARENT PSYCHOTHERAPY (CPP). Child-parent psychotherapy (CPP) must be designed to support and strengthen the relationship between a child and their parent or caregiver, and to improve and restore the child’s cognitive, behavioral, and social functioning.

004.11(A) SERVICE IDENTIFICATION BASED ON NEED. The goals, frequency and duration of the service must be identified in the child’s treatment plan and must vary according to the child’s individual needs and the identified symptoms experienced by the child. Services must be treatment-focused and not rehabilitative or habilitative in nature. Young children should receive child-parent psychotherapy (CPP) services only after a recent appropriate medical evaluation to rule out conditions of a general medical nature.

004.11(B) REASONABLE EXPECTATION OF IMPROVEMENT. There must be a reasonable expectation that child-parent psychotherapy (CPP) therapy will improve the child’s psychiatric symptoms so that the services will no longer be necessary.

004.11(C) NON-COVERED TREATMENT SERVICES. Services not following the child-parent psychotherapy (CPP) evidence-based treatment model or performed by an individual not appropriately trained in child-parent psychotherapy (CPP).

004.12 INDIVIDUAL SUBSTANCE USE DISORDER COUNSELING. Individual substance use disorder counseling must be designed to assist the beneficiary in achieving and maintaining abstinence from alcohol and drug use. This includes motivational enhancement and interventions .

004.12(A) REASONABLE EXPECTATION OF IMPROVEMENT. Outpatient substance use disorder counseling must reasonably be expected to improve the symptoms of the beneficiary’s substance use disorder which are identified in the beneficiary’s treatment plan.

004.12(B) SERVICE IDENTIFICATION BASED ON NEED. The treatment plan must identify the diagnosis that is the focus of treatment, the specific target symptoms, goals, the frequency and the estimated duration of the service and must be individualized according to the beneficiary’s needs and the identified symptoms experienced by the beneficiary. Services must be treatment focused and not rehabilitative or habilitative in nature.

004.13 FAMILY SUBSTANCE USE DISORDER COUNSELING. The services must focus on the beneficiary’s substance use disorder needs and the family as a system and must include a comprehensive family assessment. Depending on the clinical appropriateness, it is expected that all members of the family residing in the same household as the beneficiary participate in family substance use disorder counseling. Services must be designed to increase the functional level of the identified beneficiary and the beneficiary’s family related to substance use.

004.13(A) LEVEL OF CARE (LOC). The service must be for a beneficiary with a substance related disorder and meet the criteria of level of care (LOC) standards .

004.14 CONFERENCES. Conferences with family or other persons advising them on how to assist the beneficiary can be covered under limited circumstances.

004.14(A) DEMONSTRATION OF NEED. These circumstances must demonstrate a need for the therapeutic involvement and include:

(i)Following psychiatric testing ;

(ii)As required during the provision of multisystemic therapy (MST) services; or

(iii)As a treatment intervention, identified in the beneficiary’s treatment plan and requiring a progress note.

004.14(B) PRIOR AUTHORIZATION. All conferences must be prior approved by Nebraska Medicaid or its designee.

004.14(C) EXCLUSIONS. Scheduling appointments and reporting beneficiary progress are not considered conferences and must not be reimbursable. Supervisory meetings or care coordination meetings are not conferences, and must not be reimbursable.

004.15 COMMUNITY TREATMENT AIDE SERVICES (CTA). The beneficiary’s community treatment aide (CTA) plan must be a part of the comprehensive treatment plan developed by the beneficiary’s outpatient psychotherapy provider and be developed in close collaboration with the therapy provider. The community treatment aide (CTA) interventions, the beneficiary’s progress and modifications to the plan must be reviewed and approved by the outpatient therapist and must be documented by the community treatment aide (CTA) and the therapist.

004.15(A) PLACE OF SERVICE. Community treatment aide (CTA) services must be provided primarily in the beneficiary’s natural environment, but may also include other appropriate community locations where the parent or caregiver are present. Community treatment aide (CTA) services must not be used in place of a school aide or other similar services not involving the parent.

004.15(B) THERAPIST DIRECTION AND SUPERVISION. Community treatment aide (CTA) services must be delivered under the direction and supervision of the therapist providing family or individual therapy, or both, on a regular basis to the beneficiary and the beneficiary’s caregiver or family. The community treatment aide (CTA) and the licensed therapist must coordinate care and document their collaboration at least every other week to ensure the community treatment aide (CTA) activities delivered to the beneficiary remain relevant to the beneficiary’s treatment plan.

004.15(C) COMMUNITY TREATMENT AIDE (CTA) ACTIVITIES. Activities designed by community treatment aide (CTA) providers may include activities related to:

(i)Developing a written safety plan with input from the therapist, the beneficiary, and the parents or caregivers;

(ii)Instructing the parents or caregivers in de-escalation techniques and strategies;

(iii)Teaching and modeling appropriate behavioral treatment interventions and techniques and coping skills with the beneficiary and the beneficiary’s parents or caregivers;

(iv)Collecting information about medication compliance and developing reminder strategies and other interventions to enhance compliance as needed;

(v)Assisting parents or caregivers with reporting medication effects, side effects, concerns regarding side effects or compliance problems, and other information regarding progress and barriers to the treating therapist and the prescribing physician or advanced practice registered nurse (APRN);

(vi)Teaching and modeling proper and effective parenting practices; and

(vii)Providing training and rehabilitation regarding basic personal care and activities of daily living.

004.15(D) PRIOR AUTHORIZATION. Community treatment aide (CTA) services must be prior authorized by Nebraska Medicaid or its designee in order to be eligible for reimbursement.

004.15(E) PROGRAM DESCRIPTION APPROVAL. Community treatment aide (CTA) agencies must have a program description approved by Nebraska Medicaid or its designee.

004.15(F) COMMUNITY TREATMENT AIDE (CTA) PROGRAM OR CLINICAL DIRECTOR. The community treatment aide (CTA) program or clinical director may be a licensed physician who has completed a psychiatric residency or similar training program and preferably is board certified in psychiatry or addiction medicine, a psychologist, a licensed mental health practitioner (LMHP), a registered nurse (RN), an advanced practice registered nurse (APRN), or a licensed independent mental health practitioner (LIMHP). The director must have two years of professional experience in mental health or substance use disorder treatment, or both, of individuals under the age of 21.

004.15(G) COMMUNITY TREATMENT AIDE (CTA) THERAPIST. The community treatment aide (CTA) therapist must be a licensed physician who has completed a psychiatric residency or similar training program and preferably is board certified in psychiatry or addiction medicine, a psychologist, a licensed independent mental health practitioner (LIMHP), a licensed mental health practitioner (LMHP), or an advanced practice registered nurse (APRN). The community treatment aide (CTA) may be a provisionally licensed mental health practitioner (LMHP) or a provisionally licensed psychologist only if employed by an accredited organization or by exception by Nebraska Medicaid or its designee. The community treatment aide (CTA) therapist must meet all the requirements for outpatient therapy and must coordinate and collaborate with the community treatment aide (CTA) direct care staff.

004.15(H) COMMUNITY TREATMENT AIDE (CTA) DIRECT CARE STAFF. The community treatment aide (CTA) direct care staff must :

(i)Have a bachelor’s degree in psychology, social work, child development or a related field and the equivalent of one year of full-time experience in direct child or adolescent services, or both, or mental health or substance use disorder services, or both. Equivalent time in graduate studies may substitute for work experience; or

(ii)Have two years post-high school education in the human services or related fields and a minimum of two years’ experience in direct child or adolescent services, or both or mental health or substance use disorder services, or both.

004.15(I) BACKGROUND CHECKS AND TRAINING. Prior to allowing staff to treat beneficiaries, community treatment aide (CTA) agencies must gather information from abuse and neglect registries and conduct criminal background checks of all potential community treatment aide (CTA) workers and must assure that all workers have completed the community treatment aide (CTA) agency’s basic training program.

004.15(J) UNIT OF SERVICE. The unit of service for community treatment aide (CTA) staff persons must be 15 minutes.

004.16 MEDICATION MANAGEMENT. Medication management must include relevant history, a mental status examination, and medical decision-making regarding initiating or adjusting pharmacological agents.

004.17 SEX OFFENDER RISK ASSESSMENT. The resulting recommendations from a sex offender risk assessment should address treatment needs for medical, mental health and substance use disorder conditions that are diagnosed during the assessment. The assessment is not a forensic evaluation.

004.17(A) WRITTEN REPORT. Practitioners providing this assessment must provide a written report which includes the components listed below that support the treatment recommendations.

004.17(B) REPORT SIGNAGE. The report must be signed by the psychologist although parts of the assessment may be conducted by others who operate within the scope of their license and who are under the supervision of the signing psychologist.

004.17(C) RISK ASSESSMENT COMPONENTS. The components for a sexual offender risk assessment include demographic, biopsychosocial, psychological assessment results and treatment recommendations as follows:

(i)Demographic Information: Reasons for the assessment, police reports and other relevant court documents, clinical interview of beneficiary, family members and other collateral contacts, initial diagnostic interview and review of previous mental health and substance use disorder treatment, and psychological testing records;

(ii)Biopsychosocial Information: Background information, family relations and dynamics, family response to the current symptoms and problems, social functioning, school and academic history, substance use disorder history, legal history, mental health treatment history, sexual offense history, trauma and victimization history, and personal strengths;

(iii)Psychological Evaluations: Level of cognitive and adaptive functioning, personal and behavior factors, sex offender risk assessment using both static and dynamic factors, sexual misconduct patterns, perception, understanding, motivation, and empathy for victim, current supervision and access to victim as well as protective factors and strengths; and

(iv)Case Formulation and Treatment Recommendations: An integrated discussion of the relevant factors in determining the treatment recommendations and an assessment of the beneficiary’s current risk to reoffend.

004.18 ANNUAL SUPERVISION OF NEBRASKA MEDICAID ELIGIBLE INDIVIDUALS. The supervising practitioner must be available in person or by telephone to provide assistance as needed during the time services are being provided. The critical involvement of the supervising practitioner is to be reflected in the initial diagnostic interview, the treatment plan, and the interventions provided.

004.19 FUNCTIONAL FAMILY THERAPY (FFT). Functional family therapy (FFT) is family therapy targeted at youth.

004.19(A) INITIAL DIAGNOSTIC INTERVIEW. An initial diagnostic interview must be completed prior to the beginning of treatment and will serve as the initial treatment plan until a comprehensive treatment plan is completed.

004.19(B) STAFF NEEDS AND RESPONSIBILITIES. All staffing must be adequate to meet the individualized treatment needs of the beneficiary and meet the responsibilities of each staff position as outlined in the functional family therapy (FFT) model.

004.19(C) ASSESSMENT AND TREATMENT REQUIREMENTS. Assessments and treatment must address mental health and substance use disorder needs, and mental health and emotional issues related to medical conditions. The treatment plan must be individualized and include the specific problems, behaviors, or skills to be addressed; clear and realistic goals and objectives; services, strategies, and methods of intervention to be implemented; criteria for achievement; target dates; methods for evaluating the beneficiary’s progress; and the responsible professional. The treatment plan must be developed with the beneficiary and the identified, appropriate family members as part of the outpatient family therapy treatment planning process. The treatment plan must meet the following requirements:

(i) The treating provider must consult with or refer to other providers for general medical, psychiatric, and psychological needs as indicated;

(ii) It is the treating provider’s responsibility to coordinate with other treating professionals as needed;

(iii) The treatment plan will be reviewed every 90 days or more often if clinically indicated;

(iv) After hours crisis assistance must be available; and

(v) Services must be trauma informed, culturally sensitive, age and developmentally appropriate, and incorporate evidence-based practices when appropriate.

004.19(D) PROVIDER AND TEAM REQUIREMENTS. A functional family therapy (FFT) treatment provider must have a master’s degree or greater and be a member of an active team. An active functional family therapy (FFT) team requires a functional family therapy (FFT) certified clinical supervisor and at least three functional family therapy (FFT) certified treatment providers working collaboratively with one another using the functional family therapy (FFT) model.

004.19(D)(i) TREATMENT PROVIDERS. Treatment providers may be any of the following: physicians, physician assistants (PA), advanced practice registered nurses (APRN), nurse practitioners (NP), licensed psychologists, provisionally licensed psychologists, licensed independent mental health practitioners (LIMHP), licensed mental health professionals (LMPH), or provisionally licensed mental health practitioners (LMHP) acting within their scope of practice.

004.19(D)(ii) TREATMENT CLINICAL SUPERVISORS. Treatment clinical supervisors must be physicians, physician assistants (PA), advanced practice registered nurses (APRN), licensed psychologists, or licensed independent mental health practitioners (LIMHP) certified in functional family therapy (FFT) model and with experience in the practice of psychotherapy. All psychiatric and psychotherapy services will be prescribed and provided under the supervision and direction of a supervising practitioner. Supervision is not a billable service.

004.19(D)(iii) TREATMENT ASSESSMENT PROVIDERS. Treatment assessment providers may be any of the following: physicians, psychiatric advanced practice registered nurses (APRN), nurse practitioners (NP), licensed psychologists, provisionally licensed psychologists, or licensed independent mental health practitioners (LIMHP) all acting within their scope of practice.

004.20 APPLIED BEHAVIOR ANALYSIS (ABA) SERVICES. Applied behavior analysis (ABA) must involve systematically applying interventions based upon the principles of learning theory to improve socially significant behaviors and must demonstrate that the interventions employed are responsible for the improvement in behavior for individuals with autism spectrum disorder (ASD) or developmental or intellectual disabilities. Necessity for applied behavior analysis (ABA) services must be determined based on an initial diagnostic interview (IDI) and a behavior identification assessment. Applied behavior analysis (ABA) services must meet the requirements as noted in the appropriate Medicaid service definitions.

005. TREATMENT CRISIS INTERVENTION SERVICES. Crisis intervention services are available to beneficiaries age 20 or younger when the treatment of a condition needing care leads to a health check or Early and Periodic Screening, Diagnostic and Treatment (EPSDT) screen and the treatment is clinically necessary. Crisis intervention services are appropriate for a family in the midst of a child or adolescent mental health or substance use disorder crisis. The interventions focus on reducing stress and helping resolve the crisis in a positive manner, and facilitating the beneficiary's involvement to treatment. Crisis intervention services must meet all requirements in this chapter. All crisis intervention service providers must facilitate a referral for a complete health check or Early and Periodic Screening, Diagnostic and Treatment (EPSDT) screen within eight weeks of the crisis intervention. This referral must be documented in the beneficiary's clinical record.

005.01 SERVICE REQUIREMENTS. Crisis intervention services must be family-centered, community-based, developmentally appropriate, culturally competent, and must take into account the individual needs of beneficiaries age 20 and younger.

005.02 FAMILY COMPONENT. Providers must encourage family members to be involved in the assessment of the beneficiary, the development of the treatment plan, and all aspects of the beneficiary's treatment unless prohibited by the beneficiary, through legal action, or because of federal confidentiality laws. Providers must be available to schedule meetings and sessions in a flexible manner to accommodate and work with a family's schedule. This includes the ability to schedule sessions at a variety of times including weekends or evenings. The provider must document their attempts to involve the family in treatment plan development and treatment plan reviews. A variety of means of communication should be considered.

005.03 TYPES OF CRISIS INTERVENTION SERVICES. One of the following services must be included in a crisis intervention program to be approved for participation in Nebraska Medicaid .

005.03(A) NON-RESIDENTIAL CRISIS INTERVENTION. Non-residential crisis intervention services are provided to the family and beneficiary outside of a residential or institutional setting. This service includes supportive services therapy, brief assessment, and coordination services to help a family alleviate a crisis. These services must be directed by a supervising practitioner and psychiatric consultation must be readily available. Some assessment and intervention activities may be carried out by a clinical professional who is acting within their scope of practice under the direction of a supervising practitioner. The provider must have the capacity to respond to the family to unscheduled crisis intervention contacts 24 hours a day, seven days a week.

005.03(B) DAY RESIDENTIAL CRISIS INTERVENTION. Day residential crisis intervention services are provided to families when a safe and secure setting is needed to provide a therapeutic milieu for a child or adolescent for up to 23 hours and 59 minutes. This level is used when a brief stay in a secure setting will facilitate a de-escalation of the crisis. These services must be directed by a supervising practitioner with access to psychiatric consultation. The milieu and direct care interventions may be staffed by clinical professionals or technicians, under the direction of a supervising practitioner.

005.03(C) RESIDENTIAL ACUTE CRISIS INTERVENTION. Residential acute crisis intervention services are available to children and adolescents experiencing acute psychiatric crisis. The program provides crisis treatment and close supervision to stabilize a beneficiary and facilitate admission to the most appropriate treatment setting. The milieu and direct care interventions may be staffed by clinical professionals or technicians, under the direction of a supervising practitioner.

005.03(D) PROVIDERS OF CRISIS INTERVENTION SERVICES. Providers of crisis intervention services must facilitate the referral to or provide the initial diagnostic interview if it has not already occurred.

005.04 STANDARDS FOR PARTICIPATION AS A PROVIDER OF CRISIS INTERVENTION SERVICES. Programs must meet the following standards to participate in Nebraska Medicaid as a provider of crisis intervention service in addition to the standards listed in this chapter.

005.04(A) PROVIDER AGREEMENT. The provider must submit the following with the appropriate Nebraska Medicaid approved provider agreement form F:

(i)A written overview of the program's philosophy and objectives of treating youth including:

(1)A description of each available service;

(2)A list of treatment modalities available and the capacity for individualized treatment planning;

(3)A statement of qualification, education, and experience of each staff member providing treatment and the supervising practitioner and the therapeutic services each provides;

(4)A schedule covering the total number of hours that the program operates;

(5)A program overview; and

(6)Any other information requested by Nebraska Medicaid; and

(ii)Copies of licensure and certification, through the Nebraska Department of Health and Human Services, Division of Public Health, the Joint Commission , Council on Accreditation (COA), American Osteopathic Association (AOA) or Commission on the Accreditation of Rehabilitation Facilities (CARF) as appropriate.

005.04(B) STAFFING STANDARDS FOR PARTICIPATION. An agency providing crisis intervention services for children and adolescents must meet the following staffing standards to participate in Nebraska Medicaid :

(i)All services must be provided under the supervision of the supervising practitioner. This practitioner must be available at all times for consultation or face-to-face beneficiary assessment; and

(ii)Direct intervention services must be provided by a clinical staff person who is acting within their scope of practice .

005.04(C) PLACE OF SERVICE. Crisis intervention services may be provided in any of the following locations:

(i)The beneficiary's home;

(ii)A physician's private office;

(iii)A community mental health program which meets the criteria for approval by the Joint Commission or is accredited by Commission on the Accreditation of Rehabilitation Facilities (CARF), Council on Accreditation (COA), or American Osteopathic Association (AOA), and is appropriately licensed by the Nebraska Department of Health and Human Services, Division of Public Health;

(iv)A hospital licensed and certified by the State of Nebraska which is accredited by the Joint Commission or American Osteopathic Association (AOA) and has in effect a utilization review plan applicable to all Nebraska Medicaid beneficiaries;

(v)The private office of a licensed practitioner of the healing arts who is licensed by the Nebraska Department of Health and Human Services, Division of Public Health;

(vi)The beneficiary's school;

(vii)Other appropriate locations to meet the beneficiary needs for intervention; or

(viii)A facility enrolled as a residential treatment center or therapeutic group home (ThGH) under this chapter .

005.04(D) ANNUAL UPDATE. The provider must submit the following information on an annual basis:

(i)An overview of any changes in the program including any new services;

(ii)A current list of staff; and

(iii)Current copies of all licenses, letters of accreditation, and certifications.

005.05 COVERED SERVICES. Payment for crisis intervention services under Nebraska Medicaid is limited to services for clinically necessary primary psychiatric diagnoses. Nebraska Medicaid covers the following crisis intervention services:

(A)Active treatment, which must be:

(i)Provided under the supervision of the supervising practitioner by clinical staff members acting within their scope of practice ; and

(ii)Reasonably expected to improve the beneficiary's condition or resolve the crisis. The treatment interventions must, at a minimum, be designed to reduce or control the beneficiary's symptoms to facilitate the resolution of a crisis or prevent the need for care in a more restrictive level of care.

005.05(A) SPECIAL TREATMENT PROCEDURES IN CRISIS INTERVENTION SERVICES. If a child or adolescent needs behavior management and containment beyond unlocked time outs or redirection, special treatment procedures may be utilized. For crisis intervention services provided in therapeutic group homes (ThGH), please refer to the sections covering those services. For crisis intervention services provided in the child or adolescent's home, school, or other appropriate location, special treatment procedures is limited to physical restraint. Mechanical restraints and pressure point tactics are not allowed. Parents, the legal guardian, or Nebraska Medicaid case manager must approve use of these procedures and must be informed within 24 hours each time they are used. Facilities must meet the following standards regarding special treatment procedures:

(i) De-escalation techniques must be taught to staff and used appropriately before the initiation of special treatment procedures;

(ii) Special treatment procedures may be used only when a child or adolescent's behavior presents a danger to self or others, or to prevent serious disruption to the therapeutic environment;

(iii) The child or adolescent's treatment plan must address the use of special treatment procedures and have a clear plan to decrease the behavior requiring intervention; and

(iv) Attempts to de-escalate, the special treatment procedure, and subsequent processing must be documented in the clinical record and reviewed by the supervising practitioner.

005.06 ADMISSION CRITERIA. The provider of crisis intervention services must develop admission criteria for the types of services they provide. The admission criteria must be approved by Nebraska Medicaid as part of the provider enrollment.

005.07 DOCUMENTATION IN BENEFICIARY’S MEDICAL RECORD. Providers of crisis intervention services must follow the standards for clinical records specified in this chapter. Clinical records for crisis intervention services must also include, at a minimum, the following:

(A)The referral source and description of the crisis;

(B)The provider's plan to facilitate referrals to the appropriate ongoing care for the family; and

(C)The follow-up contacts with the beneficiary or family, or both.

005.08 LIMITATIONS. Nebraska Medicaid limits payment for crisis intervention to medically necessary services, subject to Nebraska Medicaid's utilization review. This period includes an average crisis resolution period of three to five days with an occasional need for up to seven days when the beneficiary's condition dictates. Payment for crisis intervention services is not available for services past seven days.

005.09 PAYMENT FOR CRISIS INTERVENTION SERVICES. If crisis intervention services are provided in the home between the hours of 10:00 p.m. and 8:00 a.m., the fee will be paid at one- and one-half times the regular rate. This shift differential is only available for unscheduled emergency services that are part of a crisis intervention service.

006. MENTAL HEALTH AND SUBSTANCE USE DISORDER DAY TREATMENT SERVICES. Day treatment services are available to beneficiaries age 20 or younger when the beneficiary has participated in a health check or Early and Periodic Screening, Diagnostic and Treatment (EPSDT) screen, the treatment is clinically necessary, and the need for this level of care is identified as part of an initial diagnostic interview, a substance use disorder assessment, or a substance use disorder addendum. These services are part of a continuum of care designed to prevent hospitalization or to facilitate the movement of the beneficiary in an acute psychiatric setting to a status in which the beneficiary is capable of functioning within the community with less frequent contact with the mental health or substance use disorder provider. Day treatment services must be community based, family centered, culturally competent, and developmentally appropriate. Day treatment services must meet all requirements in this chapter.

006.01 FAMILY COMPONENT. Providers must encourage family members to be involved in the assessment of the beneficiary, the development of the treatment plan, and all aspects of the beneficiary's treatment unless prohibited by the beneficiary, through legal action, or because of federal confidentiality laws. Providers must be available to schedule meetings and sessions in a flexible manner to accommodate and work with a family's schedule. This includes the ability to schedule sessions at a variety of times including weekends or evenings. The provider must document their attempts to involve the family in treatment plan development and treatment plan reviews. A variety of communication means should be considered.

006.02 COVERED DAY TREATMENT SERVICES. Day treatment programs must provide the following mandatory services and at least two of the following optional services. Payment for both mandatory services and optional services is included in the rate for day treatment. Individual services to the beneficiary by a supervising practitioner that are not administrative in nature and are clinically necessary will be considered for payment when billed by the supervising practitioner. Providers must not make any additional charges to Nebraska Medicaid or to the beneficiary.

006.02(A) MANDATORY SERVICES. The following services must be included in a program for day treatment to be approved for participation in Nebraska Medicaid

(i) MEDICALLY NECESSARY PSYCHOTHERAPY AND SUBSTANCE USE DISORDER. These services must demonstrate active treatment of a patient with a serious emotional disturbance. These services are subject to program limitations.

(1)Individual psychotherapy or substance use disorder counseling;

(2)Group psychotherapy or substance use disorder counseling;

(3)Family psychotherapy or substance use disorder counseling; and

(4)Family assessment.

(ii) MEDICALLY NECESSARY NURSING SERVICES. Medical services provided by a qualified registered nurse (RN) who evaluates the particular medical nursing needs of each beneficiary and provides for the medical care and treatment that is indicated on a Nebraska Medicaid approved treatment planning document and approved by the supervising practitioner.

(iii) MEDICALLY NECESSARY PSYCHOLOGICAL DIAGNOSTIC SERVICES. Testing and evaluation services must reasonably be expected to contribute to the diagnosis and plan of care established for the individual beneficiary. Testing and evaluation services may be performed by a licensed psychologist, specially licensed psychologist or a psychology resident acting within their scope of practice. Clinical necessity must be documented by the program supervising practitioner. Reimbursement for psychological diagnostic services is included in the per diem.

(iv) MEDICALLY NECESSARY PHARMACEUTICAL SERVICES. If medications are dispensed by the program, pharmacy services must be provided under the supervision of a registered pharmacy consultant; or the program may contract for these services through an outside facility or provider. All medications must be stored in a special locked storage space and administered only by a physician, advanced practice registered nurse (APRN), registered nurse (RN), or licensed practical nurse (LPN).

(v) MEDICALLY NECESSARY DIETARY SERVICES. If meals are provided by a day treatment program, services must be supervised by a registered dietitian, based on the beneficiary's individualized diet needs. Day treatment programs may contract for these services through an outside facility or provider.

(vi)TRANSITION AND DISCHARGE. Transition and discharge planning that meets the requirements of this chapter.

006.02(B) OPTIONAL SERVICES. The program must provide two of the following optional services. The beneficiary must have a need for the services, the supervising practitioner must order the services, and the services must be a part of the beneficiary's treatment plan. The therapies must be restorative in nature, not prescribed for conditions that have plateaued or cannot be significantly improved by the therapy, or which would be considered maintenance therapy. In appropriate circumstances, occupational therapy (OT) may be covered if prescribed as an activities therapy in a day treatment program:

(i)Services provided or supervised by a licensed or certified therapist may be provided under the supervision of a qualified consultant or the program may contract for these services from a licensed or certified professional as listed below:

(1)Recreational therapy;

(2)Speech therapy;

(3)Occupational therapy (OT);

(4)Vocational skills therapy; and

(5)Self-care services ;

(ii) Therapeutic psychoeducational services may be provided as part of a total program. Therapeutic psychoeducational services must be provided by teachers specially trained to work with child and adolescents experiencing mental health or substance use disorder problems. These services may meet some strictly educational requirements, but must also include the therapeutic component. Professionals providing these services must be appropriately licensed and certified for the scope of practice;

(iii)Social work services by a bachelor's level social worker: Social services to assist with personal, family, and adjustment problems which may interfere with effective use of treatment;

(iv)Crisis intervention ;

(v)Social skills building;

(vi)Life survival skills; and

(vii)Substance use disorder prevention, intervention, or treatment by a licensed alcohol and drug counselor (LADC) or provisionally licensed alcohol and drug counselor (LADC).

006.02(C) EDUCATIONAL PROGRAM SERVICES. Educational services, when required by law, must be available, though not necessarily provided by the day treatment program. Educational services must be only one aspect of the treatment plan, not the primary reason for admission or treatment. Educational services are not eligible for payment by Nebraska Medicaid, and do not apply towards the three hours or six hours of therapeutic services.

006.02(D) SPECIAL TREATMENT PROCEDURES IN DAY TREATMENT. If a child or adolescent needs behavior management and containment beyond unlocked time outs or redirection, special treatment procedures may be utilized. Special treatment procedures in day treatment are limited to physical restraint, and locked time out (LTO). Mechanical restraints and pressure point tactics are not allowed. Parents or legal guardian or a Nebraska Medicaid case manager must approve use of these procedures through informed consent and must be informed within 24 hours each time they are used. Facilities must meet the following standards regarding special treatment procedures:

(i) De-escalation techniques must be taught to staff and used appropriately before the initiation of special treatment procedures;

(ii) Special treatment procedures may be used only when a child or adolescent's behavior presents a danger to self or others, or to prevent serious disruption to the therapeutic environment;

(iii) The child or adolescent's treatment plan must address the use of special treatment procedures and have a clear plan to decrease the behavior requiring locked time out (LTO), or physical restraints; and

(iv) Attempts to de-escalate, the special treatment procedure and subsequent processing must be documented in the clinical record and reviewed by the supervising practitioner.

006.03 STANDARDS FOR PARTICIPATION.

006.03(A) PROVIDER STANDARDS. Providers of day treatment services must meet the following standards:

(i) A community mental health or substance use disorder program providing day treatment must meet the following standards:

(1)A community-based treatment facility appropriately licensed as determined by the Department of Health and Human Services, Division of Public Health; and

(2)Accreditation by the Joint Commission , the Commission on the Accreditation of Rehabilitation Facilities (CARF), the Council on Accreditation (COA) or the American Osteopathic Association (AOA). Agencies that have applied for accreditation may be enrolled on a provisional status;

(ii) A psychiatric or substance use disorder hospital providing day treatment must:

(1)Be maintained for the care and treatment of patients with primary psychiatric or substance use disorder disorders;

(2)Be licensed or formally approved as a hospital by the Nebraska Department of Health and Human Services, Division of Public Health;

(3)Be accredited by the Joint Commission or the American Osteopathic Association (AOA);

(4)Have licensed and certified psychiatric or substance use disorder beds;

(5)Meet the requirements for participation in Medicare; and

(6)Have in effect a utilization review plan applicable to all Nebraska Medicaid beneficiaries;

(iii)A licensed and certified hospital which provides acute care services and which:

(1)Is maintained for the care and treatment of patients with acute medical disorders;

(2)Is licensed or formally approved as a hospital by the Nebraska Department of Health and Human Services, Division of Public Health;

(3)Is accredited by the Joint Commission or the American Osteopathic Association (AOA);

(4)Meets the requirements for participation in Medicare for acute medical hospitals;

(5)Has in effect a utilization review plan applicable to all Nebraska Medicaid beneficiaries; and

(6)Has adequate staff to meet the requirements of the mental health or substance use disorder day treatment standards; and

(iv)If day treatment services will be provided in a school, the school must have a written contract with a mental health or substance use disorder program that meets these standards community mental health program or licensed hospital. This contract must demonstrate the working relationship between the school and the community mental health or substance use disorder program to provide the day treatment service.

006.03(B) SERVICE STANDARDS.

(i)The program must provide a minimum of three hours of services five days a week, which is considered a half day for billing purposes. Six hours a day of services is considered a full day of services. Services may not be prorated for under three hours of service for a half day or six hours of services for a full day, but may be for up to 12 hours of service;

(ii)A designated supervising practitioner must be responsible for the care provided in a day treatment program. The supervising practitioner must be present on a regularly-scheduled basis and must assume responsibility for all beneficiaries. If the supervising practitioner is present on a part-time basis, one of the clinical staff professionals acting within the scope of practice standards of the Nebraska Department of Health and Human Services, Division of Public Health must assume delegated professional responsibility for the program and must be present at all times when the program is providing services. Psychotherapy and substance use disorder counseling services must be provided by clinical staff who are operating within their scope of practice and under the direction of the supervising practitioner. The supervising practitioner's personal involvement must be documented in the beneficiary's clinical record;

(iii)A licensed psychologist, physician, doctor of osteopathy, physician assistant (PA), or advanced practice registered nurse (APRN) may refer a beneficiary to a day treatment program, but all treatment must be prescribed and directed by the program supervising practitioner;

(iv)All treatment must be conducted under the direction of the supervising practitioner in charge of the program;

(v) The following criteria must be met for a beneficiary's admission to a day treatment program:

(1)The beneficiary must have sufficient need for active treatment at the time of admission to justify the expenditure of the beneficiary's and program's time, energy, and resources; and

(2)Of all reasonable options for active treatment available to the beneficiary, treatment in this program must be the best choice for expecting a reasonable improvement in the beneficiary's condition;

(vi)Before the beneficiary is admitted to the program, a supervising practitioner must complete an initial diagnostic interview to validate the appropriateness of care;

(vii) The program supervising practitioner must determine the diagnosis and prescribe the treatment, including the modalities and the professional staff to be used. They must be responsible and accountable for all evaluations and treatment provided to the beneficiary. The goals and objectives documented on the treatment plan must reflect the recommendations from the initial diagnostic interview, the supervising practitioner and the therapist. The treatment interventions provided must reflect these recommendations, goals, and objectives. Evaluation of the treatment plan by the therapist and the supervising practitioner should reflect the beneficiary's response to the treatment interventions based on the recommendations, goals, and objectives:

(1)The multi-disciplinary team must complete the treatment plan within the first 14 days after the beneficiary's admission to the program. The plan must be reviewed and revised by the multi-disciplinary team, including the supervising practitioner, at least every 30 days or more often if necessary; and

(2)Changes in the treatment plan must be noted on the treatment planning document. An updated treatment plan must be completed every 30 days, or more frequently if necessary, to reflect changes in treatment needs. The treatment plan must be signed by the supervising practitioner for day treatment services. The treatment plan review must be documented on the treatment plan, if required, and in the medical records;

(viii)The supervising practitioner must meet personally with the beneficiary for evaluation every 30 days, or more often, as clinically necessary. Reimbursement for the 30-day update visit is not included in the day treatment per diem and can be reimbursed separately;

(ix)Every 30 days a utilization review must be conducted in accordance with this chapter. This review must be documented on the treatment plan, and the facility's treatment plan review form. Utilization review is not required for the calendar month in which the beneficiary was admitted;

(x)The program must have a description of each of the services and treatment modalities available. This includes psychotherapy services, substance use disorder counseling, nursing services, psychological diagnostic services, pharmaceutical services, dietary services, and other day treatment services:

(1)The program must have a description of how the family-centered requirement in this chapter will be met, including a complete description of any family assessment and family services;

(2)The program must have a description of how the community-based requirement in this chapter will be met;

(3)The program must state the qualifications, education, and experience of each staff member and the therapy services each provides; and

(4)The program must have a daily schedule covering the total number of hours the program operates per day. The schedule must be submitted to Nebraska Medicaid for approval. The program must be fully staffed and supervised during the time the program is available for services, and must provide at least three hours of approved treatment for each day services are provided. This schedule must be updated annually, or more frequently if appropriate;

(xi) When appropriate for brief crisis stabilization, outpatient observation up to 23 hours 59 minutes in an emergency room or acute hospital may be used in accordance with the definition of outpatient in this chapter; and

(xii)The program must have a written plan for immediate admission or readmission for appropriate inpatient services, if necessary. The written plan must include a cooperative agreement with a psychiatric or substance use disorder hospital or distinct part of a hospital, as outlined in this chapter. A copy of this agreement must accompany the provider application and agreement.

006.04 PROVIDER AGREEMENT. A provider of day treatment services must complete a provider agreement and submit the form to Nebraska Medicaid for approval. The provider must attach to the provider agreement a written overview of the program including philosophy, objectives, policies and procedures, and documentation of the requirements in this chapter are met. Staff must meet the standards outlined in this chapter, and

(A)Community mental health or substance use disorder programs and licensed health clinics must complete the appropriate Nebraska Medicaid approved provider agreement form , and submit the completed form to Nebraska Medicaid for approval. A Nebraska Medicaid approved cost reporting document must also be submitted. Satellites of community programs must bill Nebraska Medicaid through their main community program, unless the satellite has a separate provider number under Medicare. A satellite of a community program that has a separate provider number under Medicare must complete a separate provider agreement. All claims submitted to Nebraska Medicaid by these satellites must be filed under the satellite's Nebraska Medicaid provider number. The facility must have in effect a utilization review plan applicable to all Nebraska Medicaid clients; and

(B)Hospitals must complete the appropriate Nebraska Medicaid approved provider agreement form and submit the completed form to Nebraska Medicaid for approval. A Nebraska Medicaid approved cost reporting document must also be submitted.

006.04(i) ANNUAL RENEWAL. The program must renew the provider agreement, program overview, and cost report annually and whenever requested by Nebraska Medicaid .

006.05 COVERAGE CRITERIA FOR MENTAL HEALTH OR SUBSTANCE USE DISORDER DAY TREATMENT. Nebraska Medicaid covers day treatment services for beneficiaries age 20 and younger when the services meet the requirements in in this chapter and the beneficiary has participated in a health check or Early and Periodic Screening, Diagnostic and Treatment (EPSDT) screen. Day treatment services must be prior authorized by Nebraska Medicaid or its designee. The beneficiary must be observed and interviewed by the supervising practitioner at least once every 30 days, or more frequently if medically necessary, and the interaction must be documented in the beneficiary's clinical record.

006.05(A) SERVICES NOT COVERED UNDER NEBRASKA MEDICAID. Payment is not available for day treatment services for beneficiaries:

(i)Receiving services in an out-of-state facility, except as outlined in this title ;

(ii)In long term care facilities;

(iii)Whose needs are social or educational and may be met through a less structured program;

(iv)Whose primary diagnosis and functional impairment is acutely psychiatric in nature and whose condition is not stable enough to allow them to participate in and benefit from the program; or

(v)Whose behavior may be very disruptive or harmful to other program participants or staff members.

006.06 DOCUMENTATION IN THE BENEFICIARY’S CLINICAL RECORD. All documents submitted to Nebraska Medicaid must contain sufficient information for identification . In addition to the requirements of this chapter, each beneficiary's medical record must contain the following documentation:

(A)The supervising practitioner's orders;

(B)The treatment plan;

(C)The team progress notes, recorded chronologically. The frequency is determined by the beneficiary's condition, but the team's progress notes must be recorded at least daily. The progress notes must contain a concise assessment of the beneficiary's progress and recommendations for revising the treatment plan, as indicated by the beneficiary's condition, and discharge planning;

(D)Documentation indicating compliance with all requirements in this chapter;

(E)Records of the treatment plan review by the multi-disciplinary team including attendees and decisions;

(F)The program's utilization review committee's abstract or summary; and

(G)The discharge summary.

006.07 TRANSITION AND DISCHARGE PLANNING. Each provider must meet the requirements in this chapter for transition and discharge planning.

006.08 UTILIZATION REVIEW. Each program is responsible for establishing a utilization review plan and procedure which meets the following requirements. A site visit by Nebraska Medicaid for purposes of utilization review may be required for further clarification.

006.08(A) COMPONENTS OF UTILIZATION REVIEW. Utilization review must provide:

(i)Timely review, at least every 30 days, of the medical necessity of admissions and continued treatment;

(ii)Utilization of professional services provided;

(iii)High quality patient care; and

(iv)Effective and efficient utilization of available health facilities and services.

006.08(B) UTILIZATION REVIEW OVERVIEW. An overview of the program's utilization review process must be submitted with the provider application and agreement before the program is enrolled as a Nebraska Medicaid provider. The overview must include:

(i)The organization and composition of the utilization review committee which is responsible for the utilization review function;

(ii)The frequency of meetings, which must occur at least every 30 days ;

(iii)The type of records to be kept; and

(iv)The arrangement for committee reports and their dissemination, including how the program and supervising practitioner is informed of the findings.

006.08(C) UTILIZATION REVIEW COMMITTEE. The utilization review committee must contain a licensed provider who is able to diagnose and treat major mental illness within their scope of practice and at least two clinical staff professionals, as defined in this chapter. The committee's reviews may not be conducted by any person whose primary interest in or responsibility to the program is financial or who is professionally involved in the care of the beneficiary whose case is being reviewed. At Nebraska Medicaid's discretion, an alternative plan for facilities that do not have these resources readily available may be approved.

006.08(D) BASIS OF REVIEW. The review must be based on:

(i)The identification of the individual beneficiary by appropriate means to ensure confidentiality;

(ii)The identification of the supervising practitioner;

(iii)The date of admission;

(iv)The diagnosis and symptoms;

(v)The supervising practitioner's plan of treatment; and

(vi)Other supporting materials the group may deem appropriate.

006.08(E) CONTENTS OF REPORT. The written report must contain :

(i)An evaluation of treatment, progress, and prognosis based on:

(1)Appropriateness of the current level of care and treatment;

(2)Alternate levels of care and treatment available; and

(3)The effective and efficient utilization of services provided;

(ii)Verification that :

(1)Treatment provided is documented in the beneficiary's record;

(2)All entries in the beneficiary's record are signed by the person responsible for entry and dated. The supervising practitioner must sign and date all of their orders; and

(3)All entries in the beneficiary's record are dated;

(iii)Recommendations for :

(1)Continued treatment;

(2)Alternate treatment or level of care, or both; and

(3)Disapproval of continued treatment;

(iv)The date of the review;

(v) The names of the program utilization review committee members;

(vi)The date of the next review if continued treatment is recommended; and

(vii) A copy of the admission review and the extended stay review must be attached to all claims for mental health services submitted to Nebraska Medicaid for payment.

006.09 LIMITATIONS ON REIMBURSEMENT OF ALLOWABLE COSTS. The following limitations apply to reimbursement of allowable costs:

(A)Payment for a full day of day treatment is allowable when services are provided to a beneficiary for at least six hours per day;

(B)Payment for a half day of day treatment is allowable when services are provided to a beneficiary for at least three hours per day but less than six hours per day. The rate for a half day of day treatment is limited to one half of the full day rate; and

(C)For programs that provide services for more than six hours, and up to twelve hours, payment can be prorated by the hour. For each additional hour of service beyond six, Nebraska Medicaid will pay an additional amount based on the cost-report.

006.09(i) DOCUMENTATION FOR CLAIMS. The following documentation is required for all claims for day treatment and claims and must be kept in the beneficiary’s record:

(1)A psychiatric assessment with mental status exam and diagnosis;

(2)The treatment plan for admission and every 30 days thereafter;

(3)Orders by the supervising practitioner;

(4)A complete family assessment;

(5)Nurses' notes;

(6)Progress notes for all disciplines; and

(7)All claims are subject to utilization review by Nebraska Medicaid prior to payment.

006.09(ii) EXCEPTION. Additional documentation from the beneficiary’s medical record may be requested by Nebraska Medicaid prior to considering authorization of payment.

006.09(iii) COSTS NOT INCLUDED IN THE DAY TREATMENT FEE. The mandatory and optional services are considered to be part of the fee for day treatment services. The following charges can be reimbursed separately from the day treatment fee when the services are necessary, part of the beneficiary's overall treatment plan, and in compliance with Nebraska Medicaid policy:

(1)Direct beneficiary services performed by the supervising practitioner;

(2)Prescription medications, including injectable medications;

(3)Direct beneficiary services performed by a physician, physician assistant (PA), or advanced practice registered nurse (APRN) other than the supervising practitioner;

(4)Treatment services for a physical injury or illness provided by other professionals; and

(5) If the beneficiary is enrolled with another Nebraska Health Connection vendor for medical-surgical services, it may be necessary to pursue prior authorization or referral with that entity.

006.10 PROCEDURE CODES AND DESCRIPTIONS FOR MENTAL HEALTH OR SUBSTANCE USE DISORDER DAY TREATMENT. Healthcare Common Procedure Coding System (HCPCS) and Current Procedural Terminology (CPT); procedure codes used by Nebraska Medicaid are listed in the Nebraska Medicaid Practitioner Fee Schedule .

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007. THERAPEUTIC GROUP HOME (ThGH) SERVICES. Therapeutic group home (ThGH) services are available to beneficiaries age 20 or younger when the beneficiary has participated in a health check or Early and Periodic Screening, Diagnostic and Treatment (EPSDT) screen, the treatment is clinically necessary, and the need for this level of care is identified as part of an initial diagnostic interview, initial diagnostic interview addendum, a substance use disorder assessment, or a substance use disorder addendum. These services are part of a continuum of care designed to prevent hospitalization or to facilitate the movement of the beneficiary in an acute psychiatric setting to a status in which the beneficiary is capable of functioning within the community with less frequent need for clinical contact with the mental health or substance use disorder provider. Therapeutic group home (ThGH) services must be community based, family centered, culturally competent, and developmentally appropriate. Therapeutic group home (ThGH) must meet all requirements in this chapter.

007.01 FAMILY COMPONENT. Providers must encourage family members to be involved in the assessment of the beneficiary, the development of the treatment plan, and all aspects of the beneficiary’s treatment unless prohibited by the beneficiary, through legal action, or because of federal confidentiality laws. Providers must be available to schedule meetings and sessions in a flexible manner to accommodate and work with a family’s schedule. This includes the ability to schedule sessions at a variety of times including weekends or evenings. The provider must document their attempts to involve the family in treatment plan development and treatment plan reviews. A variety of communication means should be considered.

007.02 MANDATORY SERVICES. The following services must be included in a program for the therapeutic group home (ThGH) to be approved for participation in Nebraska Medicaid.

007.02(A) ACTIVE AND REHABILITATIVE TREATMENT SERVICES. Each beneficiary must be involved in at least 21 hours of active and rehabilitation treatment per week. In addition, the program must provide access to daily recreational activities for all beneficiaries, but these recreational activities are not considered a part of the 21 required treatment hours.

007.02(B) MEDICALLY NECESSARY PSYCHOTHERAPY AND SUBSTANCE USE DISORDER SERVICES. Medically necessary psychotherapy services and substance use disorder services must demonstrate active treatment of a beneficiary with a serious emotional disturbance. Beneficiaries must receive individual psychotherapy, group psychotherapy, or substance use disorder counseling for at least three hours per week, and family psychotherapy or family substance use disorder counseling at least twice monthly. Medically necessary psychotherapy and substance use disorder services include:

(i) Individual psychotherapy or substance use disorder counseling;

(ii) Group psychotherapy or substance use disorder counseling;

(iii) Family psychotherapy or substance use disorder counseling; and

(iv) Family assessment.

007.02(C) PSYCHOEDUCATIONAL GROUPS AND INDIVIDUAL PSYCHOEDUCATIONAL THERAPY SERVICES. Psychoeducational services must be available from the therapeutic group home (ThGH) and must be modified to meet the unique treatment needs of the beneficiary as described in the beneficiary’s treatment plan.

007.02(D) MEDICALLY NECESSARY NURSING SERVICES. Medical services provided by an advanced practice registered nurse (APRN), registered nurse (RN), or licensed practical nurse (LPN) under registered nurse (RN) supervision, who evaluates the particular medical nursing needs of each beneficiary and provides for the medical care and treatment that is indicated on a Nebraska Medicaid approved treatment planning document and approved by the supervising practitioner. Therapeutic group home (ThGH) programs may contract for these services through an outside facility or provider.

007.02(E) MEDICALLY NECESSARY PSYCHOLOGICAL DIAGNOSTIC SERVICES. Testing and evaluation services must reasonably be expected to contribute to the diagnosis and plan of care established for the beneficiary. Testing and evaluation services may be performed by a licensed psychologist, specially licensed psychologist or a psychology resident acting within their scope of practice. Clinical necessity must be documented by the program supervising practitioner. Therapeutic group home (ThGH) programs may contract for these services through an outside facility or provider.

007.02(F) MEDICALLY NECESSARY PHARMACEUTICAL SERVICES. If medications are dispensed by the program, pharmacy services must be provided under the supervision of a registered pharmacy consultant; or the program may contract for these services through an outside facility or provider. All medications must be stored in a special locked storage space and administered only by a physician, advanced practice registered nurse (APRN), registered nurse (RN), licensed practical nurse (LPN), or a direct care staff person approved by the Nebraska Department of Health and Human Services, Division of Public Health as a medication aide. Therapeutic group home (ThGH) programs may contract for these services through an outside facility or provider.

007.02(G) MEDICALLY NECESSARY DIETARY SERVICES. If meals are provided by a therapeutic group home (ThGH) program, services must be supervised by a registered dietitian, based on the beneficiary's individualized diet needs. Therapeutic group home (ThGH) programs may contract for these services through an outside facility or provider.

007.02(H) EDUCATIONAL AND VOCATIONAL ASSISTANCE. The beneficiary must attend a school in the community. In this setting, the beneficiary remains involved in community-based activities and may attend a community educational, vocational program or other treatment setting. The therapeutic group home (ThGH) is required to coordinate with the beneficiary’s community resources, including schools or vocational services, with the goal of transitioning the beneficiary out of the program to a less restrictive care setting for continued, sometimes intensive, services as soon as possible and as appropriate.

007.02(I) TRANSITION AND DISCHARGE. Transition and discharge planning that meets the requirements of this chapter.

007.02(J) SPECIAL TREATMENT PROCEDURES IN THERAPEUTIC GROUP HOMES (ThGH). If a child or adolescent needs behavior management and containment beyond unlocked time outs or redirection, special treatment procedures may be utilized. Special treatment procedures in therapeutic group homes (ThGH) are limited to physical restraint, and locked time out (LTO). Mechanical restraints and pressure point tactics are not allowed. Parents or legal guardian must approve use of these procedures through informed consent and must be informed within 24 hours each time they are used. Facilities must meet the following standards regarding special treatment procedures:

(i) De-escalation techniques must be taught to staff and used appropriately before the initiation of special treatment procedures;

(ii) Special treatment procedures may be used only when a child or adolescent's behavior presents a danger to self or others, or to prevent serious disruption to the therapeutic environment;

(iii) The child or adolescent's treatment plan must address the use of special treatment procedures and have a clear plan to decrease the behavior requiring locked time out (LTO), or physical restraints; and

(iv) Attempts to de-escalate, the special treatment procedure and subsequent processing must be documented in the clinical record and reviewed by the supervising practitioner.

007.03 STANDARDS FOR PARTICIPATION.

007.03(A) PROVIDER STANDARDS. Providers of therapeutic group home (ThGH) services must meet the following standards:

(i) Be a community-based treatment facility appropriately licensed as determined by the Department of Health and Human Services, Division of Public Health;

(ii) Be accredited by the Joint Commission, the Commission on the Accreditation of Rehabilitation Facilities (CARF), or the Council on Accreditation (COA). Agencies that have applied for accreditation may be enrolled on a provisional status;

(iii) To ensure a more home-like setting, each location where beneficiaries live must be in a residential community to facilitate community integration through public education, recreation, and maintenance of family connections;

(iv) Therapeutic group home (ThGH) facilities must not have more than eight beds. Existing facilities providing therapeutic group home (ThGH) services may not add beds if the bed total would exceed eight. Facilities exceeding 15 beds may not enroll as a therapeutic group home (ThGH). Facilities enrolled as a therapeutic group home (ThGH) with 9-15 bed capacity on the operative date of these regulations may continue to be operative at that capacity until alterations are made. Any facility alterations must comply with the eight bed limit; and

(v) If a provider operates multiple therapeutic group homes (ThGH), they must ensure that they do not meet the definition of an institution of mental disease (IMD).

007.03(B) SERVICE STANDARDS.

(i) The program must provide services 24 hours a day, seven days a week, 365 days per year with 24-hour awake staffing;

(ii) Staffing:

(1) A designated supervising practitioner must be responsible for the care provided in a therapeutic group home (ThGH) program and the clinical supervision of direct care staff. The supervising practitioner must be present on a regularly scheduled basis and must assume responsibility for all beneficiaries. Psychotherapy and substance use disorder counseling services must be provided by clinical staff who are operating within their scope of practice and under the direction of the supervising practitioner. The supervising practitioner's personal involvement must be documented in the beneficiary's clinical record;

(2) All treatment must be prescribed and conducted under the direction of the supervising practitioner in charge of the program;

(3) A therapeutic group home (ThGH) clinical director may be a physician with a specialty in psychiatry, physician, psychologist, advance practice registered nurse (APRN), physician assistant (PA), licensed independent mental health practitioner (LIMHP), or licensed mental health practitioner (LMHP), who is practicing within their scope of practice. Dual licensure is preferred for therapeutic group home (ThGH) services when co-occurring mental health and substance use diagnoses occur. The clinical director may not also serve in the role of the program’s therapist;

(4) A therapeutic group home (ThGH) therapist may be a psychiatrist, physician, psychologist, provisionally licensed psychologist, advanced practice registered nurse (APRN), physician assistant (PA), licensed independent mental health practitioner (LIMHP), licensed mental health practitioner (LMHP), or a provisionally licensed mental health practitioner (LMHP) who is working within their scope of practice;

(5) Therapeutic group home (ThGH) direct care staff must be 20 years of age or older and at least two years older than the oldest resident under the age of 20. Direct care staff must have a high school diploma or equivalent, and must have demonstrated skills and competencies in treatment with beneficiaries with a behavioral health diagnosis, demonstrated by at least one of the following:

(a) Bachelor's degree or higher in psychology, sociology, or a related field (preferred);

(b) One year of coursework in the human services field; or

(c) Two years of recovery experience with demonstrated competencies and skills in the treatment of individuals with a behavioral health diagnosis;

(6) Staffing ratios must be adequate to meet the individualized treatment needs of the beneficiary and each staff must meet the responsibilities outlined in the staffing requirements. Acceptable hours and ratios include:

(a) Direct care staffing ratios must be 1:6 during awake hours and 1:8 during sleep hours. At least one staff member per shift is required to have a current cardiopulmonary (CPR) and first aid certification;

(b) A registered nurse (RN) or advanced practice registered nurse (APRN) must be available in person or on-call 24 hours a day, seven days a week, 365 days per year; and

(c) The ratio of therapeutic group home (ThGH) therapists to beneficiaries served must be no greater than 1:12;

(iii) The following criteria must be met for a beneficiary's admission to a therapeutic group home (ThGH) program:

(1) The beneficiary must have sufficient need for active treatment at the time of admission to justify the expenditure of the beneficiary's and program's time, energy, and resources; and

(2) Of all reasonable options for active treatment available to the beneficiary, treatment in this program must be the best choice for expecting a reasonable improvement in the beneficiary's condition;

(iv) Before the beneficiary is admitted to the program, a licensed provider must complete an initial diagnostic interview to validate the appropriateness of care;

(v) The goals and objectives documented on the treatment plan must reflect the recommendations from the initial diagnostic interview, the supervising practitioner, and the therapist. The treatment interventions provided must reflect these recommendations, goals, and objectives. Evaluation of the treatment plan by the therapist and the supervising practitioner should reflect the beneficiary's response to the treatment interventions based on the recommendations, goals, and objectives:

(1) The multi-disciplinary team must complete the treatment plan within the first seven days after the beneficiary's admission to the program. The plan must be reviewed and revised by the multi-disciplinary team, including the supervising practitioner, at least every 14 days or more often if necessary; and

(2) Changes in the treatment plan must be noted on the treatment planning document. An updated treatment plan must be completed every 14 days, or more frequently, if necessary, to reflect changes in treatment needs. The treatment plan must be signed by the beneficiary and their parent or guardian, and the supervising practitioner for therapeutic group home (ThGH) services. The treatment plan review must be documented on the treatment plan, if required, and in the clinical records;

(vi) The supervising practitioner must meet personally with the beneficiary for evaluation every 30 days, or more often, as clinically necessary. Reimbursement for the 30-day update visit is not included in the therapeutic group home (ThGH) per diem and can be reimbursed separately as an individual psychotherapy service;

(vii) Every 30 days a utilization review must be conducted per this chapter. This review must be documented on the treatment plan, and the facility's treatment plan review form. Utilization review is not required for the calendar month in which the beneficiary was admitted;

(viii) The program must have written documentation of each of the services and treatment modalities available. This includes psychotherapy services, substance use disorder counseling, nursing services, psychological diagnostic services, pharmaceutical services, dietary services, and other therapeutic group home (ThGH) services:

(1) The program must have written documentation of how the family-centered requirement in this chapter will be met, including a complete description of any family assessment and family services;

(2) The program must have written documentation of how the community-based requirement in this chapter will be met; and

(3) The program must state the qualifications, education, and experience of each staff member and the therapy services each provides;

(ix) When brief crisis stabilization is clinically necessary, outpatient observation up to 23 hours 59 minutes in an emergency department or acute hospital may be used as follows:

(1) In accordance with the definition of outpatient in this chapter; and

(x) The program must have a written policy for immediate admission or readmission for appropriate inpatient services when it is clinically necessary. The policy must include a cooperative agreement with a psychiatric or substance use disorder hospital or distinct part of a hospital, as outlined in this chapter. A copy of the cooperative agreement must accompany the provider application and provider agreement.

007.04 COVERAGE CRITERIA FOR THERAPEUTIC GROUP HOMES (ThGH). Nebraska Medicaid covers therapeutic group home (ThGH) services for beneficiaries age 20 and younger when the services meet the requirements in this chapter and the beneficiary has participated in a health check or Early and Periodic Screening, Diagnostic and Treatment (EPSDT) screen. Therapeutic group home (ThGH) services must be prior authorized by Nebraska Medicaid or its designee. The beneficiary must be observed and interviewed by the supervising practitioner at least once every 30 days, or more frequently if clinically necessary, and the interaction must be documented in the beneficiary 's clinical record.

007.04(A) COSTS NOT INCLUDED IN THE THERAPEUTIC GROUP HOME (ThGH) FEE. Therapeutic group home (ThGH) services are reimbursed for the treatment of unlicensed direct care staff who are supervised by a licensed practitioner and work in the therapeutic group home (ThGH) milieu. The following charges may be reimbursed separately from the therapeutic group home (ThGH) fee when the services are medically necessary, part of the beneficiary’s overall treatment plan, and are in compliance with other state and federal regulations:

(i) Direct psychotherapy services provided by the supervising practitioner;

(ii) Prescription drugs including injectable medications;

(iii) Direct services performed by a physician, advanced practice registered nurse (APRN), or physician assistant (PA), other than the physician directing the program;

(iv) All laboratory or physical health diagnostic procedures prescribed by a physician, advanced practice registered nurse (APRN), or physician assistant (PA);

(v) Treatment services for physical injury or illness provided by non-mental health practitioners operating within their scope of practice; and

(vi) Individual psychotherapy services provided by licensed clinicians.

007.04(B) SERVICES NOT COVERED. Payment is not available for therapeutic group home (ThGH) services for beneficiaries:

(i) Receiving services in an out-of-state facility, except as outlined in these regulations;

(ii) In long-term care facilities (LTC);

(iii) Whose needs are social or educational and may be met through a less structured program;

(iv) Whose primary diagnosis and functional impairment is acutely psychiatric in nature and whose condition is not stable enough to allow them to participate in and benefit from the program; and

(v) Whose primary diagnosis and functional impairment is due to a developmental disability.

007.05 DOCUMENTATION IN THE BENEFICIARY’S CLINICAL RECORD. All documents submitted to Nebraska Medicaid must contain sufficient information for identification of the beneficiary. In addition to the requirements of this chapter, each beneficiary's medical record must contain the following documentation:

(A) The supervising practitioner's orders;

(B) The treatment plan;

(C) The team progress notes, recorded chronologically. The frequency is determined by the beneficiary's condition, but the team's progress notes must be recorded at least daily. The progress notes must contain a concise assessment of the beneficiary's progress and recommendations for revising the treatment plan, as indicated by the beneficiary's condition, and discharge planning;

(D) Documentation indicating compliance with all requirements in this chapter;

(E) Records of the treatment plan review by the multi-disciplinary team including attendees and decisions;

(F) The program's utilization review committee's abstract or summary; and

(G) The discharge summary.

007.06 TRANSITION AND DISCHARGE PLANNING. Each provider must meet the requirements in this chapter for transition and discharge planning.

007.07 UTILIZATION REVIEW. Each program is responsible for establishing a utilization review plan and procedure which meets the following guidelines. A site visit by Nebraska Medicaid staff for purposes of utilization review may be required for further clarification.

007.07(A) COMPONENTS OF UTILIZATION REVIEW. Utilization review must provide:

(i) Timely review, at least every 30 days, of the medical necessity of admissions and continued treatment;

(ii) Utilization of professional services provided;

(iii) High quality patient care; and

(iv) Effective and efficient utilization of available health facilities and services.

007.07(B) UTILIZATION REVIEW OVERVIEW. An overview of the program's utilization review process must be submitted with the provider application and provider agreement before the program is enrolled as a Nebraska Medicaid provider. The overview must include:

(i) The organization and composition of the utilization review committee which is responsible for the utilization review function;

(ii) The frequency of meetings, which must be not less than once a month;

(iii) The type of documentation to be kept; and

(iv) The arrangement for committee reports and their dissemination, including how the program and supervising practitioner is informed of the findings.

007.07(C) UTILIZATION REVIEW COMMITTEE. The utilization review committee must contain a licensed provider who is able to diagnose and treat major mental illness within their scope of practice and at least two clinical staff professionals, as defined in this chapter. The committee's reviews may not be conducted by any person whose primary interest in or responsibility to the program is financial or who is professionally involved in the care of the beneficiary whose case is being reviewed. At Nebraska Medicaid's discretion, an alternative plan for facilities that do not have these resources readily available may be approved.

007.07(D) BASIS OF REVIEW. The review must be based on:

(i) The identification of the beneficiary by appropriate means to ensure confidentiality;

(ii) The identification of the supervising practitioner;

(iii) The date of admission;

(iv) The diagnosis and symptoms;

(v) The supervising practitioner's plan of treatment; and

(vi) Other supporting materials the group may deem appropriate.

007.07(E) CONTENTS OF REPORT. The written report must contain:

(i) An evaluation of treatment, progress, and prognosis based on:

(1) Appropriateness of the current level of care and treatment;

(2) Alternate levels of care and treatment available; and

(3) The effective and efficient utilization of services provided;

(ii) Verification that:

(1) Treatment provided is documented in the beneficiary's record;

(2) All entries in the beneficiary's record are signed by the person responsible for entry and dated. The supervising practitioner must sign and date all of their orders; and

(3) All entries in the beneficiary's record are dated;

(iii) Recommendations for:

(1) Continued treatment;

(2) Alternate treatment or level of care, or both; and

(3) Disapproval of continued treatment;

(iv) The date of the review;

(v) The names of the program utilization review committee members;

(vi) The date of the next review if continued treatment is recommended; and

(vii) A copy of the admission review and the extended stay review must be attached to all claims for mental health services submitted to Nebraska Medicaid for payment.

007.08 DOCUMENTATION FOR CLAIMS. The following documentation is required for all claims for therapeutic group homes (ThGH) and claims must be kept in the beneficiary’s record. Additional documentation from the beneficiary's medical record may be requested by Nebraska Medicaid prior to considering authorization of payment.

(A) A psychiatric assessment with mental status exam and diagnosis;

(B) The treatment plan for admission and every 30 days thereafter;

(C) Orders by the supervising practitioner;

(D) A complete family assessment;

(E) Nurse's notes;

(F) Progress notes for all disciplines; and

(G) All claims are subject to utilization review by Nebraska Medicaid prior to payment.

007.09 PROCEDURE CODES AND DESCRIPTIONS FOR MENTAL HEALTH OR SUBSTANCE USE DISORDER THERAPEUTIC GROUP HOMES (ThGH). Healthcare Common Procedure Coding System (HCPCS) and Current Procedural Terminology (CPT); procedure codes used by Nebraska Medicaid are listed in the Nebraska Medicaid Practitioner Fee Schedule.

008. INPATIENT PSYCHIATRIC SERVICES FOR BENEFICIARIES UNDER AGE 19 IN PSYCHIATRIC RESIDENTIAL TREATMENT FACILITIES (PRTF).

008.01 PSYCHIATRIC RESIDENTIAL TREATMENT FACILITIES (PRTF) FOR CHILDREN AND ADOLESCENTS. A Psychiatric Residential Treatment Facility (PRTF) is a facility that provides inpatient psychiatric services to beneficiaries under the age of 19. A Psychiatric Residential Treatment Facility (PRTF) must provide the inpatient psychiatric services under the direction of a physician or advanced practice registered nurse (APRN), must be accredited, and must comply with all the requirements of applicable state and federal regulations.

008.02 PRIOR AUTHORIZATION. In order for an admission to a Psychiatric Residential Treatment Facility (PRTF) to be reimbursed by Nebraska Medicaid, the beneficiary must have a certification of need for services as set forth in this chapter and be prior authorized by Nebraska Medicaid or its designee. Prior authorization applies to all admissions described in this chapter.

008.03 CERTIFICATION OF NEED FOR SERVICES. A team certifying need for services must certify, prior to admission, that:

(A)Ambulatory care resources available in the community do not meet the treatment needs of the beneficiary;

(B)Proper treatment of the beneficiary’s psychiatric condition requires services on an inpatient basis under the direction of a physician or advanced practice registered nurse (APRN); and

(C)The services can reasonably be expected to improve the beneficiary’s condition or prevent further regression so that the services will no longer be needed.

008.04 TEAM CERTIFYING NEED FOR SERVICES. Certification of need for services must be made by an independent team which includes a physician or advanced practice registered nurse (APRN); has competence in diagnosis and treatment of mental illness, preferably in child psychiatry; and has knowledge of the beneficiary’s situation.

008.04(A) INDIVIDUALS WHO BECOME ELIGIBLE FOR NEBRASKA MEDICAID WHILE IN PSYCHIATRIC RESIDENTIAL TREATMENT FACILITY (PRTF). For an individual who applies for Nebraska Medicaid while in the Psychiatric Residential Treatment Facility (PRTF), the certification must be made by the team responsible for the plan of care as specified in this chapter and cover any period before application for which claims are made.

008.04(B) EMERGENCY ADMISSIONS. For emergency admissions, the certification must be made by the team responsible for the plan of care within 14 days after admission.

008.05 ACTIVE TREATMENT. Inpatient psychiatric service must involve active treatment which means implementation of a professionally developed and supervised individual plan of care, as described in this section, which is developed and implemented no later than 14 days after admission and is designed to achieve the beneficiary’s discharge from inpatient status at the earliest possible time.

008.06 INDIVIDUAL PLAN OF CARE. The plan of care means a written plan developed for each beneficiary to improve their condition to the extent that inpatient care is no longer necessary. The plan of care must:

(A)Be based on a diagnostic evaluation that includes examination of the medical, psychological, social, behavioral and developmental aspects of the beneficiary’s situation and reflects the need for inpatient psychiatric care;

(B)Be developed by a team of professionals specified in this section, in consultation with the beneficiary and their parents, legal guardian, or others in whose care the beneficiary will be released after discharge;

(C)State treatment objectives;

(D)Prescribe an integrated program of therapies, activities, and experiences designed to meet the objectives; and

(E)Include post-discharge plans and coordination of inpatient services with partial discharge plans and related community services to ensure continuity of care with the beneficiary’s family, school, and community upon discharge. The discharge plan must:

(i)Identify the custodial parent or custodial caregiver anticipated at discharge;

(ii)Identify the school the beneficiary will attend;

(iii)Include individualized educational program (IEP) recommendations as necessary;

(iv)Outline the aftercare treatment plan; and

(v) List barriers to community reintegration, including barriers for the custodial parent or custodial caregiver, and progress toward resolving these barriers since the last review.

008.07 TEAM DEVELOPING INDIVIDUAL PLAN OF CARE.

(A)The individual plan of care must be developed by an interdisciplinary team of physicians or advanced practice registered nurses (APRN) and other personnel who are employed by, or provide services to beneficiaries in the facility;

(B)Based on education and experience, the team must be capable of:

(i)Assessing the beneficiary’s immediate and long-range therapeutic needs, developmental priorities, and personal strengths and liabilities;

(ii)Assessing the potential resources of the beneficiary’s family;

(iii)Setting treatment objectives; and

(iv)Prescribing therapeutic modalities to achieve the plan’s objectives;

(C)The team must include, as a minimum, either:

(i)A board-eligible or board-certified psychiatrist;

(ii)A licensed psychologist and a physician or advanced practice registered nurse (APRN) ; or

(iii)A physician or advanced practice registered nurse (APRN) with specialized training and experience in the diagnosis and treatment of mental diseases and a licensed psychologist; and

(D)The team must also include one of the following:

(i)A psychiatric social worker;

(ii)A licensed registered nurse (RN) with specialized training or one year’s experience in treating mentally ill individuals;

(iii) A licensed occupational therapist (OT) who has specialized training or one year of experience in treating mentally ill individuals; or

(iv)A licensed psychologist.

008.08 REPORTS OF EVALUATION AND PLANS OF CARE. A written report of each evaluation and plan of care must be entered in the beneficiary’s record:

(A)At the time of admission; or

(B)If the beneficiary is already in the Psychiatric Residential Treatment Facility (PRTF), immediately upon completion of the evaluation or plan.

008.09 REVIEW OF PLAN OF CARE. The plan of care must be reviewed every 30 days by the team as specified in this section, to:

(A)Determine that services being provided continue to be required on an inpatient basis; and

(B)Recommend changes in the plan as indicated by the beneficiary’s overall progress from the treatment provided at this level of care.

008.10 TREATMENT SERVICES PROVIDED BY THE PSYCHIATRIC RESIDENTIAL TREATMENT FACILITY (PRTF). Providers of Psychiatric Residential Treatment Facility (PRTF) services must provide 40 hours of psychotherapy and other treatment interventions per week. The following services and frequency of services are included in the Psychiatric Residential Treatment Facility (PRTF) rate and must be available to the beneficiary unless clinically contraindicated:

(A)Twice weekly individual psychotherapy or substance use disorder counseling, or both;

(B)Minimum three times a week group psychotherapy or substance use disorder counseling, or both;

(C) Weekly family mental health or substance abuse disorder counseling, or both. A family therapy session is provided on the day of admission and the day prior to discharge;

(D)Occupational therapy (OT) as clinically indicated;

(E)Physical therapy (PT) as clinically indicated;

(F)Speech therapy as clinically indicated;

(G)Laboratory services;

(H)Transportation;

(I)Medical services, as necessary; and

(J)Nursing service availability seven days a week, 365 days a year by an onsite nurse during awake hours and by an on-call availability during sleep hours.

008.11 PSYCHOEDUCATION SERVICES PROVIDED IN PSYCHIATRIC RESIDENTIAL TREATMENT FACILITY (PRTF). Psychoeducational services must be available from the Psychiatric Residential Treatment Facility (PRTF) and must be modified to meet the unique treatment needs of the beneficiary as described in the individual’s plan of care:

(A)Crisis intervention and aftercare planning;

(B)Life survival skills as clinically indicated;

(C)Social skills building;

(D)Substance use prevention interventions;

(E)Self-care services as clinically indicated;

(F)Medication education, compliance, and information regarding the effectiveness of medication;

(G)Health care issues which may include nutrition, hygiene, and personal wellness;

(H)Vocational and career planning as clinically indicated; and

(I)Recreational activity, which is not considered in 40 hours per week of therapy but healthful outcomes of recreation and exercise may be a part of a psycho-educational group service.

008.12 INDIVIDUAL PARTICIPATION IN PSYCHIATRIC RESIDENTIAL TREATMENT FACILITY (PRTF) SERVICES. Every beneficiary need not partake in all treatment services that are available in the Psychiatric Residential Treatment Facility (PRTF) if such services are clinically contraindicated. If individual, group, or family psychotherapy services are not appropriately beneficial to the beneficiary’s need and plan of care, the plan of care must identify the rationale for this omission. However, in no case should a child or adolescent receive less than 40 hours of Psychiatric Residential Treatment Facility (PRTF) services each week.

008.13 STAFFING STANDARDS FOR PSYCHIATRIC RESIDENTIAL TREATMENT FACILITIES (PRTF). A Psychiatric Residential Treatment Facility (PRTF) must operate 24 hours a day, seven days a week, and 365 days per year with 24-hour awake staffing. Staffing ratios should be 1:4 during awake hours and 1:6 during sleep hours. The following positions are required to be staffed, with a minimum of the stated qualifications.

008.13(A) SUPERVISING PRACTITIONER. The Psychiatric Residential Treatment Facility (PRTF) Supervising Practitioner must be a licensed physician.

008.13(B) PROGRAM OR CLINICAL DIRECTOR. A program or clinical director must be a licensed mental health practitioner (LMHP), licensed registered nurse (RN), licensed advanced practice registered nurse (APRN), licensed independent mental health practitioner (LIMHP), licensed physician with a specialty in psychiatry, or licensed psychologist. Dual-credentialing is required for Psychiatric Residential Treatment Facility (PRTF) services when co-occurring conditions occur. The program or clinical director must have two years professional experience in a treatment setting similar to a Psychiatric Residential Treatment Facility (PRTF). The program or clinical director may not also serve in the role of the program’s therapist.

008.13(C) THERAPIST. A Psychiatric Residential Treatment Facility (PRTF) therapist must be a licensed practitioner whose scope of practice includes mental health or substance use disorder services or both, including a licensed mental health practitioner (LMHP), licensed independent mental health practitioner (LIMHP), provisionally licensed mental health practitioner (LMHP),

licensed alcohol and drug counselor (LADC), licensed psychologist, provisionally licensed psychologist, licensed advanced practice registered nurse (APRN), or licensed physician with a specialty in psychiatry.

008.13(D) REGISTERED NURSE (RN) OR ADVANCED PRACTICING REGISTERED NURSE (APRN). Nursing services must be provided by a registered nurse (RN), or Advanced Practice Registered Nurse (APRN) licensed by the state in which they practice.

008.13(E) DIRECT CARE STAFF. Direct care staff must meet the following requirements: Be 20 years of age or older and at least two years older than the oldest resident and have a high school diploma or its equivalent. Direct care staff must be appropriately trained and responsible for basic interaction care as well as assisting in the implementation of the plan of care that is within their scope of practice.

008.14 RESTRAINT AND SECLUSION. Restraint and seclusion activities utilized by the Psychiatric Residential Treatment Facility (PRTF) must be in compliance with federal standards for restraint and seclusion.

008.15 MEDICALLY NECESSARY SERVICES AND SUPPLIES. The following services must be available to the beneficiary and may be billed separately to Nebraska Medicaid:

(A)Medically necessary services and supplies not otherwise included in the Psychiatric Residential Treatment Facility (PRTF) rate when that care is reflected in the plan of care; and

(B)The Psychiatric Residential Treatment Facility (PRTF) must :

(i)Arrange for and oversee the provision of such services and supplies;

(ii)Maintain all medical records of care furnished to the beneficiary; and

(iii)Ensure that all services and supplies are furnished under the direction of a physician or advanced practice registered nurse (APRN).

009. INPATIENT MENTAL HEALTH SERVICES FOR BENEFICIARIES 20 AND YOUNGER IN INSTITUTIONS FOR MENTAL DISEASE (IMD). Inpatient mental health services in an institution for mental disease (IMD) are available to beneficiaries age 20 and younger when the beneficiary participates in a health check or Early and Periodic Screening, Diagnostic and Treatment (EPSDT) screen, and the treatment is medically necessary. Inpatient mental health services in an institution for mental disease (IMD) must be family centered, and community based, culturally competent, and developmentally appropriate. Services for children who are wards of the State of Nebraska must be prior-authorized by and consent for treatment must be obtained from the beneficiary’s case manager or the case manager's supervisor.

009.01 LEGAL BASIS. Nebraska Medicaid covers institution for mental disease (IMD) services according to federal regulations . Nebraska Medicaid provides institution for mental disease (IMD) services under Nebraska Statute

009.02 STANDARDS FOR PARTICIPATION. To participate in Nebraska Medicaid , the institution for mental disease (IMD) must:

(A)Be in conformity with all applicable federal, state, and local laws;

(B)Be licensed as a hospital by the Nebraska Department of Health and Human Services, Division of Public Health or the licensing agency in the state where the institution for mental disease (IMD) is located;

(C)Be certified as meeting the conditions of participation for hospitals in federal regulations ;

(D)Be accredited by the Joint Commission or the American Osteopathic Association (AOA), and submit a copy of the most recent accreditation survey with the appropriate Nebraska Medicaid approved provider agreement form ;

(E)Meet the definition of an institution for mental disease (IMD) as stated in this chapter;

(F)Meet the current Joint Commission or American Osteopathic Association (AOA) standards of care; and

(G)Meet all requirements in this chapter.

009.02(i) PROVIDER AGREEMENT. The provider must complete the appropriate Nebraska Medicaid approved provider agreement form and submit the form, along with a copy of its current Joint Commission or American Osteopathic Association (AOA) accreditation survey, program, policies, and procedures to Nebraska Medicaid to enroll in Nebraska Medicaid as a provider. If approved, Nebraska Medicaid notifies the institution for mental disease (IMD) of its provider number.

009.02(ii) ANNUAL UPDATE. With the annual cost report, the provider must submit a copy of all program information, their most recent license and accreditation certificates, and any other information specifically requested by Nebraska Medicaid. Claims will not be paid if this has not been received and approved.

009.02(iii) MONTHLY REPORTS. The institution for mental disease (IMD) must submit a monthly report to Nebraska Medicaid . The report must be submitted by the 15th of the following month. The report must contain:

(1)The names of all Nebraska Medicaid beneficiaries admitted or discharged during the month; and

(2)The date of each Nebraska Medicaid beneficiary’s admission or discharge.

009.02(iv) RECORD REQUIREMENTS. Transfers to another institution for mental disease (IMD) or readmission constitutes a new admission for the receiving facility. The psychiatrist must complete, sign, and date the appropriate form within 48 hours after admission. If beneficiary applies for assistance while in the facility, copies of the admission notes, and plan of care must be attached to the appropriate signed form to certify that inpatient services are or were needed.

009.02(iv)(1) AN INDIVIDUAL WHO APPLIES FOR NEBRASKA MEDICAID WHILE IN THE INSTITUTION FOR MENTAL DISEASE (IMD). For an individual who applies for Nebraska Medicaid while in the institution for mental disease (IMD), the certification must be:

(a)Made by the team that develops the individual plan of care, in compliance with this chapter ; and

(b)Cover any period before application for which claims are made.

009.02(iv)(2) PRIOR AND CONTINUED AUTHORIZATON. When Nebraska Medicaid eligibility is determined, authorization for previous and continued care must be obtained from the Nebraska Medicaid contracted peer review organization or management designee.

009.03 INTERDISCIPLINARY TEAM.

009.03(A) COMPOSITION. The team must include a board-certified psychiatrist. The team must also include at least two of the following:

(i)Licensed mental health practitioner (LMHP);

(ii)A registered nurse (RN) with specialized training or one year's experience in treating individuals with mental illness;

(iii)An occupational therapist (OT) who is licensed, if required by state law, and who has specialized training or one year's experience in treating mentally ill individuals; or

(iv)A clinical psychologist.

-009.04 INSPECTIONS OF CARE. Inspections of care will be conducted as outlined in federal regulations.

009.05 INPATIENT MENTAL HEALTH SERVICES FOR BENEFICIARIES 20 AND YOUNGER IN AN INSTITUTION FOR MENTAL DISEASE (IMD). Nebraska Medicaid covers inpatient mental health services in an institution for mental disease (IMD) for beneficiaries age 20 and younger under federal regulations . The following requirements must be met to receive Nebraska Medicaid payment for these services.

009.05(A) ADMISSION CRITERIA. See requirements in this chapter .

009.05(B) ADMISSION EVALUATION. A psychiatrist must make an admission evaluation when the beneficiary is admitted to the hospital. The admission evaluation must include:

(i)An initial assessment, within 24 working hours of the admission of the health status and related psychological, medical, social, and educational needs of each individual beneficiary;

(ii)A determination of the range and kind of services required; and

(iii)If all admission criteria have been met, this evaluation must include an initial treatment plan.

009.05(C) TREATMENT PLAN REQUIREMENTS.

(i)The treatment plan must meet the requirements in this chapter and in federal regulations ; and

(ii)The treatment plan must be developed by the psychiatrist and the interdisciplinary team defined in this chapter .

009.05(C)(1) RECERTIFICATION OF NEED. This review also serves as the recertification of need for services. The individual plan of care must be developed by the facility interdisciplinary team.

009.05(D) PRIOR AUTHORIZATION. Institution for mental disease (IMD) services for beneficiaries age 20 and younger must be prior-authorized.

009.05(D)(1) TRANSFERS. Transfers to another institution for mental disease (IMD) or readmissions constitute a new admission for the receiving facility. This procedure must be followed for each transfer or readmission.

009.05(E) CERTIFICATION OF NEED FOR SERVICES. For persons becoming eligible for Nebraska Medicaid after admission, in accordance with federal regulations , the facility interdisciplinary team must certify that:

(i)Ambulatory care resources available in the community do not meet the treatment needs of the beneficiary;

(ii)Proper treatment of the beneficiary's psychiatric conditions requires services on an inpatient basis under the direction of a psychiatrist; and

(iii)The services can reasonably be expected to improve the beneficiary's condition or prevent further regression so that the services will no longer be needed.

009.05(E)(1) CERTIFICATION PROCEDURE. The certification must be made at the time of admission, or if the individual applies for Nebraska Medicaid while in the institution for mental disease (IMD), before Nebraska Medicaid authorizes payment. This is accomplished by completion of the appropriate Nebraska Medicaid approved confidential report form. The form must be signed by the team physician, psychiatrist, or advanced practice registered nurse (APRN) making the determination. A copy of the physician referral must accompany the completed appropriate Nebraska Medicaid approved confidential report form .

009.05(F) INITIAL CERTIFICATION. A psychiatrist must pre-certify, at the time of admission, that the individual requires inpatient services in a psychiatric hospital. The psychiatrist must complete the appropriate Nebraska Medicaid approved confidential report form at the time of admission or within 48 hours of admission. If the individual applies for Nebraska Medicaid while in a psychiatric hospital, the psychiatrist must certify the individual’s needs before Nebraska Medicaid authorizes payment.

009.05(G) SIXTY-DAY RECERTIFICATION. A psychiatrist must recertify, in the beneficiary's record, the beneficiary's need for continued care in an institution for mental disease (IMD) or need for alternative arrangements at least every 60 days after the initial certification.

009.05(H) INTERDISCIPLINARY PLAN OF CARE. The psychiatrist and the facility interdisciplinary team must develop and implement an individual written plan of care for each beneficiary within 48 hours after the beneficiary's admission. This plan of care must be placed in the beneficiary's chart when completed. Care plans must address family involvement. This requirement may be met by completion of the appropriate form, which is retained in the beneficiary's record. The written plan of care must include:

(i)Diagnoses, symptoms, complaints, and complications indicating the need for admission;

(ii) A description of the beneficiary's functional level;

(iii)Objectives;

(iv)Any orders for:

(1)Medications;

(2)Treatments;

(3)Restorative and rehabilitative services;

(4)Activities;

(5)Therapies;

(6)Social services;

(7)Diet; and

(8)Special procedures recommended for the beneficiary's health and safety;

(v)Plans for continuing care, including review and modification of the plan of care;

(vi)Appropriate medical treatment in the institution for mental disease (IMD) every 60 days;

(vii)Appropriate social services every 60 days; and

(viii)Plans for discharge, including referrals for outpatient follow-up care.

009.05(J) REQUIRED PSYCHIATRIST SERVICES. The beneficiary must be treated by a psychiatrist at least six out of seven days, or as medically necessary and the interaction must be documented in the beneficiary's medical record.

009.05(K) FACILITY INTERDISCIPLINARY PLAN OF CARE TEAM REVIEW. The attending or staff psychiatrist and other personnel involved in the beneficiary's care must review each plan of care at least every 30 days. The beneficiary's record must contain documentation of the 30-day interdisciplinary team review.

009.05(L) ADMISSION EVALUATION. Institution for mental disease (IMD) staff must develop an admission evaluation for each beneficiary within 30 days after the beneficiary's admission. This evaluation must be placed in the beneficiary's record when completed. The admission evaluation must include :

(i)The appropriate Nebraska Medicaid approved confidential report form pursuant to this chapter ;

(ii)A medical evaluation, including:

(1)Diagnosis;

(2)Summary of current medical findings;

(3)Medical history;

(4)Mental and physical functional capacity;

(5)Prognosis; and

(6)The psychiatrist's recommendation concerning the beneficiary's admission to the institution for mental disease (IMD) or the beneficiary's need for continued care in the institution for mental disease (IMD) if the beneficiary applies for Nebraska Medicaid while in the institution for mental disease (IMD) ;

(iii)A psychiatric evaluation;

(iv)A social evaluation; and

(v)An initial plan of care sufficient to meet the beneficiary's needs until the facility interdisciplinary team has developed the individual written plan of care.

009.05(M) DISCHARGE PLANNING. The institution for mental disease (IMD) must make available to the psychiatrist current information on resources available for continued out-of-hospital care of beneficiaries and must arrange for prompt transfer of appropriate medical and nursing information to ensure continuity of care upon the beneficiary's discharge. The institution for mental disease (IMD) is responsible for discharge planning. In cooperation with community regional mental health programs, the institution for mental disease (IMD) must :

(i)Initiate alternate care arrangements;

(ii)Assist in beneficiary transfer; and

(iii)Follow-up on the beneficiary's alternate care arrangements.

009.05(M)(1) LONG-TERM CARE (LTC) FACILITY STAFF INVOLVEMENT AND TRAINING. When the beneficiary is being transferred to a long-term care (LTC) facility , the facility's staff must be included in the discharge process and must receive appropriate and adequate medical and nursing information to ensure continuity of care. The institution for mental disease (IMD) must also contact Nebraska Medicaid .

010. THERAPEUTIC FAMILY CARE SERVICES. Therapeutic family care occurs in a foster home when specially trained foster parents are available at all times to provide consistent behavior management programs. Therapeutic family care services must be community-based, family focused, culturally competent, and developmentally appropriate. Treatment is provided within a family environment with services that focus on improving the beneficiary and family's adjustment emotionally, behaviorally, socially, and educationally. Nebraska Medicaid does not make payment for care that is custodial in nature.

History

• Effective 2026-06-28

Chapter 33 Health Check (early Periodic Screening, Diagnosis and Treatment [epsdt]) Services

Neb. Admin. Code tit. 471, ch. 33 Health Check (early Periodic Screening, Diagnosis and Treatment [epsdt]) Services {#sec-471-nac-33 omnilex-key=us-ne-regs-official--title-471--471 NAC 33}

001. SCOPE AND AUTHORITY . The regulations govern the services provided under Nebraska’s Medicaid program as defined by Nebraska Revised Statute §§ 68-901 et seq.

002. DEFINITIONS . The following definitions apply:

002.01 CONTINUING CARE. The provision of HEALTH CHECK preventive, acute, and chronic care services by a single provider, who coordinates care, maintains a consolidated medical record of the child, and is the child's regular source of health care.

002.02 DIAGNOSTIC. The determination of the nature or cause of a physical or mental disease or abnormality.

002.03 EARLY. The practice of assessing and identifying problems as soon as an individual's or a family's eligibility for assistance has been established; or, in the case of a family already receiving assistance, as early as possible in the individual's life. This includes informing Medicaid-eligible pregnant women so that prevention begins prenatally.

002.04 ENVIRONMENTAL LEAD INVESTIGATION. An assessment of the child's home or primary residence by a health professional certified as a lead inspector using a portable x-ray fluorescence (XRF) analyzer.

002.05 EARLY PERIODIC SCREENING, DIAGNOSIS AND TREATMENT (EPSDT). Federally mandated program for children under age 21 that requires states to provide comprehensive services and furnish all Medicaid coverable, appropriate, and medically necessary services needed to correct and ameliorate health conditions, based on certain federal guidelines.

002.06 PERIODIC. Checking children's health at age-appropriate intervals established for examination or screening to ensure continued health and to detect conditions requiring treatment.

002.07 SCREENING SERVICES. Regularly scheduled periodic child health assessments to examine and evaluate the general physical and mental health, growth, development, and nutritional status of eligible children. The screenings are performed to identify individuals who may require diagnosis, further examination, and treatment.

003. PROVIDER REQUIREMENTS .

003.01 GENERAL PROVIDER REQUIREMENTS. To participate in Nebraska Medicaid, providers of HEALTH CHECK services must comply with all applicable provider participation requirements codified in 471 NAC 2 and 3. In the event that provider participation requirements in 471 NAC 2 or 3 conflict with requirements outlined in this 471 NAC 33, the individual provider participation requirements in 471 NAC 33 will govern.

003.02 SERVICE SPECIFIC PROVIDER REQUIREMENTS.

003.02(A) SCREENING PROVIDERS. Screening services must be performed by or under the supervision of a physician, dentist, or other provider licensed under State or Federal law to furnish primary medical and health services. Periodic and interperiodic examinations must, at a minimum, include the health screening services defined within this chapter. Vision and hearing screening examinations cannot be limited to the screening physician but may be obtained directly from an ophthalmologist or optometrist for vision services and licensed audiologist for the hearing service.

003.02(B) CONTINUING CARE PROVIDERS. Managed care plans will be considered continuing care providers if the following provisions are met. A continuing care provider is one who:

(1) Agrees to provide to formally enrolled children screening, diagnosis, and treatment for conditions identified during screening or referral to a provider capable of providing the appropriate services. As appropriate, the formal enrollment means that the HEALTH CHECK-eligible child or family has agreed to use one provider as a regular source of continuing care services for a stated period of time, and that mutual obligations of both client and provider are recognized by signed enrollment agreement;

(2) Maintains a complete health history, including information received from other providers;

(3) Is responsible for providing needed physician services for acute, episodic, and chronic illnesses and conditions;

(4) Ensures accountability by submitting reports reasonably required by the Department; and

(5) Works with the HEALTH CHECK case manager, if one is assigned.

003.02(B)(i) ENROLLMENT AGREEMENT. The enrollment agreement must specify what options the provider will use to provide the following HEALTH CHECK services:

(1) Provision of dental services, or direct referral to a dentist or referral to the Department to obtain dental services;

(2) Provision of all or part of the required transportation and scheduling assistance, or referral to the Department to obtain such assistance; and

(3) Referral assistance for treatment not covered by the plan but needed, or referral to the Department to obtain assistance as well as other provisions outlined in the agreement.

003.02(C) HEALTH CHECK SPECIAL SERVICES. All providers of the following special services must be licensed Nebraska Medicaid-enrolled providers who have submitted written required documentation and received written approval from the Department. All providers requesting to provide the following HEALTH CHECK special services must submit a request in writing.

003.02(C)(i) NUTRITIONAL COUNSELING. Physicians providing HEALTH CHECK services or licensed medical nutrition therapists may be approved to provide nutritional counseling. Those requesting to provide this service must submit a written request and include (1) person(s) providing services and their credentials, (2) general content of nutritional counseling session, (3) conditions most frequently expected to be encountered, (4) usual length and frequency of sessions, and (5) customary charge. The Department may request periodic review of the services. Requests for reapproval must be submitted when a change in approved content occurs. A referral must be made to the Special Supplemental Food Program for Women, Infants, and Children (WIC) for ongoing nutritional counseling for children under five, or for lactating, postpartum, or pregnant women.

003.02(C)(ii) LACTATION COUNSELING. The following providers may provide all lactation counseling services: physician, nurse practitioner (NP), physician assistant (PA), midwife (MW), and registered nurse (RN). Any such provider must have current certification as an International Board Certified Lactation Consultant. The Department may request periodic review of the services.

003.02(C)(iii) CHILDBIRTH EDUCATORS. Licensed practitioners who are Lamaze Certified Childbirth Educator (LCCE) or Certified Childbirth Educator (CCCE) and request to provide this service for Nebraska Medicaid-eligible individuals age 20 and younger must complete Form MC-19: Medical Assistance Provider Agreement, and return the form with a letter stating the class type, general description, class outline or statement of content, and length of sessions for initial approval. Childbirth educators must include proof of certification or course completion by a recognized childbirth education association. Requests for reapproval must be submitted when a change in the initial proposal occurs. The Department may request periodic review of the services. Requests to approve changes to approved services must be submitted to the Department. Approval is based on guidelines from recognized childbirth education associations and demonstrate appropriateness.

003.02(C)(iv) WELL CHILD CLUSTER VISITS. Providers interested in providing this service must submit a description of the cluster visit, including format, group size, scheduling, and content to the Department to request initial prior approval. Requests to approve any changes to the approved service must be submitted to the Department.

004. SERVICE REQUIREMENTS .

004.01 GENERAL SERVICE REQUIREMENTS. HEALTH CHECK, the Nebraska Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) Program, is a service available to all individuals age 20 and younger eligible for medical assistance. The HEALTH CHECK Program ensures the availability and accessibility of required health care resources and aids Nebraska Medicaid-eligible children and their parents or caretakers effectively use them.

004.01(A) PRIOR AUTHORIZATION. Unless otherwise outlined, all services not covered by the Department must be prior authorized by the Department. The provider must submit requests for prior authorization using the standard electronic Health Care Services Review - Request for Review and Response transaction (ASC X12N 278) or by completing and submitting a written request. The plan of care may be submitted on Form EPSDT-5: Plan of Care or as a statement by the screening practitioner. If the initial request is denied, additional information may be sent for reconsideration. A request for prior authorization must include:

(i) A copy of the screening exam form or the name of the screening practitioner and the date of the screening exam that identified the condition; and

(ii) A plan of care that includes:

(1) History of the condition;

(2) Physical findings and other signs and symptoms, including appropriate laboratory data;

(3) Recommended service or procedure, including the potential provider of service or where the services will be obtained;

(4) Estimated cost, if available; and

(5) Expected outcome(s).

004.01(B) MEDICAL NECESSITY. The Department incorporates the medical necessity requirements outlined in 471 NAC 1 as if fully rewritten herein. Services and supplies that do not meet the requirements in 471 NAC 1 are not covered.

004.02 COVERED SERVICES.

004.02(A) HEALTH CHECKS. The screening examination is performed to identify those health problems that require further examination and treatment. The Recommendations for Preventive Pediatric Health Care published by the American Academy of Pediatrics are recommended as guidelines for content and minimum frequency for HEALTH CHECK examinations. The physician may establish an alternate periodicity schedule based on medical necessity. The initial newborn assessment in the hospital is considered a HEALTH CHECK screening. Total obstetrical care fulfills the requirement of a HEALTH CHECK examination for HEALTH CHECK participants. Claims for screening exams will be subject to random selection of medical chart review to ensure the minimum components of the screening examination are performed.

004.02(A)(i) COMPONENTS OF HEALTH SCREENING. Each health screening must include the minimum components identified and outlined in 471 NAC 33-004.02(A)(i)(1) through 471 NAC 33-004.02(A)(i)(5); and at the screening physician's judgment, the components in 471 NAC 33-004.02(A)(i)(6) through 471 NAC 33-004.02(A)(i)(8).

004.02(A)(i)(1) HEALTH AND DEVELOPMENTAL HISTORY. A comprehensive history must be obtained on the initial examination and updated at subsequent periodic examinations. If a formal development test is given to assess development, it may be covered separately from the full screening package by the screening physician if that is the physician's customary practice. The history is to include:

(a) Contact information;

(b) A description of the family;

(c) Medical, developmental and behavioral information of the child and the family;

(d) Assessment of nutritional status to determine whether the child has any symptoms related to nutritional status; and

(e) A risk assessment of children and adolescents for early identification of mental health or substance use concerns.

004.02(A)(i)(2) COMPREHENSIVE UNCLOTHED PHYSICAL EXAMINATION. This component must be performed during each initial and subsequent periodic examination, and must include a physical growth evaluation, a check of the general appearance of the child to determine overall health status, and a check of the organ systems.

004.02(A)(i)(3) IMMUNIZATIONS. In order to obtain appropriate immunizations for age and health history, assessment of the immunization status must be determined at each screening examination, and updated according to the most current immunization schedule of the Advisory Committee on Immunization Practices (ACIP) or American Academy of Pediatrics (AAP). Immunizations must be given at the time of the screening examination unless medically contraindicated.

004.02(A)(i)(3)(a) CHILDREN AND ADOLESCENTS AGE 18 AND YOUNGER. Medicaid does not cover a physician’s private stock vaccine when the vaccine is available through the Vaccine for Children Program (VFC) program.

004.02(A)(i)(3)(b) ADOLESCENTS AGE 19 AND 20. The Department covers routine preventative immunizations under the HEALTH CHECK program. The Department covers the physician’s private stock vaccine plus an administration fee for immunization of these individuals.

004.02(A)(i)(4) LABORATORY TESTS. The Department covers appropriate laboratory procedures, including blood lead testing for identified age and populations groups, as determined by the screening physician. Tests may include but are not limited to:

(a) HEMOGLOBIN AND HEMATOCRIT. A microhematocrit determination or hemoglobin concentration test from venous blood or a finger stick according to the American Academy of Pediatrics Recommendations for Pediatric Preventive Health Care;

(b) SICKLE CELL. If indicated by population group.

(c) TUBERCULIN TESTING. (Purified Protein Derivative [PPD]). Tuberculin testing is recommended annually for children with risk factors;

(d) LEAD TOXICITY SCREENING. An assessment of risk of high-dose lead exposure and blood lead testing by either capillary or venipuncture collection method. All children ages 6-72 months of age are considered at risk for lead poisoning and must be assessed. If the answers to all of the following questions are negative, a child is considered at low risk for high doses of lead exposure but is to receive a blood lead test at 12 months and 24 months. If the answer to any of the following questions is positive, a child is considered at high risk and a blood lead test must be obtained immediately and at subsequent screening examinations. In addition, any child between the ages of 25 and 72 months with no record of a previous blood lead screening must receive one. Physicians are to reference Centers for Disease Control (CDC) guidelines for patient management and treatment. A provider must ask the following risk assessment questions:

(i) Does your child live in or regularly visit a house built before 1978? Does the house have peeling or chipping paint?

(ii) Does your children live in a house built before 1978 with recent, ongoing, or planned renovation or remodeling?

(iii) Has your child or anyone that your child has come into contact with had lead poisoning?

(iv) Does your child frequently come in contact with an adult who works with lead (construction, welding, pottery)?

(v) Does your child live near a lead smelter, battery-recycling plant, or other industry likely to release lead?

(vi) Do you use any home or folk remedies that may contain lead?

(vii) Does your child live near a heavily traveled major highway where soil and dust may be contaminated with lead?

(viii) Does your home's plumbing have lead pipes or copper with lead solder joints?

(xi) Has your child had a blood lead test in the last 12 months?

(e) ENVIRONMENTAL INVESTIGATION. Patient specific environmental investigations must be covered if the physician has diagnosed lead toxicity, and blood lead testing by venipuncture method shows that the child's blood lead level is above 10 micrograms per deciliter. Non-medical activities such as removal of lead sources, providing alternate housing, or analysis of samples that are sent to laboratories are not covered. The environmental investigation must include:

(i) An interview with the family to gather basic information about the habits of the child and provide information about source of lead exposure, nutritional guidelines, prevention, and clean-up advice; and

(ii) Written recommendations to the owner of the house or apartment for the immediate and permanent removal or reduction of the lead sources.

(f) URINALYSIS. A rapid screening or dip test to detect the presence of sugar and albumin;

(g) SERUM CHOLESTEROL DETERMINATION. If indicated; and

(h) OTHERS. Other tests that may be determined appropriate in accordance with the periodicity schedule based on individual's age, sex, health history, clinical symptoms, and exposure to disease.

004.02(A)(i)(5) HEALTH EDUCATION AND ANTICIPATORY GUIDANCE. The provider must give the parent(s), caretaker, and child anticipatory guidance or assistance in understanding what to expect in terms of the child's development, and provide information about the benefits of healthy lifestyles and practices as well as accident and disease prevention. Health education is to be part of the initial and subsequent periodic examinations. This includes nutritional education or counseling when done by the assessing physician or auxiliary staff that does not require management by a medical nutritional therapist.

004.02(A)(i)(6) VISION SCREEN. Age appropriate visual assessment, including medically necessary and reasonable diagnosis and treatment for defects in vision. Vision screening may be obtained directly from a qualified provider of these screening services. Vision services will be covered as provided in 471 NAC 24. Vision screening must be performed to detect problems in acuity, color blindness, and ocular alignment.

004.02(A)(i)(6)(a) VISION SCREEN WITHIN THE CONTEXT OF THE HEALTH SCREEN. Screening for visual problems for children from birth to age three may be subjective through history taking and observation. Beginning at age three, if the child can safely be tested, testing is recommended at each periodic health screening or more often when medically indicated.

004.02(A)(i)(6)(b) REFERRAL CRITERIA GUIDELINES. Children with any ocular signs or symptoms such as blurred vision; squinting; wandering eye; crossed eye; excessive blinking; itchy, burning, or scratchy eyes; red eye or eyelid; swollen or crusted eyelid; headache if associated with reading or other demanding visual task should be referred to an optometrist or ophthalmologist. Additionally, children who fail any of the following tests must be referred to an optometrist or ophthalmologist:

(i) Any abnormality of the external or internal eye as detected with the ophthalmoscope;

(ii) Visual acuity with a two-line difference between eyes; visual acuity of 20/50 or worse in either eye for children three-five years old; visual acuity of 20/40 or worse in either eye for children six and older;

(iii) Inability of either eye to follow a penlight through a full range of motion. Wandering, turning, or jumping of the eyes when the eyes are alternately covered while the child is carefully watching a small distant object. Wandering, turning, or jumping of the eyes when repeated while the child focuses on a small object at reading distance; or

(iv) Failure to discriminate color is not necessarily a basis for referral, but the child and family should be counseled concerning any deficit.

004.02(A)(i)(6)(c) VISION SCREEN PERFORMED BY OPHTHALMOLOGIST OR OPTOMETRIST. The Department covers annual eye examinations for HEALTH CHECK participants beginning at age three. More frequent exams will also be covered if needed to determine the existence of suspected conditions.

004.02(A)(i)(7) HEARING SCREEN. Age appropriate hearing assessment, including medically necessary and reasonable diagnosis and treatment for defects in hearing. The hearing screening may be obtained directly from a qualified provider of these screening services. Hearing services will be covered as provided in 471 NAC 23. Hearing screening must be performed to detect problems in hearing loss and speech development.

004.02(A)(i)(7)(a) REFERRAL CRITERIA GUIDELINES. Appropriate overall criteria for referral may be based on a failed response of 30 dB or greater in any frequency in either ear. Beginning at age three, if the child can safely be tested, audiometric screening is appropriate.

004.02(A)(i)(7)(b) HEARING SCREEN WHEN PERFORMED BY A LICENSED AUDIOLOGIST. Hearing screening examinations are those performed with no connection to treatment or diagnosis for a specific illness, symptoms, complaint, or injury. The examination must follow the standards outlined by the American Speech-Language Hearing Association (ASHA) for pure tone screening. The hearing periodicity schedule outlines the recommended and appropriate minimum frequency for hearing screening examination. Frequent exams will be covered if needed to determine the existence of suspected problems. Hearing screening examinations or for HEALTH CHECK participants do not require prior authorization for payment. Hearing services will be covered as provided in 471 NAC 23.

004.02(A)(i)(8) DENTAL SCREENING. The dental screening examination must be performed to detect deterioration of hard tissues and inflammation or swelling of soft tissues. For children under the age of 21, this may be performed by a visual inspection of the palate and dental ridge as part of the health screening examination. A direct referral to a dentist is required beginning at age one as indicated on the health screening periodicity schedule or earlier if determined medically necessary. Thereafter, dental screening examinations are authorized at six-month intervals or more frequently based on medical necessity. Additionally, more frequent dental examinations are authorized to determine the existence of suspected conditions. Dental screening examinations for HEALTH CHECK participants do not require prior authorization for payment. Dental services will be covered as provided in 471 NAC 6.

004.02(A)(i)(8)(a) ORTHODONTIC TREATMENT. Medicaid covers orthodontic treatment for individuals age 20 and younger in accordance with 471 NAC 6.

004.02(B) PERIODICITY SCHEDULES. The minimum required guidelines for health screening examinations can be found in "Recommendations For Preventive Pediatric Health Care" published by the American Academy of Pediatrics. Wards of the Department may be screened each time they are placed in a foster home or facility. Physical examinations may be performed when necessary for school, camp, or similar activity.

004.02(C) INTERPERIODIC SCREENING. Interperiodic screening examinations, performed outside of the periodicity schedule, will be covered when medically necessary to:

(1) Diagnose an illness or condition that was not present at the regularly scheduled screening; or

(2) Determine if there has been a change in a previously diagnosed illness or condition that requires additional services.

004.02(C)(i) INTERPERIODIC SCREENING DETERMINATION. The determination of whether an interperiodic screening is medically necessary may be made by the child’s physician or dentist, or by a health, developmental, or educational professional who comes into contact with the child outside of the formal health care system. If the minimum components of a periodic health screening as previously defined are not performed, and only illness care is provided, the service should be reported and claimed as an acute care service. These visits require that a complete HEALTH CHECK screen be done.

004.02(D) DIAGNOSIS SERVICES. If, under certain circumstances, a diagnosis is not provided at the same time as screening, the Department covers diagnosis services provided during a second appointment. The diagnosis may or may not require further follow-up and may result in referral for treatment.

004.02(E) TREATMENT SERVICES. HEALTH CHECK follow-up services necessary to diagnose or to treat a condition identified during a HEALTH CHECK health, visual, hearing, or dental screening examination are covered under the following conditions:

(1) The service is required to treat a condition (to correct or ameliorate defects and physical or mental illnesses or conditions) that has been identified and documented during a periodic or interperiodic HEALTH CHECK screening examination;

(2) The provider of services is a Nebraska Medicaid-enrolled provider;

(3) The service is consistent with applicable federal and state laws that govern the provision of health care; and

(4) The service must be medically necessary, safe and effective, not considered experimental or investigational and must be generally employed by the medical profession.

004.02(E)(i) SUPPLIES, ITEMS, OR EQUIPMENT. Supplies, items, or equipment that is determined to be not medical in nature will not be covered.

004.02(E)(ii) ALTERNATIVE SERVICES. Where alternative and medically appropriate modes of treatment exist and are available, Medicaid may choose among the alternatives which services are available based on cost-effectiveness. Any alternative services must be prior authorized.

004.02(E)(iii) SERVICE SPECIFIC CRITERIA. Services currently covered by the Department will be governed by each service specific chapter in NAC 471. Services not covered by the Department but defined in Section 1905(a) of the Social Security Act must meet the conditions of items (1) through (4) above. Criteria and requirements for certain services are outlined in this chapter.

004.02(F) HEALTH CHECK SPECIAL SERVICES. The following services are covered to prevent, correct, or ameliorate a disease or condition identified during a screening examination. These services are considered part of the HEALTH CHECK benefit and are available to Nebraska Medicaid-eligible individuals under 21. Payment for special services is made according to the Nebraska Medicaid Practitioner Fee Schedule unless included as part of a capitation plan. Instructions for billing must be included with the written approval. The Department may also withdraw a provider's approval by written notification to the provider if the provider no longer meets the following identified requirements.

004.02(F)(i) MEDICAL NUTRITION THERAPY. This service involves medically necessary counseling provided by a licensed medical nutritional therapist. The child’s condition must indicate that a nutritional problem or a condition of such severity exists that nutritional counseling beyond that normally expected as part of the standard medical management is warranted. This service is covered when the client is referred by a physician or nurse practitioner. Therapies must be in accordance with currently accepted dietary and nutritional protocols. A referral must be made to the Special Supplemental Food Program for Women, Infants, and Children (WIC) for ongoing nutritional information for children under five, or for lactating, postpartum, or pregnant women.

004.02(F)(ii) RISK REDUCTION SERVICES. Risk reduction services include:

(a) Family home visitation for risk assessment and risk reduction services;

(b) Health education and infant-child care and parenting session or breast-feeding instruction sessions;

(c) Early pregnancy sessions;

(d) Prepared childbirth session or comparable cesarean birth sessions; and

(e) Prepared childbirth refresher series.

004.02(F)(ii)(1) PREPARED CHILDBIRTH SESSIONS. The basic six to eight-week series of childbirth sessions, early pregnancy sessions, refresher sessions, cesarean birth sessions, breast-feeding session, and infant care sessions are covered when provided by licensed and Nebraska Medicaid-enrolled practitioners approved by the Department. The services are covered when a comparable community service is not readily available at no cost.

004.02(F)(ii)(2) PEDIATRIC PRENATAL VISIT. Pediatric prenatal visits are covered if scheduled in the last trimester of the pregnancy. The following items must be completed as a part of pediatric prenatal visit:

(a) Gather medical information, give information, answer questions, and initiate a continuing relationship in the best interest of the child;

(b) Discuss the benefits of early and regular health care, of appointment-keeping, and utilizing the most appropriate place of service;

(c) Include a maternal and family health history and related data gathering;

(d) Prepare parent(s) for hospital birth information on breast-feeding vs. bottle feeding, information on infant care, and information on parenting classes;

(e) Preparation parent(s) for potential changes in family and sibling relationships with birth;

(f) Provide information on effects of drugs and medications on pregnancy and nursing infants;

(g) Discuss preparation for home care and home safety; and

(h) Provide information on well baby care, information on choosing child care, and office philosophy and practices.

004.02(F)(iii) WELL CHILD CLUSTER VISIT. The cluster visit is a well child visit in a group setting with parent-child pairs of similar age offering the opportunity for the provision of extended physician-parent and child time with a focus on psychosocial aspects as well as physical aspects of well child care. Cluster visits are covered for infants and children, according to the American Academy of Pediatric schedule for examinations. The cluster visit must include a complete HEALTH CHECK examination. The parent may opt for this service instead of the individual visit for the parent(s).

004.02(G) LACTATION COUNSELING. Lactation counseling services are covered for children in the post-partum period and their mothers who need help with breastfeeding. Services may be sought for difficulties such as inadequate milk supply, poor milk extraction, poor weight gain, nipple and breast pain, breast infections, and engorgement. Lactation counseling services are covered for children age birth through ninety days postpartum or ninety days corrected for gestational age; however, it may be available after 90 days postpartum when medically necessary. There is a limit of five counseling sessions per child, and each session may last up to ninety minutes. Comprehensive lactation counseling must include the following:

(i) A face-to-face encounter with the mother and child lasting a minimum of thirty minutes;

(ii) Comprehensive maternal, infant and feeding assessment related to lactation;

(iii) Interventions at a minimum:

(1) Observation of mother and child during breastfeeding;

(2) Instruction in positioning techniques and proper latching to the breast; and

(3) Counseling in nutritive suckling and swallowing, milk production and release, frequency of feedings and feeding cues, expression of milk and use of pump if indicated, assessment of infant nourishment and reasons to contact a health care provider;

(iv) Information on community supports such as Women, Infant and Children (WIC); and

(v) Evaluation of outcomes from interventions.

005. BILLING AND PAYMENT FOR HEALTH CHECK SERVICES .

005.01 BILLING.

005.01(A) GENERAL BILLING REQUIREMENTS. Providers must comply with all applicable billing requirements codified in 471 NAC 3. In the event that individual billing requirements in 471 NAC 3 conflict with billing requirements outlined in this 471 NAC 33, the individual billing requirements in 471 NAC 33 will govern.

005.01(B) SPECIFIC BILLING REQUIREMENTS. Providers must bill the Department using Form CMS-1500 or the standard electronic Health Care Claim: Professional transaction (ASC X12N 837) for HEALTH CHECK exams, HEALTH CHECK-associated services, and other comparable exams. The physician or the physician's authorized agent must submit the physician’s usual and customary charge for each procedure code listed on or in the claim.

005.01(B)(i) PROCEDURE CODES. Physicians must use Healthcare Common Procedure Coding System (HCPCS) procedure codes when submitting claims or encounter data to the Department. Healthcare Common Procedure Coding System (HCPCS) and Current Procedural Terminology (CPT) procedure codes used by Medicaid are listed in the Nebraska Medicaid Practitioner Fee Schedule.

005.01(B)(ii) VACCINE FOR CHILDREN PROGRAM (VFC) PROGRAM. When a physician uses federal-purchased vaccine for immunizations, the physician must bill the Department only for the administration. The physician must use the modifier “SL” with the vaccine code when billing for the administration. Billed charges for the administration of Vaccine for Children Program (VFC) vaccines cannot exceed the state maximum as determined by the federal Vaccine for Children Program (VFC) program. Contact the Nebraska Vaccine for Children Program (VFC) program with questions regarding the Nebraska maximum.

005.02 PAYMENT.

005.02(A) GENERAL PAYMENT REQUIREMENTS. The Department will reimburse the Provider for services rendered in accordance with the applicable payment regulations codified in 471 NAC 3. In the event that individual payment regulations in 471 NAC 3 conflict with payment regulations outlined in this 471 NAC 33, the individual payment regulations in 471 NAC 33 will govern.

005.02(B) SPECIFIC PAYMENT REQUIREMENTS. The Department pays for covered HEALTH CHECK services, except for clinical laboratory services or individuals enrolled in managed care, at the lower of:

(1) The provider's submitted charge; or

(2) The allowable amount for that procedure code in the Nebraska Medicaid Practitioner Fee Schedule for that date of service.

005.02(B)(i) VACCINE FOR CHILDREN PROGRAM (VFC) PROGRAM. The Department reimburses for the administration of Vaccine for Children Program (VFC) vaccine according to the Nebraska Medicaid Practitioner Fee Schedule.

005.02(B)(ii) SPECIAL SERVICES. Payment for special services is made according to the Nebraska Medicaid Practitioner Fee Schedule unless included as part of a capitation plan. The Department may also withdraw a provider's approval by written notification to the provider if the provider no longer meets the following identified requirements.

005.02(B)(iii) ENVIRONMENTAL INVESTIGATION FOR LEAD CONTAMINATION. Payment will be made under an interagency contract with local or state health departments utilizing a certified lead inspector at a negotiated rate that includes the initial environmental investigation and a follow-up visit, if needed.

History

• Effective 2022-02-12

Chapter 34 Rural Health Clinics (rhc's)

Neb. Admin. Code tit. 471, ch. 34 Rural Health Clinics (rhc's) {#sec-471-nac-34 omnilex-key=us-ne-regs-official--title-471--471 NAC 34}

34-001 Standards for Participation : To participate in the Nebraska Medical Assistance Program (NMAP), a Rural Health Clinic must be certified by the Centers for Medicare and Medicaid Services (CMS) for participation in the Medicare program.

34-002 Services Provided for Clients Enrolled in the Nebraska Health Connection (NHC) : Certain NMAP clients are required to participate in the Nebraska Medicaid Managed Care Program known as the Nebraska Health Connection (NHC). See 471-000-122 for a listing of the NHC plans.

34-002.01 Health Maintenance Organization (HMO) Plans: The NHC HMO plans are required to provide, at a minimum, coverage of services as described in this Chapter. The prior authorization requirements, payment limitations, and billing instructions outlined in this Chapter do not apply to services provided to clients enrolled in an NHC HMO plan with the following exceptions:

1. Medical Transplants: As defined under 471 NAC 18-004.40, transplants continue to require prior authorization by NMAP and are reimbursed on a fee-for-service basis, outside the HMO's capitation payment;

2. Abortions: As currently defined, abortions continue to require prior authorization by NMAP and are included in the capitation fee for the HMO; and

3. Family Planning Services: Family planning services do not require a referral from a primary care physician (PCP). As defined in 471 NAC 18-004.26, the client must be able to obtain family planning services upon request and from a provider of choice who is enrolled in NMAP. Family planning services are reimbursed according to the Nebraska Medicaid Practitioner Fee Schedule.

Services provided to clients enrolled in an NHC HMO plan are not billed to NMAP. The provider must provide services only under arrangement with the HMO.

34-002.02 Primary Care Case Management (PCCM) Plans: All NMAP policies apply to services provided to NHC clients enrolled in a PCCM plan. For services that require prior authorization under 471 NAC 18-004.01, the provider must obtain prior authorization from the PCCM plan under the directions for prior authorization of the PCCM plan with the following exceptions:

1. Medical Transplants: As define under 471 NAC 18-004.40, transplants are subject to prior authorization by NMAP; and

2. Abortions: As currently defined, abortions require prior authorization by NMAP.

34-002.02A Referral Management: When medically necessary services that cannot be provided by the PCP are needed for the client, the PCP must authorize the services to be provided by the approved provider as needed with the following exceptions:

1. Visual Care Services: All surgical procedures provided by an optometrist or ophthalmologist require approval from the PCCM plan. Providers must contact the client's PCCM primary care physician before providing surgical services. Non-surgical procedure provided by an optometrist or ophthalmologist do not require referral/approval from the PCP; however, when an optometrist or ophthalmologist diagnoses, monitors, or treats a condition, except routine refractive conditions, the practitioner must send a written summary of the client's condition and treatment/follow-up provided, planned, or required to the client's PCP.

2. Dental Services: Dentists or oral surgeons providing medically necessary services not covered under 471 NAC 6-000 must bill that service on Form CMS-1500 or the standard electronic Health Care Claim: Professional transaction (ASC X12N 837), using CPT procedure codes. These services require referral/ authorization from the client's PCP. The provider shall contact the PCP before providing these services. If a client requires hospitalization for these services, the provider must contact the PCP for referral/authorization.

3. Family Planning Services: Family planning services do not require a referral from the PCP. As defined in 471 NAC 18-004.26, the client must be able to receive family planning services upon request and from a provider of choice who is enrolled in NMAP.

34-002.03 Mental Health and Substance Abuse Services Mental health and substance abuse services (MH/SA) are provided through the MH/SA managed care plan for all NHC clients. The plan includes the Client Assistance Program (CAP). Clients may access five services annually with any CAP-enrolled provider without prior authorization from the plan. All other MH/SA services must be prior authorized as directed by the plan.

34-003 Covered RHC Services : NMAP covers services provided by RHC's on or after July 1, 1990, under this chapter. NMAP defines covered Rural Health Clinic services as the following services provided by a Certified Rural Health Clinic:

1. Services provided by a physician within the scope of practice under state law, if the physician performs the services in the clinic or the services are provided away from the clinic and the physician has an agreement with the clinic provided that s/he will be paid by the clinic for the services;

2. Services provided by a physician assistant, nurse practitioner, nurse midwife, or other specialized nurse practitioner if the services are provided in accordance with Medicare requirements;

3. Services and supplies that are provided as an incident to professional services provided by a physician, physician assistant, nurse practitioner, nurse midwife, or other specialized nurse practitioner;

4. Part-time or intermittent visiting nurse care and related medical supplies (other than drugs and biologicals) if -

a. The clinic is located in an area in which the Centers for Medicare and Medicaid Services has determined that there is a shortage of home health agencies;

b. The services are provided by a registered nurse or licensed practical nurse or a licensed vocational nurse who is employed by, or otherwise compensated for services by the clinic;

c. The services are provided under a written plan of treatment that is established and reviewed at least every 60 days by a physician, physician assistant, nurse practitioner, nurse midwife, or other specialized nurse practitioner and review and approved at least every 60 days by a supervising physician of the clinic; and

d. The services are provided to a "homebound" client. For the purposes of visiting nurse care, a "homebound" client is one who is permanently or temporarily confined to his/her place of residence because of a medical or health condition. The client may be considered homebound if the client leaves the place of residence infrequently. For this purpose, "place of residence" does not include a hospital or skilled nursing facility.

34-004 Payment for Rural Health Clinic Services : NMAP will pay for services provided by Rural Health Clinics in compliance with Section 1902 (bb) of the Social Security Act. The Department assures that payments to all RHCs will result in a payment to the clinic in the amount which is at least equal to the Prospective Payment System.

34-004.01 Definitions means the following definitions apply within this chapter:

Encounter means a face-to-face visit between a Medicaid-eligible patient and a physician, physician assistant, nurse practitioner, nurse midwife, specialized nurse practitioner, visiting nurse, clinical psychologist, or clinical social worker during which an FQHC service is rendered. Encounters with more than one health professional and multiple encounters with the same health professional which take place on the same day and at a single location constitute a single visit, except for cases in which the patient, subsequent to the first encounter, suffers an illness or injury requiring additional diagnosis or treatment.

Encounter Payments means PPS rate paid to the RHC by the Department multiplied by the number of encounters billed.

Encounter Rate means the all-inclusive PPS rate that the Department reimburses the RHC for an encounter.

Independent Rural Health Clinic means A clinic that is free standing with no association to a hospital, nursing facility, or home health agency.

Medicare Cost Report means the report filed by each RHC provider with its Medicare intermediary as required by Chapter 9 of the Medicare Rural Health Clinic and Federal Qualified Health Center Manual.

Prospective Payment System (PPS) means the payment system where in a reimbursement rate is paid for services provided.

Provider-Based Rural Health Clinic means a rural health clinic that is an integral part of a hospital, nursing facility, or home health agency that is participating in Medicare and is licensed, governed and supervised by the facility.

34-005 Prospective Payment System

34-005.01 Payment for Services Provided by Provider-Based Rural Health Clinics Associated with Hospitals Having 50 Beds or Greater: The Department will compute the Prospective Payment System (PPS) base rate as follows:

1. Combine reasonable costs from the RHC fiscal year 1999 and 2000 cost reports; then

2. Divide the cost by the combined Total Adjusted Visits from the two fiscal year cost reports (Form CMS-222-92 Worksheet C, Part 1, Line 6; or Form CMS-2552-96 Worksheet M-3, Line 6).

Effective October 1, 2001, the Department will update the PPS base rate annually using the Medicare Economic Index (MEI).

34-005.02 Payment for Services Provided by Provider-Based RHCs Associated with Hospitals Having Less Than 50 Beds: NMAP pays for RHC services provided by provider- based clinics that are associated with hospitals of less than 50 beds at the lower of cost or charges as established by Medicare.

34-005.03 Payment for Services Provided by Independent Rural Health Clinics (IRHCs): The Department will compute the PPS base rate for IRHCs as follows:

1. Combine reasonable costs from the RHC fiscal year 1999 and 2000 cost reports; then

2. Divide the cost by the combined total adjusted visits from the two fiscal year cost reports.

Effective October 1, 2001, the Department will update the PPS base rate annually using the Medicare Economic Index (MEI).

34-005.04 Rates for New RHCs: The Department will establish rates for a new RHC entering the program after 1999 as follows:

1. For the initial year, the interim rate will be an average of the PPS rate of all RHCs in Nebraska. The interim rate will be retroactively settled based on the RHC’s initial cost report.

2. The RHC’s individual PPS base rate will be computed using its initial cost report.

3. Once the PPS base rate has been established, it will be updated annually based on the Medicare Economic Index (MEI).

34-005.05 RHC Managed Care Payment: RHCs that provide services under a contract with a Medicaid managed care entity (MCE) will receive quarterly state supplemental payments for the cost of furnishing such services that are an estimate of the difference between the payment the RHC receives from the MCE(s) and the payments the RHC would have received under the PPS methodology or payments as established under Section 34-005.02 for those RHC receiving payment as a provider based RHC associated with hospitals having less than 50 beds.

34-005.05A At the end of each RHC fiscal year, for each Independent RHC and Provider based RHC associated with hospital of 50 or more beds the Department will compare:

1. The total amount of supplemental and MCE payments received by the RHC; to

2. The amount that the actual number of visits provided under the RHC’s contract with the MCE(s) would have yielded under the PPS methodology.

The Department will pay the RHC the difference between item 1 and item 2 if the PPS amount exceeds the total amount of supplement and MCE payments. The RHC must refund the difference between item 1 and item 2 if the PPS payment is less than the total amount of the supplemental and MCE payments.

34-005.05B At the end of each RHC fiscal year for Provider based RHC associated with hospital having less than 50 beds, the Department will compare:

1. The total amount of the supplemental and the MCE(S) payments received by the RHC

2. The amount that the clinic would have received as payment under section 34-005.02.

The Department will pay the RHC the difference between item 1 and 2 if the actual amount exceeds the total amount of supplement and MCE payments. The RHC must refund the difference between item 1 and item 2 if the actual payment is less than the supplemental and MCE payments received by the RHC.

34-006 Payment for Non-RHC Services : For those non-RHC services, NMAP makes payment according to the Nebraska Medicaid Practitioners Fee Schedule.

34-007 Payment for Telehealth Services : Payment for telehealth services will be the Medicaid rate for the comparable in-person service. RHC core services provided via telehealth technologies are not covered under the encounter rate.

34-007.01 Payment for Telehealth Transmission Costs: Payment for telehealth transmission costs related to non-core services will be the lower of:

1. The provider’s submitted charge; or

2. The maximum allowable amount.

The Department will pay for transmission costs for line charges when directly related to a covered telehealth service. The provider must be in compliance with the standards for real time, two way interactive audiovisual transmissions (see 471 NAC 1-006).

34-008 Cost Reports : Providers participating with NMAP as RHCs must submit an annual cost report to the Department. The RHC must report and supply the Department with necessary documentation regarding, cost reports, and any other documentation when requested.

The Medicare cost report form CMS-222-92 can be found in the Provider Reimbursement Manual-Part 2 (Pub.15-2), Chapter 29 located at http://www.cms.gov/maunals/PBM/list.asp on the CMS website.

Hospital-based RHCs associated with hospitals of 50 beds or greater must complete Worksheet M of Form CMS-2552-96. Hospital and Hospital Complex Cost Report Found in provider reimbursement manual-Part 2 (Pub. 15-2), Chapter 36, located at http://www.cms.hhs.gov/Manuals/PBM/list.asp on the CMS website.

34-009 Billing for RHC Services : All RHCs must bill for Rural Health Services as defined in 471 NAC 34-003 on Form CMS-1450 or the standard electronic Health Care Claim: Institutional transaction (ASC X12N 837). RHCs will use the appropriate HCPCS/CPT procedure codes and revenue codes when billing for all services.

IRHCs must use Form CMS-1500 (see 471-000-58) or the standard electronic Health Care Claim: Professional transaction (ASC X12N 837) to bill NMAP for clinical radiology/laboratory services using the non-Rural Health Clinic provider number.

All Provider-Based RHCs must use Form CMS-1450 or the standard electronic Health Care Claim: Institutional transaction (ASC X12N 837) to bill NMAP for clinical laboratory services and radiology services using the hospital provider number.

History

• Effective 2010-03-10

Chapter 35 Rehabilitative Psychiatric Services

Neb. Admin. Code tit. 471, ch. 35 Rehabilitative Psychiatric Services {#sec-471-nac-35 omnilex-key=us-ne-regs-official--title-471--471 NAC 35}

TITLE 471 NEBRASKA MEDICAL ASSISTANCE PROGRAM SERVICES

CHAPTER 35 REHABILITATIVE PSYCHIATRIC SERVICES

001. SCOPE AND AUTHORITY. These regulations govern services provided under the Medical Assistance Act, Nebraska Revised Statute (Neb. Rev. Stat.) §§ 68-901-68-9,101.

001.01 INTRODUCTION. Nebraska Medicaid covers rehabilitative psychiatric services to rehabilitate beneficiaries experiencing severe and persistent mental illnesses in the community and thereby avoid more restrictive levels of care . Rehabilitative psychiatric services for children age 20 and younger are covered under Early and Periodic Screening, Diagnostic and Treatment (EPSDT) treatment plans, as described in this title . Rehabilitative psychiatric services for adults age 21 and older are covered under the rules and regulations of this chapter. The services must be medically necessary and the most appropriate level of treatment for the beneficiary . This does not include treatment for a primary substance use disorder diagnosis.

002. DEFINITIONS. The following definitions apply:

002.01 COLLATERAL CONTACT. Contacts which occur outside the provider organization without the beneficiary present and are related to the beneficiary’s individual treatment, rehabilitation, and recovery plan.

002.02 DIRECT BENEFICIARY CONTACT. Face-to-face or telehealth services between the community support worker and the beneficiary.

002.03 FAMILY THERAPY. A therapeutic service between the beneficiary and their family and a qualified licensed practitioner who provides intervention as identified by the family-focused goals of the individual treatment, rehabilitation, and recovery plan. Consent from the beneficiary must be documented prior to the involvement of the family and delivery of the service.

002.04 GROUP PSYCHOTHERAPY. Group psychotherapy service provided by a licensed clinician who is practicing within their scope of practice and provides a psychotherapy service in groups of no fewer than three and no more than twelve beneficiaries.

002.05 INDIVIDUAL PSYCHOTHERAPY. An individual treatment and rehabilitation service between an identified beneficiary and a qualified licensed practitioner who focuses upon the identified goals of the individual treatment, rehabilitation, and recovery plan.

002.06 MEDICAL NECESSITY. Nebraska Medicaid incorporates the definition of medical necessity from these regulations. Services and supplies that do not meet the definition of medical necessity in these regulations are not covered. Services may be subject to specific limitations or prior authorization requirements listed in this chapter.

002.06(A) REHABILITATIVE PSYCHIATRIC MEDICAL NECESSITY. Rehabilitative psychiatric services are medically necessary when those services can reasonably be expected to increase or maintain the level of functioning in the community of beneficiaries with severe and persistent mental illness.

002.06(A)(i) PHYSICIAN SERVICES. The fact that the physician has performed or prescribed a procedure or treatment or the fact that it may be the only treatment for a particular injury, sickness, or mental illness does not mean that it is covered by Nebraska Medicaid. Services and supplies, which do not meet the definition of medical necessity set out in this chapter are not covered.

002.07 PSYCHIATRIC RESIDENTIAL REHABILITATION. A facility-based, non-hospital or non-nursing facility program for beneficiaries disabled by severe and persistent mental illness, who are unable to reside in a less restrictive residential setting.

002.08 SECURE PSYCHIATRIC RESIDENTIAL REHABILITATION. A secure facility-based, non-hospital or non-nursing facility program for beneficiaries disabled by severe and persistent mental illness, who are unable to reside in a less restrictive setting.

002.09 SEVERE AND PERSISTENT MENTAL ILLNESS. Beneficiaries with severe and persistent mental illness must meet the following criteria:

(A)The beneficiary is age 21 and over;

(B)The beneficiary has a primary diagnosis of schizophrenia, major affective disorder, or other major mental illness . Developmental disorders, or psychoactive substance use disorders can be included if they co-occur with the primary mental illnesses listed above;

(C)The beneficiary has a persistent mental illness as demonstrated by the presence of the disorder for the last 12 months or, which is expected to last 12 months or longer and will result in a degree of limitation that seriously interferes with the beneficiary's ability to function independently in an appropriate and effective manner in two of the three following functional areas: vocation and education, social skills, and activities of daily living;

(i)Functional limitations in the area of vocation and education abilities are defined as:

(1) An inability to be consistently employed or an ability to be employed only with extensive supports, except that a person who can work but is recurrently unemployed because of acute episodes of mental illness is considered vocationally impaired;

(2) Deterioration or decompensation resulting in an inability to establish or pursue educational goals within a normal time frame or without extensive supports; and

(3) An inability to consistently and independently carry out home management tasks, including household meal preparation, washing clothes, budgeting, and childcare tasks and responsibilities;

(ii)Functional limitations in the area of social skills and abilities are defined as:

(1) Repeated inappropriate or inadequate social behavior or an inability to behave appropriately or adequately without extensive or consistent support or coaching or outside of special contexts or situations; or

(2) An inability to consistently participate in adult activities without extensive support or coaching or outside of limited special activities established for persons with mental illness or interpersonal impairments; or

(3) A history of dangerousness to self or others;

(iii)Functional limitations in the area of activities of daily living are defined as an inability to consistently perform the range of practical daily living tasks required for basic adult functioning in the community. A beneficiary may be considered to have functional limitations in this area if they are unable to perform tasks from at least three of the following five domains :

(1) Grooming, hygiene, washing of clothes, and meeting nutritional needs;

(2) Care of personal business affairs;

(3) Transportation and care of residence;

(4) Procurement of medical, legal, and housing services; or

(5) Recognition and avoidance of common dangers or hazards to self and possessions;

(D)The beneficiary has a significant risk of continuing to either live in a severely impaired manner or requiring institutionalization without provision of mental health services, and whose risk has persisted for one year or longer and is likely to continue for one year or longer; and

(E)The beneficiary does not have a primary diagnosis of substance use disorder or developmental disability.

002.10 SUBSTANCE USE DISORDER COMMUNITY SUPPORT. A rehabilitative and supportive service for beneficiaries with primary Axis I diagnosis of substance use disorder.

002.11 SUPERVISING PROVIDER. The supervising provider must be:

(A) Currently licensed and eligible to practice independently under Nebraska state law;

(B) Currently enrolled with Nebraska Medicaid and eligible to provide Medicaid services;

(C) Eligible to provide supervision to the supervisee under Nebraska state law; and

(D) Within their scope of practice to prescribe and oversee the service being provided.

003. PROVIDER PARTICIPATION. Providers of rehabilitative psychiatric services must comply with all applicable provider participation requirements.

004. SERVICES PROVIDED TO BENEFICIARIES ENROLLED IN NEBRASKA MEDICAL ASSISTANCE PROGRAM MANAGED CARE.

004.01 COVERED SERVICES. The following rehabilitative services are covered by Nebraska Medicaid:

(A) Community support;

(B) Day rehabilitation; and

(C) Psychiatric residential rehabilitation.

005. COMMUNITY SUPPORT. The following community support service requirements apply.

005.01 COMMUNITY SUPPORT. The community support program is designed to:

(A)Provide and develop the necessary skills, services, and supports to enable beneficiaries to reside and participate in the community;

(B) Improve the skills of daily living and quality of life;

(C)Facilitate communication and coordination between rehabilitative mental health providers that serve the same beneficiary; and

(D)Decrease the frequency and duration of hospitalization.

005.02 SERVICES PROVIDED IN COMMUNITY SUPPORT. Community support providers must provide beneficiary advocacy, ensure continuity of care, support beneficiaries in time of crisis, provide or procure skill training, ensure the acquisition of necessary resources, to assist beneficiaries with spend downs and other financial insurance coverage programs, and assist the beneficiary in achieving community and social integration. The community support program must provide a clear focus of accountability for meeting the beneficiary’s needs within the resources available in the community. The role or roles of the community support provider may vary based on beneficiary’s needs. Community support is a service in which the beneficiary’s contact occurs outside of program offices in community locations, frequently in the beneficiary’s private residence, consistent with the needs and desires of each beneficiary . 90-day treatment, rehabilitation, and recovery team meetings are not considered to be a community support service. The frequency of contact between the community support provider and the beneficiary is individualized and adjusted in accordance with the needs of the beneficiary.

005.03 INITIAL DIAGNOSTIC INTERVIEW. Prior to admission to a community support program, an initial diagnostic interview must be completed by an independently licensed practitioner, a psychiatrist, psychologist, or a licensed independent mental health practitioner (LIMHP). The purpose of this assessment is to determine or verify the presence of a severe and persistent mental illness which requires psychiatric rehabilitation services. The document must include the need of the specific rehabilitation services necessary to meet the treatment and recovery goals of the beneficiary.

005.04 SEPARATE AND DISTINCT SERVICE. Community support is a separate and distinct service, and will not be provided as a component of other rehabilitative psychiatric services or mental health outpatient services. Agencies that provide more than one level of rehabilitative psychiatric or mental health outpatient service must have staff dedicated to the community support program. These community support staff must not provide any other rehabilitative psychiatric or treatment service to the beneficiary.

005.04(A) PROGRAM COMPONENTS. The community support program must:

(i)Facilitate communication and coordination among the rehabilitative mental health providers serving the beneficiary;

(ii)Ensure that the beneficiary has a diagnosis of severe and persistent mental illness, as exhibited by the completion of an initial diagnostic interview, no more than 12 months prior to admission to a community support program. The initial diagnostic interview must identify the need for community support and outline the needed services and resources for the beneficiary;

(iii)Ensure completion of a strength-based needs assessment which can include skills inventories, interviews, and other tools to develop treatment and rehabilitation plans, which must be completed within 30 days of admission by the rehabilitation team or team members;

(iv)Ensure the completion of an individual treatment, rehabilitation, and recovery plan for each beneficiary served. The individual treatment, rehabilitation, and recovery plan must be completed within 30 days following the admission of the beneficiary and reviewed and updated every 90 days or as often as clinically necessary thereafter while receiving services. The individual treatment, rehabilitation, and recovery plan must be based on the results of comprehensive assessments and is developed with the beneficiary’s involvement and through an interdisciplinary team process. The individual treatment, rehabilitation, and recovery plan must include methods and interventions to address: activities of daily living, community living skills, budgeting, education, independent living skills, social skills, interpersonal skills, psychiatric emergency or relapse, medication management including recognition of signs of relapse and control of symptoms, mental health services, physical health care, vocational and educational resource acquisition, and other related areas as necessary for successful living in the community;

(v)Ensure the individual treatment, rehabilitation, and recovery plan encompasses the supportive and rehabilitative interventions that will be directly provided by the community support program;

(vi)Identify the provision of services and interventions identified in the individual treatment, rehabilitation, and recovery plan as the responsibility of other rehabilitative service providers;

(vii)Develop and implement strategies to assist the beneficiary in becoming engaged and remaining engaged in medically necessary mental health treatment and psychiatric rehabilitation services;

(viii)Provide service coordination and case management activities, including coordination or assistance in accessing medical, social, education, housing, transportation or other appropriate support services as well as linkage to other community services identified in the individual treatment, rehabilitation, and recovery plan;

(ix)Facilitate communication between the treatment and rehabilitation providers and with the primary care physician, psychiatrist, or advanced practice registered nurse (APRN) serving the beneficiary;

(x)Monitor beneficiary progress of the services being received and participate in the revision of the individual treatment, rehabilitation, and recovery plan as needed or at the request of the beneficiary;

(xi)Provide contact as needed with other service provider, beneficiary family member, and other significant people in the beneficiary’s life to facilitate communication necessary to support the beneficiary in maintaining community living;

(xii)Assist the beneficiary in the developing, evaluating, and updating a crisis and relapse prevention plan. This plan must be coordinated with any other rehabilitative service and include the beneficiary’s natural supports;

(xiii)Provide therapeutic support and intervention to the client in time of crisis. If hospitalization is necessary, facilitate, in cooperation with the inpatient treatment provider, the beneficiary’s transition back into the community upon discharge;

(xiv)Participate with and report to the treatment and rehabilitation team on the progress of the beneficiary in areas of medication compliance, relapse prevention, social skill acquisition, application, education, substance use disorder, and ability to sustain community living;

(xv)Monitor medication compliance; and

(xvi)Assist the beneficiary with all health insurance issues including share of cost eligibility issues. Ensure the beneficiary’s understanding of financial benefits and procedures to use those benefits .

005.04(B) ADMISSION CRITERIA. Community support services require a prior authorization by Nebraska Medicaid or its designee. To be eligible for community support services, the beneficiary must meet all of the criteria described in this chapter. .

() 005.04(C) STAFFING REQUIREMENTS. Staff of rehabilitative programs that deliver rehabilitative services must either be licensed practitioners operating within their scope of practice or be skilled direct care staff that meet the following minimum standards:

(i)Have demonstrated skills and competencies in working with people experiencing severe and persistent mental illness;

(ii)Have completed a staff training curriculum for initial orientation and complete a continuing education curriculum at intervals as defined and prepared by the providing agency. This curriculum and periodic updates must be included in the program description submitted to Nebraska Medicaid; and

(iii) Be trained in the principles of recovery.

00.0 005.04(D) CLINICAL STAFF. The community support program must have available a:

(i) LICENSED CLINICAL SUPERVISOR. The clinical supervisor must qualify as a licensed practitioner and must participate in the individual treatment, rehabilitation, and recovery plan development and provide clinical supervision, consultation, and support. The licensed clinical supervisor will review the community support beneficiary’s clinical needs and progress toward their goals with the community support worker every 30 days. The review can be accomplished by the supervisor consulting with the community support worker on their assigned beneficiaries and providing clinical guidance or recommendations to better serve the beneficiary.

(ii) OTHER CONSULTANTS. Consultation by licensed professionals for general medical, psychopharmacology, and psychological issues, as well as overall program design as necessary. These consultations must themselves meet the standards laid out in the appropriate sections of these regulations.

005.04(E) DIRECT CARE STAFF. The community support program must have community support staff who meet the following requirements:

(i)Direct care staff must have a minimum level of experience or training that is satisfied by one of the following:

(1) A bachelor’s degree or higher in psychology, sociology, or a related human services field;

(2) Two years of coursework in a human service field; or

(3) Two years of experience or training in a human service field, and two years of lived recovery experience, with demonstrated skills in the treatment of individuals with a behavioral health diagnosis; and

(ii)Community support staff must receive monthly supervision by the community support clinical supervisor.

005.05 PROGRAM AVAILABILITY. The community support program must establish hours of service delivery that ensure program staff are accessible and responsive to the needs of the beneficiary. Scheduled services must include evening and weekend hours. The community support program must directly provide or otherwise demonstrate that each beneficiary has on-call access to a licensed mental health practitioner (LMHP) 24 hours per day . Access to a licensed mental health practitioner (LMHP) must be documented in the beneficiary's individual treatment, rehabilitation, and recovery plan.

005.06 CONTACTS. The frequency of contact between the beneficiary and the community support worker must be individualized and adjusted in accordance with the needs of the beneficiary. Community support providers must ensure that the amount of direct contact is sufficient to meet the beneficiary’s needs as identified in the individual treatment, rehabilitation, and recovery plan. Contacts may either be direct beneficiary contact or collateral contact.

(A) DIRECT BENEFICIARY CONTACT. Direct beneficiary contacts are contacts with the beneficiary that focus on the development of skills, or the management of other activities or goals identified on the individual treatment, rehabilitation, and recovery plan. Contacts must occur in community settings and be medically necessary for the beneficiary’s recovery. Face-to-face contact must be individualized to the beneficiary’s recovery needs and must be identified in the beneficiary’s individual treatment, rehabilitation, and recovery plan . Contacts must be timed in units, with each unit being equivalent to a 15-minute period, with contacts being limited in duration with a maximum of 144 units per 180-day period. In situations of beneficiary absence or unavailability for a scheduled contact, providers must document the circumstances in which the scheduled contact did not occur and the program’s response to the lack of beneficiary’s availability to participate in the community support intervention.

(B) COLLATERAL CONTACT. Collateral contacts must be documented in the beneficiary's clinical record and are considered an essential supportive component to the beneficiary's treatment, recovery, and rehabilitation plan but may not be billed as a separate service to Nebraska Medicaid.

005.07 CLINICAL DOCUMENTATION. Rehabilitative psychiatric service providers must maintain a clinical record that is confidential, complete, accurate, and contains up-to-date information relevant to the beneficiary’s care and services. The record must sufficiently document assessments; individual treatment, rehabilitation, and recovery plans and plan reviews; and important provider discussion. The clinical record must document beneficiary contacts describing the nature and extent of the services provided, such that a clinician unfamiliar with the service can identify the beneficiary’s service needs and services received. The documentation must reflect the rehabilitative services provided, be consistent with the goals in the treatment and recovery plan, and be based upon the comprehensive assessment. The absence of appropriate, legible, and complete records can result in the recoupment of previous payments for services. Providers must provide the clinical record in the English language, however, providers must accommodate beneficiaries of other cultures and language in order that the beneficiary can completely participate in and understand their treatment and recovery rehabilitation program. Each entry must identify the date, beginning and end time of the service, and the location of service. The individuals in attendance must be identified by name and relationship to the identified beneficiary and the name and title of the staff person providing the intervention and entering the information.

005.07(A) CLINICAL RECORDS. Clinical records must be maintained at the provider’s headquarters. Records must be kept in a locked file when not in use. For purposes of confidentiality, disclosure of treatment information is subject to all the provisions of applicable state and federal laws. The beneficiary’s clinical record must be available for review by the beneficiary, and their guardian with appropriate consent, unless there is a specific medically indicated reason to preclude this availability. The specific reason must be documented in the clinical record and reviewed periodically.

005.07(B) CLINICAL RECORD REQUIREMENTS. The clinical record must include, at a minimum:

(i)Beneficiary identifying data, including demographic information and the beneficiary’s legal status;

(ii)Assessment and evaluations;

(1)initial diagnostic interview completed prior to admission;

(2)Strength-based needs assessment; and

(3)Other appropriate assessments;

(iii)Treatment and recovery plan and updates to plans;

(iv) Documentation of review of client rights with the beneficiary;

(v) A chronological record of all services provided to the beneficiary. Each entry must include the staff member who performed the service received. Each entry includes the date the service was performed, the duration of the service, including the beginning and end time, the place of the service, and the staff member’s name and title and legible signature ;

(vi)Documentation of the involvement of family and significant others;

(vii)Documentation of treatment and recovery services and discharge planning;

(viii)A chronological listing of the medications prescribed for the beneficiary, including dosages and schedule, and the beneficiary’s response to the medication;

(ix)Documentation of coordination with other services and treatment providers;

(x)Discharge summaries from previous levels of care;

(xi)Discharge summary when appropriate; and

(xii)Any clinical documentation requirements identified in the specific service.

005.08 PROVIDER PARTICIPATION. Providers must comply with all applicable provider participation requirements . The provider must sign an agreement at the time of enrollment that states the provider will submit initial and annual cost information to Nebraska Medicaid as a part of the enrollment. The cost information must be updated upon request.

005.08(A) LICENSURE REQUIREMENTS. Community support providers must be appropriately licensed when licensure is required to provide the service and the program must have acquired national accreditation in The Joint Commission , the Commission on Accreditation of Rehabilitation Facilities (CARF), or Council on Accreditation (COA) as a condition for enrollment as a participating provider. Accreditation must be maintained throughout the Nebraska Medicaid participation period.

005.09 BENEFICIARY RIGHTS POLICY. Individual staff and the treatment and recovery team must provide all services in a manner to support and maintain the beneficiary’s rights with a continuous focus on empowerment and movement toward recovery. Providers must have a written beneficiary rights and responsibilities policy and staff must review beneficiary rights, responsibilities, and grievance procedures with each new beneficiary at admission, at treatment and recovery plan review, and at the request of the beneficiary. This review must be documented in the clinical record. Substance use disorder and mental health treatment providers must comply with all state and federal beneficiary rights requirements.

005.09(A) BENEFICIARIES’ RIGHTS. Beneficiaries’ rights must be observed when providing mental health and substance use disorder services through Nebraska Medicaid. The beneficiary has the right to:

(i)Be treated with respect and dignity regardless of state of mind or condition;

(ii)Have privacy and confidentiality related to all aspects of care;

(iii)Be protected from neglect; physical, emotional or verbal abuse; and exploitation of any kind;

(vi)Be part of developing an individual treatment and recovery plan and decision-making regarding their treatment and rehabilitative services;

(v)Refuse treatment or therapy unless ordered by a mental health board or court;

(vi)Be free of any sexual exploitation or harassment;

(vii)Voice complaints and file grievances without discrimination or reprisal and to have those complaints and grievances addressed; and

(viii)Receive such forms, instructions, and assistance as needed to file a complaint or request a state fair hearing.

005.10 BILLING FOR COMMUNITY SUPPORT SERVICES. Community support services must be billed in 15-minute increments for a maximum of 144 units per 180 days.

006. DAY REHABILITATION. The following day rehabilitation service requirements apply.

006.01 DAY REHABILITATION. The day rehabilitation program is designed to:

(A)Enhance and maintain the ’s beneficiary's ability to function in community settings; and

(B)Decrease the frequency and duration of hospitalization. Beneficiaries served in this program receive rehabilitation and support services to develop and maintain the skills needed to successfully live in the community. Day rehabilitation is a facility-based program. The program must provide:

(i) Prevocational services including services designed to rehabilitate and develop the general skills and behaviors needed to prepare the beneficiary to be employed or engage in other related substantial gainful activity. The program does not provide training for a specific job or assistance in obtaining permanent competitive employment positions for beneficiaries;

(ii) Community living skills and daily living skills development;

(iii) Beneficiary skills development for self-administration of medication, as well as recognition of signs of relapse and control of symptoms;

(iv)Planned socialization and skills training and recreation activities focused on identified rehabilitative needs;

(v)Skill building in the usage of public transportation or assistance in accessing suitable local transportation to and from the day rehabilitation program;

(vi)A scheduled program of services to beneficiaries for a minimum of five hours per day, five days per week. Specific services for each beneficiary will be individualized, based on beneficiary needs; and

(vii)Directly provide or otherwise demonstrate that each beneficiary has on-call access to a mental health provider 24 hours per day .

006.02 SUPPORTIVE SERVICES. The program provides the following supportive services for all active beneficiaries: referrals, problem identification and solution, and coordination of the day rehabilitative program with other services.

007. PSYCHIATRIC RESIDENTIAL REHABILITATION. The following psychiatric residential rehabilitation service requirements apply.

007.01 PSYCHIATRIC RESIDENTIAL REHABILITATION. The psychiatric residential rehabilitation program is designed to:

(A)Increase the beneficiary's functioning so that they can eventually live successfully in the residential setting of their choice, based on their capabilities and resources; and

(B)Decrease the frequency and duration of hospitalization.

007.02 PURPOSE. The psychiatric residential rehabilitation program provides skill building in community living skills, daily living skills, medication management, and other related psychiatric rehabilitation services as needed to meet individual beneficiary needs. These facilities are integrated into the community, and every effort is made for these residences to approximate other homes in their neighborhoods.

007.03 PROGRAM COMPONENTS. The program provides:

(A)COMMUNITY SKILLS. Community living skills and daily living skills development;

(B)MEDICATION. Beneficiary skills development for self-administration of medication, as well as recognition of signs of relapse and control of symptoms; and

(C)TRANSPORTATION. Skill building in the usage of public transportation or assistance in accessing suitable local transportation to and from the psychiatric residential rehabilitation program.

007.04 LICENSURE REQUIREMENTS. The program must be licensed as a residential care facility, domiciliary, or mental health center by the Department .

007.05 STAFFING REQUIREMENTS. The program must have the appropriate staff coverage to provide services for beneficiaries needing to remain in the residence during the day.

007.06 BED LIMITATION. The maximum capacity for this facility must not exceed 16 beds.

007.07 SUPPORTIVE SERVICES. The program provides the following supportive services for all active beneficiaries: referrals, problem identification and solution, and coordination of the residential rehabilitation program with other services the beneficiary may be receiving.

007.08 REFERRALS FOR REHABILITATIVE PSYCHIATRIC SERVICES. Referrals for rehabilitative psychiatric services will be directed to Nebraska Medicaid or its designee. The referral must include documentation that establishes:

(A)The beneficiary's eligibility for Nebraska Medicaid; and

(B)How the beneficiary meets the definition of serious and persistent mental illness specified in this chapter.

007.09 ELIGIBILITY FOR REHABILITATIVE PSYCHIATRIC SERVICES. To be eligible for rehabilitative psychiatric services, the beneficiary must be eligible for Nebraska Medicaid, meet the definition of severe and persistent mental illness, and be authorized by Nebraska Medicaid or its designee for specific services.

007.10 SERVICE NEEDS ASSESSMENT AND REHABILITATIVE PSYCHIATRIC SERVICE RECOMMENDATIONS. All beneficiaries determined eligible for rehabilitative psychiatric services must be assessed and have rehabilitative psychiatric service recommendations developed by a referring provider according to specified protocols.

008. APPEALS AND FAIR HEARINGS. Appeal and fair hearing procedures are governed by this title and federal regulations.

009. ASSERTIVE COMMUNITY TREATMENT (ACT). The assertive community treatment (ACT) team provides high intensity services and must be available to provide treatment, rehabilitation, and support activities seven days per week, 24 hours per day, 365 days per year. The team must have the capacity to provide multiple contacts each day as dictated by beneficiary need. The team must provide ongoing continuous care for an extended period of time, and beneficiaries admitted to the service who demonstrate any continued need for treatment, rehabilitation, or support must not be discharged except by mutual agreement between the beneficiary and the team. Services provided must focus on treatment and rehabilitation of the effects of serious mental illness, as well as support and assistance in meeting such basic human needs as housing, transportation, education, and employment.

009.01 CLINICAL TEAM. assertive community treatment (ACT) must be provided by a self-contained clinical team which:

(A)Assumes overall responsibility and clinical accountability for beneficiaries disabled by severe and persistent mental illness by directly providing treatment, rehabilitation, and support services and by coordinating care with other providers;

(B)Does not refer beneficiaries to outside service providers when services are identified as a responsibility of the assertive community treatment (ACT) program as outlined in this chapter. ;

(C)Provides services on a long-term basis with continuity of caregivers over time;

(D)Delivers most of the services outside program offices;

(E)Emphasizes outreach, relationship building, and individualization of services;

( (F)Provides psychiatric treatment and rehabilitation that is culturally sensitive and competent; and

(G)Shares team roles expecting each staff member to know all the beneficiaries and assist in assessment, treatment planning, and care delivery as needed.

009.02 ADMISSION AND DISCHARGE CRITERIA.

009.02(A) ADMISSION CRITERIA. Nebraska Medicaid covers assertive community treatment (ACT) services for those persons disabled by severe and persistent mental illness who are unable to remain stable in community living without high intensity services. Assertive community treatment (ACT) services must be prior authorized by Nebraska Medicaid or its designee. To be eligible for assertive community treatment (ACT) services, beneficiaries must meet all of the criteria described in this chapter , and demonstrate indicators of high need and utilization.

009.02(B) DISCHARGE CRITERIA. The assertive community treatment (ACT) program is intended to provide services over a long period of time. Beneficiaries admitted to the service who demonstrate continued need for treatment, rehabilitation, or support must not be discharged except by mutual agreement between the beneficiary and the assertive community treatment (ACT) team. Discharge from the assertive community treatment (ACT) team occurs when the beneficiary and program staff mutually agree to termination of services. Specific documentation must be included in the beneficiary's clinical chart when a discharge occurs. Discharge may occur in the following situations:

(i) GEOGRAPHIC RELOCATION. The beneficiary moves outside the team's geographic area of responsibility. In such cases, the assertive community treatment (ACT) team must arrange for transfer of mental health service responsibility to a provider wherever the beneficiary is moving. To meet this responsibility, the assertive community treatment (ACT) team must maintain contact with the beneficiary until this service transfer is arranged;

(ii) SIGNIFICANTLY IMPROVED FUNCTIONING. The beneficiary demonstrates by functional assessment measurement the ability to function with minimal assistance in the following functional areas: vocation and education, social skills, and activities of daily living;

(iii) BENEFICIARY REQUESTED DISCHARGE. Requested discharge despite the team's best efforts to develop an individual treatment, rehabilitation, and recovery plan acceptable to the beneficiary. Efforts to develop an acceptable individual treatment, rehabilitation, and recovery plan must be documented in the beneficiary's clinical record; and

(iv) HOSPITALIZATION OF THE BENEFICIARY IN AN INSTITUTION FOR MENTAL DISEASE (IMD). Nebraska Medicaid is not able to reimburse for services provided to beneficiaries over age 20 and under age 64 who are being treated in an institution for mental disease (IMD).

009.03 STAFF REQUIREMENTS. Each assertive community treatment (ACT) team must provide a comprehensively staffed team, including a psychiatrist, team leader, a peer support person, and program assistants. The assertive community treatment (ACT) team must have among its staff individuals who are qualified to provide the required services. Each assertive community treatment (ACT) team must employ, at a minimum, the following number of clinical staff persons, peer support, and psychiatrists to provide the treatment, rehabilitative, and supportive services. Providers are responsible for verifying that staff are appropriately licensed or certified.

009.03(A) STAFF QUALIFICATIONS. All clinical staff must be appropriately licensed or credentialed as required by the Department of Health and Human Services, Division of Public Health. All clinical staff must have at least two years of experience working with persons with serious and persistent mental illness. All clinical staff must maintain sufficient hours of continuing education to maintain certification or licensure.

009.03(B) BACKGROUND CHECKS. The employer of the assertive community treatment (ACT) team members is responsible and accountable for the activities and interventions of the assertive community treatment (ACT) team staff. The employer must consider which type of criminal background and Abuse and Neglect Central Registry checks are appropriate for their staff and how the results impact hiring decisions. The use of criminal background and Abuse and Neglect Central Registry checks must be described in the employer’s policy and procedure manual and be available for review.

009.03(C) STAFF CONFIGURATION. The configuration of an assertive community treatment (ACT) team depends on the number of beneficiaries to be served. The assertive community treatment (ACT) team must maintain a 1:10 staff to beneficiary ratio. The team psychiatrist or mental health advanced practice registered nurse (APRN), if used, and program assistant are not included in the ratio:

(i) MINIMUM STAFF CONFIGURATION. The following minimum staffing configuration must be met in each assertive community treatment (ACT) team regardless of the number of beneficiaries served. This configuration may serve up to 50 beneficiaries. The team must have at least one member who demonstrates competency in drug and alcohol use and dependence or is a licensed alcohol and drug counselor (LADC). The assertive community treatment (ACT) team must include:

(1) TEAM PSYCHIATRIST. One team psychiatrist, who must be a board certified or board eligible psychiatrist. The team psychiatrist must provide coverage at a minimum of 16 hours per week. This psychiatry time must be spent exclusively on assertive community treatment (ACT) team activities. The team psychiatrist provides clinical services including psychiatric assessment, individual treatment, rehabilitation, and recovery plan development and approval, psychopharmacologic and medical treatment, and crisis intervention to all assertive community treatment (ACT) team beneficiaries. The team psychiatrist must be available 24 hours per day and seven days per week for crisis management. The team psychiatrist works with the team leader to monitor each beneficiary’s clinical status and response to treatment, provides staff clinical supervision, and participates in the development of all individual treatment, rehabilitation, and recovery plans;

(2) TEAM LEADER. The team leader must be a psychiatrist, physician, physician assistant (PA), or advanced practice registered nurse (APRN), or have at least a master’s degree in nursing, social work, psychiatric rehabilitation, psychology, or counseling. The team leader must have demonstrated clinical and administrative experience;

(3) MENTAL HEALTH PROFESSIONAL. One full time mental health professional who is a licensed psychologist, provisionally licensed psychologist, licensed independent mental health practitioner (LIMHP), licensed mental health practitioner (LMHP), or provisionally licensed mental health practitioner (LMHP);

(4) NURSING STAFF. One full time registered nurse (RN);

(5) MENTAL HEALTH WORKER. One full time mental health worker who meets one of the following qualifications:

(a)Is a licensed alcohol and drug counselor (LADC);

(b)Has a bachelor’s degree in psychology, sociology, or a behavioral health field; or

(c)Has a bachelors' degree in a field other than behavioral sciences or has a high school degree, and has work experience with adults with severe and persistent mental illness or with individuals with similar human services needs;

(6) SUBSTANCE USE SPECIALIST. One full time substance use specialist who meets one of the following qualifications:

(a) Is a licensed alcohol and drug counselor (LADC) or a provisionally licensed alcohol and drug counselor (LADC);

(b) Has at least one year of training or experience in substance use disorder treatment and is a licensed independent mental health practitioner (LIMHP), licensed mental health practitioner (LMHP), or provisionally licensed mental health practitioner (LMHP);

(7) VOCATIONAL SPECIALIST. One full time vocational specialist with at least one year of training or experience in vocational rehabilitation and support;

(8) ADDITIONAL STAFF. One additional full time staff person who meets the qualifications of the mental health professional or mental health worker;

(9) PEER SUPPORT. A half time coverage of peer support. This team member position must be a self-identified consumer of mental health services. The peer support staff must have training, experience, and ability to work with the team in carrying out appropriate aspects of the individual treatment, rehabilitation, and recovery plan. The peer support staff must hold a certification through the Department of Health and Human Services, Division of Behavioral Health as a certified peer support provider;

(10) SUPPORT STAFF. At least one full-time support staff person. Support staff is defined as a non-clinician responsible for working under the direction of the team leader to support all non-clinical operations of the assertive community treatment (ACT) team. This is a full time position and not considered in the staff to beneficiary ratio;

(ii)ADVANCED PRACTICE REGISTERED NURSE (APRN) OPTIONAL CONFIGURATION. When a psychiatrist is not providing coverage, an advanced practice registered nurse (APRN) may substitute for coverage. The advanced practice registered nurse (APRN) may provide coverage for existing psychiatry time while not replacing the team psychiatrist responsibility in the above services. The advanced practice registered nurse (APRN) must work collaboratively with the psychiatrist. An advanced practice registered nurse (APRN) can provide services within their scope of practice, except for the mandatory services which must be delivered by the team psychiatrist as described in this chapter. The team psychiatrist must be available for consultation and direction of the treatment activities provided by the advanced practice registered nurse (APRN). There must be a documented agreement between the team psychiatrist and the advanced practice registered nurse (APRN) for 24 hours per day, seven days per week psychiatric coverage. A copy of the agreement must be sent to Nebraska Medicaid at the time of enrollment, prior to the initiation of services, and at any time the agreement is modified or terminated;

(iii) EXPANDED STAFF CONFIGURATION. If an assertive community treatment (ACT) team will serve more than 50 beneficiaries, the following staff must be added:

(1) REGISTERED NURSE (RN). At least one additional registered nurse (RN) to meet the nursing needs of the expanded population;

(2) PEER SUPPORT. At least one full time peer support specialist;

(3) TEAM PSYCHIATRIST. Additional psychiatric coverage of 2.6 hours for every eight beneficiaries;

(4) MENTAL HEALTH PROFESSIONAL. At least two mental health professionals; and

5. ADDITIONAL STAFF. Additional staff to maintain a minimum 1:10 staff to beneficiary ratio. This ratio excludes the team psychiatrist, and advanced practice registered nurse (APRN) if used, and the program assistant. The configuration of the assertive community treatment (ACT) team must reflect the needs of the beneficiary population.

009.03(D) STAFF FUNCTIONS. The assertive community treatment (ACT) team must perform the following functions:

(i) CLINICAL SUPERVISION. All members of the assertive community treatment (ACT) team who are not licensed to practice independently must have clinical supervision. A member of the assertive community treatment (ACT) team who is a psychiatrist, advance practice registered nurse (APRN), or a licensed independent mental health practitioner (LIMHP), must be designated as the clinical supervisor. The clinical supervisor must have regular contact with the client and with members of the assertive community treatment (ACT) team who are not independently licensed to practice. Clinical supervision must include:

(1)Review of the beneficiary’s clinical status;

(2)Ensuring appropriate treatment services are provided to the beneficiary;

(3)Review and improvement of the assertive community treatment (ACT) team member’s service provision;

(4)Provision of clinical supervision during daily team meetings, individual treatment, rehabilitation, and recovery plan meetings, side-by-side and face-to-face supervision sessions, and through a review of the beneficiary’s clinical record; and

(5) Appropriate documentation of clinical supervision activities;

(ii) CRISIS INTERVENTION AND RESPONSE. In addition to the beneficiary specific crisis intervention plans, the assertive community treatment (ACT) team must have a procedure to respond to emergencies and crises;

(iii) ASSESSMENT. Initial and updated assessments of the beneficiary must be provided as described in this chapter. Appropriate staff must be assigned to this function based on individualized beneficiary need. The beneficiary and their family, as allowed by beneficiary permission, must be involved in all assessments;

(iv) TREATMENT PLANNING. Initial and updated individual treatment, rehabilitation, and recovery plans must be developed as described in this chapter. In addition to the team leader and team psychiatrist, appropriate staff must be assigned to this function based on individualized beneficiary need. One specific staff person must be designated to document the individual treatment, rehabilitation, and recovery plan for the clinical record. The beneficiary and their family, as allowed by beneficiary permission, must be involved in development, review, and revision of all individual treatment, rehabilitation, and recovery plans;

(v) INDIVIDUAL TREATMENT, REHABILITATION, AND RECOVERY PLAN COORDINATION. individual treatment, rehabilitation, and recovery plan coordination is an organized process of coordination among the multi-disciplinary team in order to provide a full range of appropriate treatment, rehabilitation, and support services to a beneficiary in a planned, coordinated, efficient, and effective manner, as outlined in the individual treatment, rehabilitation, and recovery plan; and

(vi) INTERVENTIONS. Based on individualized beneficiary need and preference and assertive community treatment (ACT) team qualifications, experience, and training, assertive community treatment (ACT) team members must be assigned to provide the active treatment, rehabilitative, and supportive services described in this chapter.

009.04 ACT PROGRAM ORGANIZATION.

009.04(A) HOURS OF OPERATION, COVERAGE, AND AVAILABILITY OF SERVICES. The assertive community treatment (ACT) team must meet the following requirements related to availability and scheduling:

(i) HOURS OF OPERATION AND AVAILABILITY OF SERVICES. The assertive community treatment (ACT) team must be available to provide treatment, rehabilitation, and support interventions 24 hours per day, seven days per week, 365 days a year. The assertive community treatment (ACT) team must be able to:

(1)Meet the beneficiaries needs at all hours of the day including evenings, weekends, and holidays;

(2)Provide services at the time that is most appropriate and natural for the beneficiary as described in the beneficiary’s individual treatment, rehabilitation, and recovery plan; and

(3)Operate a minimum of 12 hours per day and eight hours each weekend day and every holiday; and

(ii) PSYCHIATRIC COVERAGE. Psychiatric coverage must be available at all times. If availability of the team psychiatrist during all hours is not feasible, alternative psychiatric backup must be arranged. The covering psychiatrist or advanced practice registered nurse (APRN) must have an orientation to the assertive community treatment (ACT) team concept and be supportive of its services. The covering psychiatrist or advanced practice registered nurse (APRN) must be able to get beneficiary specific information from an assertive community treatment (ACT) team member.

009.04(B) SERVICE INTENSITY. The assertive community treatment (ACT) team services must be able to provide the level of service intensity as dictated by beneficiary need. Beneficiary need is determined through the severity of symptoms and limitations in daily living and is documented in the beneficiary’s individual treatment, rehabilitation, and recovery plan. No other psychiatric service or psychiatric rehabilitation service may be reimbursed, except for acute and subacute inpatient hospitalization for assessment and stabilization, when prior authorized by Nebraska Medicaid or its designee.

009.04(C) PLACE OF SERVICE. The assertive community treatment (ACT) team must provide most of the interventions and service contacts in the community, in non-office-based settings.

009.04(D) SHARED RESPONSIBILITY. The responsibility of the total beneficiary caseload is shared by the entire assertive community treatment (ACT) team, even though team members can serve as a primary contact for certain beneficiaries.

009.04(E) STAFF COMMUNICATION AND PLANNING. The assertive community treatment (ACT) team must use systems and methods for continuous daily communication and planning. These must include:

(i) DAILY ORGANIZATIONAL STAFF MEETING. A daily organizational staff meeting must be held to review the status of all program beneficiaries, update the team on contacts provided in the past 24 hours and to communicate essential information on current events and activities as they relate to the interventions provided by the assertive community treatment (ACT) team;

(ii) DAILY TEAM ASSIGNMENT SCHEDULE. The daily team assignment schedule must list all of the interventions that need to be provided on that day and the assertive community treatment (ACT) team member assigned to complete the intervention;

(iii) DAILY LOG. A daily log must be used to document that a beneficiary review has occurred;

(iv) CLIENT WEEKLY CONTACT SCHEDULE. The client weekly contact schedule must be a written schedule of all treatment, rehabilitation, and support interventions which staff must carry out to fulfill the goals and objectives in the beneficiary’s individual treatment, rehabilitation, and recovery plan; and

(v) INDIVIDUAL TREATMENT, REHABILITATION, AND RECOVERY PLAN MEETINGS. treatment, rehabilitation, and recovery plan meetings must be regularly scheduled meetings to identify and assess individual beneficiary needs and problems; to establish measurable long- and short-term treatment and service goals; to plan treatment and service interventions; and to assign staff persons responsible for providing the services. If the beneficiary and their family are not able to participate, the meeting must include their input. Appropriate support must be provided to maximize the participation of the beneficiary and their family. If necessary, the individual treatment, rehabilitation, and recovery plan should address any barriers to participation. The assertive community treatment (ACT) team must conduct individual treatment, rehabilitation, and recovery plan meetings, under the supervision of the team leader and team psychiatrist.

009.05 PROGRAM COMPONENTS AND INTERVENTIONS. Operating as a continuous treatment and rehabilitative service, the assertive community treatment (ACT) team must have the capability to provide assessment, comprehensive treatment, rehabilitation, and support services as a self-contained clinical service unit. Services must be available 24 hours a day, seven days a week, 365 days per year. Services must be provided by the most appropriate assertive community treatment (ACT) team members operating within their scope of practice. Services must include:

009.05(A) ASSESSMENT AND EVALUATION.

: 009.05(A)(i) INITIAL ADMISSION ASSESSMENT. Prior to accepting the beneficiary for admission, the assertive community treatment (ACT) team must assess and determine the appropriateness of the beneficiary for admission to the assertive community treatment (ACT) team program. The assessment must include a review of clinical information and beneficiary interview and may include additional assessment activities.

009.05(A)(ii) COMPREHENSIVE ASSESSMENT. The comprehensive assessment is unique to the assertive community treatment (ACT) program in its scope and completeness. A comprehensive assessment is the process used to evaluate a beneficiary's past history and current condition in order to identify strengths and problems, outline goals, and create a comprehensive individual treatment, rehabilitation, and recovery plan. The comprehensive assessment reviews information from all available resources including past medical records, beneficiary self-report, interviews with family or significant others if approved by the beneficiary, and other appropriate resources, as well as current assessment by team clinicians from all disciplines. A comprehensive assessment must be initiated and completed within 30 days after the beneficiary's admission to the assertive community treatment (ACT) program, according to the following requirements:

(1) Each assessment area must be completed by staff with skill and knowledge in the area being assessed and must be based upon all available information and resources, including beneficiary self-reports, reports of family members and other significant parties, written summaries from other agencies, including police, courts, and outpatient and inpatient facilities, interviews with the beneficiary, and standardized assessment materials;

(2)The comprehensive assessment must include a thorough medical and psychiatric evaluation and must identify beneficiary strengths as well as problems. The assessment must gather sufficient information to develop an individual treatment, rehabilitation, and recovery plan; and

(3)The comprehensive assessment may be added to, revised, or clarified during a beneficiary’s tenure in the assertive community treatment (ACT) program.

009.05(B) INDIVIDUAL TREATMENT, REHABILITATION, AND RECOVERY PLAN DEVELOPMENT AND COORDINATION. Individual treatment, rehabilitation, and recovery plan development and coordination is a continuing process involving each beneficiary, the beneficiary's family, guardian, and support system as appropriate, and the team, which individualizes service activity and intensity to meet beneficiary-specific treatment, rehabilitation, and support needs. The written individual treatment, rehabilitation, and recovery plan documents the beneficiary's goals and the services the beneficiary will receive in order to achieve them. The plan also delineates the roles and responsibilities of the team members who will carry out the services. An initial individual treatment, rehabilitation, and recovery plan must be developed upon the beneficiary’s admission to the assertive community treatment (ACT) team. The comprehensive individual treatment, rehabilitation, and recovery plan must be developed for each beneficiary within 21 days of the completion of the comprehensive assessment. This individual treatment, rehabilitation, and recovery plan will be developed and revised according to this section.

009.05(B)(i) COMPREHENSIVE INDIVIDUAL TREATMENT, REHABILITATION, AND RECOVERY PLAN DEVELOPMENT. A comprehensive individual treatment, rehabilitation, and recovery plan is developed through an organized process of coordination among the multi-disciplinary team in order to provide a full range of appropriate treatment, rehabilitation, and support services to the beneficiary in a planned, coordinated, efficient, and effective manner. The comprehensive individual treatment, rehabilitation, and recovery plan provides a systematic approach for meeting a beneficiary's needs, treatment rehabilitation, and support needs, and documenting progress on treatment, rehabilitation, and service goals.

009.05(B)(i)(1) KEY AREAS. The following key areas must be addressed in the individual treatment, rehabilitation, and recovery plan based upon the individual needs of the beneficiary: symptom stability, symptom management and education, housing, activities of daily living, employment and daily structure, family and social relationships, and crisis support. The individual treatment, rehabilitation, and recovery plan must be developed in collaboration with the beneficiary or guardian, if any, and, when appropriate, the beneficiary’s family. The beneficiary's participation and consent in the development of the individual treatment, rehabilitation, and recovery plan must be documented. The plan must be signed by the beneficiary and the team psychiatrist.

This plan must:

(a)Identify the beneficiary's needs and problems;

(b)List specific long- and short-term goals with specific measurable objectives for these needs and problems;

(c)List the specific treatment and rehabilitative interventions and activities necessary for the beneficiary to meet these objectives and to improve their capacity to function in the community; and

(d)Identify the assertive community treatment (ACT) team members who will be providing the intervention.

009.05(B)(ii) INDIVIDUAL TREATMENT, REHABILITATION, AND RECOVERY PLAN REVIEWS. The assertive community treatment (ACT) team must review and revise the beneficiary's individual treatment, rehabilitation, and recovery plan every six months, whenever there is a major decision point in the beneficiary's course of treatment, or more often if necessary. The team psychiatrist, team leader, and appropriate staff from the assertive community treatment (ACT) team must participate in each individual treatment, rehabilitation, and recovery plan review. The assertive community treatment (ACT) team must include the beneficiary in the review. Guardians and family members should be encouraged to participate, as allowed by the beneficiary.

009.05(B)(ii)(1) DOCUMENTATION. The individual treatment, rehabilitation, and recovery plan review must be documented in the beneficiary's clinical record. This documentation must include a description of the beneficiary's progress and functioning since the last individual treatment, rehabilitation, and recovery plan review, the beneficiary's current functional strengths and limitations, a list of attendees, the discussion related to the individual treatment, rehabilitation, and recovery plan, and any changes to the plan. The plan and review will be signed by the beneficiary and the team psychiatrist, which indicates this is the most appropriate level of care for the beneficiary and that the treatment, rehabilitative, and service interventions are medically necessary.

009.05(B)(iii) BENEFICIARY AND FAMILY PARTICIPATION. The assertive community treatment (ACT) team is responsible for engaging the beneficiary in active involvement in the development of the treatment and service goals. With the permission of the beneficiary, assertive community treatment (ACT) team staff must involve pertinent agencies and members of the beneficiary's family and social network in the formulation of individual treatment, rehabilitation, and recovery plans.

009.05(C) TREATMENT, REHABILITATIVE, AND SUPPORTIVE INTERVENTIONS. The assertive community treatment (ACT) team must be able to provide treatment, rehabilitative, and supportive interventions to beneficiaries assigned to the assertive community treatment (ACT) team. The interventions are categorized into three areas and the specific application of each type of intervention must be based on the beneficiary’s specific goals and objectives. The interventions must address the needs identified in the comprehensive assessment. While there are no requirements that the beneficiary receive a minimum number of a specific categories of intervention, the beneficiary must receive the interventions that are appropriate for their needs.

009.05(C)(i) TREATMENT INTERVENTIONS. All interventions must be performed by professionals acting within the appropriate scope of practice.

009.05(C)(i)(1) MEDICAL ASSESSMENT, MANAGEMENT, AND INTERVENTION. The assertive community treatment (ACT) team must provide the interventions necessary to treat the beneficiary’s psychiatric and physical conditions.

009.05(C)(i)(2) INDIVIDUAL, FAMILY, AND GROUP THERAPY OR COUNSELING. The assertive community treatment (ACT) team must provide individual, family, and group therapy or counseling to assist the beneficiary to gain skills in interpersonal relationships, identify and resolve conflicts, and systematically work on identified individual goals. These interventions must focus on lessening distress and symptomology, improving psychological defenses and role functioning, and increasing and reinforcing the beneficiary's understanding of and participation in treatment, rehabilitative services, and activities of daily living.

009.05(C)(i)(3) MEDICATION. The assertive community treatment (ACT) team must provide the prescription, preparation, delivery, administration, and monitoring of medications.

009.05(C)(i)(4) CRISIS INTERVENTION. The assertive community treatment (ACT) team must provide crisis intervention services by assessing beneficiary needs that require immediate attention and initiate a resolution to the need.

009.05(C)(i)(5) SUBSTANCE USE DISORDER SERVICES. The assertive community treatment (ACT) team must provide Substance use disorder services to assist the beneficiary in achieving periods of abstinence and stability. The interventions must include assessment, individual and group counseling, education, and skill development. The interventions should help the beneficiary:

(a)Learn to identify substance use, effects, and patterns;

(b)Recognize the relationship between substance use, mental illness, and psychotropic medications; and

(c)Develop motivation to eliminate or decrease substance use and coping skills or alternatives to minimize substance use.

009.05(C)(ii) REHABILITATIVE INTERVENTIONS.

009.05(C)(ii)(1) SYMPTOM MANAGEMENT SKILL DEVELOPMENT. The assertive community treatment (ACT) team must provide symptom management skill development to help the beneficiary cope with and gain mastery over symptoms and functional impairments in the context of adult role functioning.

009.05(C)(ii)(2) VOCATIONAL SKILL DEVELOPMENT. The assertive community treatment (ACT) team must provide vocational skill development that includes individualized assessment and planning for employment based upon functional assessment and the beneficiary's needs, desires, interests, and abilities.

009.05(C)(ii)(3) ACTIVITIES OF DAILY LIVING AND COMMUNITY LIVING SKILL DEVELOPMENT. The assertive community treatment (ACT) team must provide services to help the beneficiary rehabilitate their functional impairments and limitations related to activities of daily living and living in a community setting. The services will help beneficiaries carry out personal hygiene and grooming tasks, perform household activities, find housing that is safe and affordable, develop or improve money management skills, use available transportation, and have and effectively use a personal physician and dentist.

009.05(C)(ii)(4) SOCIAL AND INTERPERSONAL SKILL DEVELOPMENT. The assertive community treatment (ACT) team must provide interventions to help the beneficiary rehabilitate their social functioning.

009.05(C)(ii)(5) LEISURE TIME SKILL DEVELOPMENT. The assertive community treatment (ACT) team must provide interventions to rehabilitate the beneficiary’s ability to use leisure time appropriately.

009.05(C)(iii) SUPPORTIVE INTERVENTIONS.

009.05(C)(iii)(1) ASSISTANCE. The assertive community treatment (ACT) team must provide support services, direct assistance, and coordination to ensure that the beneficiary obtains the basic necessities of daily life.

009.05(C)(iii)(2) SUPPORT. The assertive community treatment (ACT) team must provide support to beneficiaries, on a planned and as needed basis, to help them accomplish their personal goals, gain a sense of personal mastery and empowerment, and to cope with the stresses of day-to-day living. This includes interaction that focuses on decreasing distress, improving understanding and reinforcing the beneficiary’s participation in services.

009.05(C)(iii)(3) FAMILY INVOLVEMENT. The assertive community treatment (ACT) team will provide education, support, and consultation to beneficiaries’ families and other major supports, with beneficiary agreement and consent. The assertive community treatment (ACT) team must encourage family members and other major sources of support to be involved in the services received by the beneficiary unless prohibited by the beneficiary, through legal action, or because of confidentiality laws. This includes education about the beneficiary's illness and condition and the role of the family in the therapeutic process, intervention to resolve conflict, and ongoing communication and collaboration between the assertive community treatment (ACT) team and the beneficiary’s family.

009.05(C)(iii)(4) POSITIVE PEER ROLE MODELING. The assertive community treatment (ACT) team will offer opportunities for positive peer role modeling and peer support including practical problem-solving approaches to daily challenges, peer perspective on steps to recovery and support, mentoring toward greater independence, empowerment, and ability to manage severe symptomology.

009.06 NATIONAL ACCREDITATION AND CERTIFICATION. Providers must be nationally accredited under specific assertive community treatment (ACT) team standards , or must be actively pursuing accreditation in order to be enrolled. Providers that are actively pursuing accreditation with a national body must submit their accreditation plan for consideration. Providers actively pursuing accreditation will be enrolled on a provisional status.

009.07 CLINICAL DOCUMENTATION REQUIREMENTS. Records must be kept in accordance with the national accreditation body surveying the provider. The clinical records for assertive community treatment (ACT) team services must include the following information:

(A)Team psychiatrist's orders;

(B)Treatment, rehabilitation, and service planning;

(C)Progress and contact notes must be recorded by all assertive community treatment (ACT) team members providing services to the beneficiary;

(D)Reports of consultations, laboratory results, and other relevant clinical and medical information; and

(E)Documentation of transition and discharge planning.

009.08 PERFORMANCE IMPROVEMENT AND PROGRAM EVALUATION. The assertive community treatment (ACT) team must have a performance improvement and program evaluation plan that meets the criteria for accreditation in the approved national accreditation organization. In addition, the program will participate in all aspects of statewide assertive community treatment (ACT) evaluation projects.

009.09 PROVIDER ENROLLMENT. An assertive community treatment (ACT) team must complete the appropriate Nebraska Medicaid approved provider agreement form, and submit the completed agreement and a program overview that addresses the requirements in these regulations to Nebraska Medicaid for approval. The assertive community treatment (ACT) team must maintain written policies and procedures that document compliance with all of the standards and requirements in this chapter . Annual updates of enrollment may be required. The provider must submit updates of the identity and expertise of assertive community treatment (ACT) team members as new staff are added to the program.

009.10 PRIOR AUTHORIZATION. Reimbursement for services from the assertive community treatment (ACT) team must be prior authorized by Nebraska Medicaid or its designee.

009.11 TELEHEALTH. Assertive community treatment (ACT) team interventions can be provided via telehealth when provided according to this title .

009.12 REIMBURSEMENT AND BILLING INFORMATION. Nebraska Medicaid pays for assertive community treatment services at established rates. Providers must follow these billing requirements:

(A)Claims for services provided by the assertive community treatment (ACT) team must be billed on the appropriate completed Nebraska Medicaid approved health care claim form ;

(B)Claims for assertive community treatment (ACT) team services must use the procedure codes determined by Nebraska Medicaid ; and

(C)The unit of service for assertive community treatment (ACT) team reimbursement is one day.

009.13 LIMITATIONS ON THE REIMBURSEMENT FOR ASSERTIVE COMMUNITY TREATMENT (ACT) TEAM SERVICES. Nebraska Medicaid eligibility for beneficiaries age 21 to 64 who are admitted to an institution for mental disease (IMD) for longer than ten days will end .

010. SECURE PSYCHIATRIC RESIDENTIAL REHABILITATION. secure psychiatric residential rehabilitation facilities are integrated into the community and provide programming in an organized, structured setting, including treatment and rehabilitation services and offer support to beneficiaries with a severe and persistent mental illness or co-occurring substance use disorders, or both. These beneficiaries demonstrate a moderate to high risk for harm to self or others and are in need of recovery, treatment, and rehabilitation services. The beneficiaries who are in need of this level of care have long standing limitations with limited ability to live independently over an extended period of time. These beneficiaries have needed a high level of psychiatric intervention and have limitations in all three functional areas, vocational and educational, social skills, and activities of daily living as defined in this chapter. The secure psychiatric residential rehabilitation program provides skill building and other related recovery oriented psychiatric rehabilitation services as needed to meet individual beneficiary needs.

010.01 PURPOSE. The secure psychiatric residential rehabilitation program is designed to:

(A)Increase the beneficiary's functioning while improving psychiatric stability so that they can eventually live successfully and safely in a less restrictive residential setting of their choice and capabilities;

(B) Decrease the frequency and duration of hospitalization;

(C)Decrease or eliminate all high risk, unsafe behavior to self or others; and

(D)Improve the ability to function independently by improving ability to function.

010.02 PROGRAM COMPONENTS. A secure psychiatric residential rehabilitation program provides a variety of on-site psychosocial rehabilitation and skill acquisition activities and treatment each day. The program must facilitate beneficiary driven skills training and activities as appropriate. A secure psychiatric residential rehabilitation program must provide services identified on the beneficiary specific individual treatment, rehabilitation, and recovery plan, providing culturally-sensitive and trauma-informed care. The activities must include :

(A)Ongoing assessment;

(B)Arrangement for general medical care including laboratory services, psychopharmacological services, or psychological services, as necessary;

(C)Provision of a minimum of 42 hours per week of on-site staff led psychosocial rehabilitation activities and skill acquisition;

(D)Programming focused on relapse prevention, recovery, nutrition, daily living skills, social skill building, community living, substance use disorders, education, medication education and self-administration, symptom management, and focus on improving the level of functioning to get to a less restrictive level of care;

(E)Educational and vocational focus as appropriate; and

(F)Access to community-based rehabilitation and social services to assist in transition to community as symptoms are managed and behaviors are stabilized.

010.03 ASSESSMENTS. The following assessments must be completed:

(A)A comprehensive mental health and substance use disorder assessment by an independently licensed mental health practitioner (LMHP) must occur prior to admission. As appropriate, a substance use disorder addendum must be developed to clarify or update the treatment needs and recommendations and gather information that covers the time frame where a beneficiary was not receiving treatment;

(B)Following admission and within 24 hours of stay, an assessment by the program's psychiatrist must be completed;

(C)A history and physical must be completed by a physician, physician assistant (PA), or advanced practice registered nurse (APRN) within 24 hours of admission and be available in the clinical record;

(D)A nursing assessment must be completed by a registered nurse (RN) within 24 hours of admission; and

(E)A functional assessment must be completed initially upon admission and annually with continued stay at this level of service.

010.04 INDIVIDUAL TREATMENT, REHABILITATION, AND RECOVERY PLANNING. An initial individual treatment, rehabilitation, and recovery plan must be completed within 24 hours of admission. secure psychiatric residential rehabilitation service providers must develop an individual treatment, rehabilitation, and recovery plan with the beneficiary within 30 days following admission to the program. The plan must include treatment protocols for substance use disorder issues. With the beneficiary’s consent, the beneficiary’s family or guardian must be included in all assessment and treatment, rehabilitation, and recovery planning. The provider must make every effort to be available and responsive to the beneficiary’s family or guardian to assist their involvement in the beneficiary’s recovery. The plan must be reviewed and revised with the beneficiary, discussing and documenting the discharge plan a minimum of every 30 days according to the following requirements.

010.04(A) INDIVIDUAL TREATMENT, REHABILITATION, AND RECOVERY PLAN. The individual treatment, rehabilitation, and recovery plan must be based upon a comprehensive assessment and completed within 30 days of admission. This plan must:

(i)Be oriented to the principles of recovery and meaningful beneficiary participation;

(ii)Apply the principles of recovery to include meaningful beneficiary participation, and a life in the community of the beneficiary’s choosing;

(iii)Incorporate and be consistent with best practices;

(iv)Include the beneficiary’s individualized goals and expected outcomes;

(v)Contain prioritized objectives that are measurable and time-limited;

(vi)Describe therapeutic interventions to be used in achieving the goals and objectives that are recovery-oriented, trauma-informed, and strength-based;

(vii)Identify staff responsible for implementing the therapeutic interventions;

(viii)Specify the planned frequency and duration of each therapeutic method;

(ix)Delineate the specific behavioral criteria to be met for discharge or transition to a lower level of care and reviewed weekly;

(x)Include a plan developed with the beneficiary that includes strategies to avoid crisis or admission to a higher level of care using principles of recovery and wellness;

(xi)Include the signature of the beneficiary, parent, or guardian;

(xii)Include the health care proxy and trauma safety forms when available and with beneficiary’s consent;

(xiii)Include documentation that the initial individual treatment, rehabilitation, and recovery plan has been completed within the timeframe specified in the program’s policies and procedures;

(xiv)Document that the plan has been reviewed, updated every 30 days, and revised according to client needs and progress; and

(xv)Document that the plan was reviewed by the program's treatment practitioners a minimum of every 30 days and that written revisions were approved, signed, and dated each 30 days by the program psychiatrist.

010.04(B) TREATMENT SERVICES. The program must offer structured, planned treatment and rehabilitation services as prescribed by the individualized treatment, rehabilitation, and recovery plan. The following services must be available and offered to the beneficiary:

(i)Individual psychotherapy;

(ii)Group psychotherapy;

(iii)Family therapy; and

(iv)Psychoeducational services.

010.04(C) SUPPORTIVE SERVICES. The program must provide the following supportive services for all active beneficiaries: referrals as necessary, problem identification and solution, and coordination of the secure psychiatric residential rehabilitation program treatment and activities with other services the beneficiary may be receiving.

010.05 STAFFING. The secure psychiatric residential rehabilitation provider must contract with or employ a licensed psychiatrist for the program. The psychiatrist’s hours must be at a sufficient level to provide weekly direct contact with the beneficiary; to provide assessment; to review the individual treatment, rehabilitation, and recovery plan; to evaluate beneficiary’s level of progress; to assist in eliminating barriers to recovery; and to provide psychiatric consultation as necessary 24 hours per day, and seven days per week . Programs must have staff available in skill and numbers to meet the acuity of the beneficiaries being served. Programs must have ability to call staff back when necessary.

010.05(A) STAFFING STANDARDS. Secure psychiatric residential rehabilitation providers must meet the following minimum staffing requirements. The program must employ a:

(i)Program director;

(ii)Licensed mental health practitioner (LMHP), or licensed alcohol and drug counselor (LADC), or both. ;

(iii)Registered nurse (RN); and

(iv)Direct care staff.

010.05(A)(1) PROGRAM DIRECTOR REQUIREMENTS. The program director must:

(a)Be fully licensed as a mental health practitioner, which could be a psychiatrist, advanced practice registered nurse (APRN), a registered nurse (RN), a licensed mental health practitioner (LMHP), a licensed independent mental health practitioner (LIMHP) or psychologist; and

(b)Possess leadership, supervisory, and management skills.

010.05(A)(2) RESPONSIBILITIES OF THE SECURE PSYCHIATRIC RESIDENTIAL REHABILITATION PROGRAM DIRECTOR. The program director must:

(a)Complete and sign a comprehensive biopsychosocial assessment for each beneficiary within 14 days of admission or delegate responsibility for the assessment to the program's licensed practitioner who functions as the therapist for the program;

(b)Develop, approve, and sign an initial individual treatment, rehabilitation, and recovery plan within the first 24 hours of admission;

(c)Supervise and participate in the development of a comprehensive individual treatment, rehabilitation, and recovery plan with the beneficiary and the program staff within 30 days of admission. The program director must approve and sign the plan prior to implementation;

(d)Supervise the professional staff and direct care staff by onsite presence during programming;

(e)Assure adequate staff training through initial and ongoing training sessions and provide supervision of staff competency checks;

(f)Supervise and provide direction regarding all documentation requirements, including organization and completeness of clinical records; and

(g)Supervise and direct the development and implementation of the discharge plan.

010.05(A)(3) RESPONSIBILITIES OF THE REGISTERED NURSE (RN). The registered nurse (RN) must:

(a)Complete a nursing assessment within 24 hours of admission;

(b)Participate in the development of the individual treatment, rehabilitation, and recovery plan and the plan updates;

(c)Oversee and monitor daily medication administration;

(d)Provide medication education as necessary;

(e)Communicate with the psychiatrist and physician consultants as necessary; and

(f)Monitor, supervise, and oversee the program’s daily activities in conjunction with and in the absence of the program director.

010.05(A)(4) RESPONSIBILITIES OF THE MENTAL HEALTH PRACTITIONER. The mental health practitioner must:

(a)Complete a comprehensive assessment within 14 days of admission when this responsibility is delegated by the program director;

(b)Participate in the development of the individual treatment, rehabilitation, and recovery plan and the updates;

(c)Provide individual, group, and family psychotherapy according to the beneficiary's individual treatment, rehabilitation, and recovery plan;

(d)Communicate with the program director and psychiatrist regarding the clinical needs of the beneficiary as necessary;

(e)Monitor, supervise, and oversee the program's daily treatment and activities in the absence of the program director as assigned by the program director;

(f) Assist with aggressive discharge planning; and

(g)Maintain a maximum staffing ratio of one practitioner to eight beneficiaries.

010.05(A)(5) DIRECT CARE STAFF. Direct care staff to beneficiary ratios must be sufficient to meet beneficiary needs, and ratios must be enhanced to meet beneficiary needs as necessary. The secure psychiatric residential rehabilitation program must employ direct care staff who:

(a)Are on site and available to the beneficiaries at a ratio of one staff per four beneficiaries during awake hours and a minimum of one awake direct care per staff per six beneficiaries during overnight hours; and

(b) Have a bachelor's degree in psychology, sociology, or related human services field, except that two years of course work in the human services field and two years of experience and training or two years of lived recovery experience is an acceptable substitute. Each staff must have demonstrated skills and competency in treatment with individuals with mental health diagnosis.

010.06 DISCHARGE PLANNING. Discharge and transition planning must begin upon admission. The beneficiary’s family or guardian must be included in discharge planning as authorized by the beneficiary. The plan must be recovery-oriented, trauma-informed, and strength-based. Providers must meet the following standards regarding recovery and discharge planning:

(A)Discharge planning must be consistent with the goals and objectives identified in the individual treatment, rehabilitation, and recovery plan and clearly documented in the clinical record;

(B)Discharge planning must address the beneficiary’s needs for ongoing services to maintain the gains and to continue as normal functioning as possible following discharge. A crisis, relapse, and safety plan must be in place;

(C)Providers must make or facilitate referrals and applications to the next level of care or community support services, or both ;

(D)Providers must arrange for the prompt transfer of clinical records and information to ensure continuity of care; and

(E)A written discharge summary must be provided as part of the clinical record. It must identify the readiness for discharge and contain the signature of a fully licensed clinician and date of signature and must identify a summary of the services provided.

010.07 CLINICAL DOCUMENTATION. Clinical records must be maintained at the beneficiary’s primary rehabilitation site.

010.08 CLINICAL RECORD REQUIREMENTS. The clinical record must include information required in this chapter and, at a minimum:

(A)Assessment and evaluations:

(i)Psychiatric assessment, including the name of the clinician and the date of the assessment;

(ii) Comprehensive assessment; and

(iii) Other assessments completed related to the beneficiary’s behavioral health diagnosis;

(B)The beneficiary’s diagnostic formulation, including all five axes; and

(C)The individual treatment, rehabilitation, and recovery plan and updates to plans.

010.09 PROVIDER PARTICIPATION. Providers are required to provide annual updates of program information and cost information to determine ongoing compliance with Nebraska Medicaid regulations. Providers must maintain documentation of policies and procedures that meet the standards and regulations described in this chapter.

010.10 BED LIMITATION. The maximum capacity for the provider of secure psychiatric residential rehabilitation services must not exceed 16 beds.

010.11 TREATMENT PRIOR AUTHORIZATION. All secure psychiatric residential rehabilitation services must be prior authorized by Nebraska Medicaid or its designee, including initial admissions and continued stay requests.

010.12 INSPECTIONS OF CARE (IOC). Nebraska Medicaid or its designee can periodically inspect the care which includes the treatment, rehabilitative, and recovery services provided to beneficiaries in each type of service.

011 . SUBSTANCE USE DISORDER COMMUNITY SUPPORT. Substance use disorder community support interventions provide direct rehabilitation and support services to beneficiaries in the community to assist the beneficiary in maintaining abstinence, stabilizing community living, and preventing exacerbation of symptoms and admissions to more restrictive levels of care. Services are based upon medical necessity as identified in the beneficiary’s treatment and recovery plan and must be provided in 15-minute increments.

011.01 PROGRAM COMPONENTS. The substance use disorder community support program must:

(A)Facilitate communication and coordination among all health care professionals providing services to the beneficiary;

(B)Ensure completion of a strength-based needs assessment completed within 30 days of admission by the rehabilitation team or team member;

(C)Develop and implement strategies to encourage the beneficiary to become engaged and remain engaged in necessary substance use and mental health treatment services as recommended and included in the treatment and recovery plan;

(D)Have access to the comprehensive substance use disorder assessment conducted prior to admission by an independently licensed practitioner practicing within their scope of practice, which must be reviewed and updated within 30 days of admission into the program. As appropriate, a substance use disorder addendum must be developed to clarify or update the treatment needs and recommendations and gather information that covers any time frame where a beneficiary was not receiving treatment;

(E)Participate with and report to the treatment and recovery team on the beneficiary’s progress and response to community support intervention in areas of relapse prevention of substance use and application of education and skills in the recovery environment;

(F)Review and update the treatment and recovery plan and discharge plan with the beneficiary and other approved family supports every 90 days or more often as clinically necessary;

(G)Coordinate with the providers of mental health services when the beneficiary has a co-occurring diagnosis and receiving mental health services by a licensed practitioner either located in the agency or in a separate program;

(H)Assist in facilitating the transfer to and the transition to other levels of treatment service;

(I) Assist in the development, evaluation, and update in a crisis and relapse plan with the beneficiary;

(J)Provide contact as needed with other providers, beneficiary family members, and other significant individuals in the beneficiary’s life to facilitate communication necessary to support the beneficiary in maintaining community living;

(K)When prescribed, monitor medication compliance, and report compliance issues as necessary;

(L)Assist the beneficiary with all health insurance issues; and

(M)Assist in the discharge plan for the beneficiary and support development of community-based resources.

011.02 PROGRAM AVAILABILITY. The substance use disorder Community Support program must establish hours of service delivery that ensure program staff availability and accessibility to the treatment, rehabilitation, and recovery needs of the beneficiary. The frequency of face-to-face contacts with the beneficiary is based upon clinical need.

011.03 STAFFING REQUIREMENTS. Substance use disorder Community Support programs must employ a licensed practitioner to provide supervision of the substance use disorder Community Support program. The licensed practitioner must supervise any individualized treatment and recovery service interactions provided by a community support worker. The licensed clinical supervisor will review community support beneficiary’s clinical needs and progress toward their goals with the community support worker every 30 days. The support worker must have a minimum of:

(i) Bachelor’s degree in psychology, sociology, or related human service field, or

(ii) Two years coursework in a human services field and two years of training or training, or

(iii) Two years of lived recovery experience with demonstrated skills and competencies in the provision of substance use disorder services and demonstrated skill in competency in working with chronic substance dependence.

011.03(A) CLINICAL DOCUMENTATION. Direct care staff employed by the agency before the effective date of these regulations will be considered to meet staffing requirements when the provider submits documentation identifying the name, address and provider number of the provider, service provided, names of direct care staff employed before the effective date of these regulations, and their date of hire. Documentation must be submitted 30 days following the effective date of these regulations.

011.04 ASSESSMENT AND TREATMENT PLANNING. Outpatient substance use disorder treatment must be delivered following the completion of the comprehensive substance use disorder assessment. Prior to delivery of services, an individual treatment and recovery plan must be developed by the provider with the beneficiary. The plan must be individualized, reviewed, and approved by the beneficiary and therapist, and adjusted as clinically necessary. As appropriate, a substance use disorder addendum must be developed to clarify or update the treatment needs and recommendations and gather information that covers any time frame where a beneficiary was not receiving treatment.

011.05 DOCUMENTATION. Outpatient substance use disorder treatment providers must document in a summary the treatment service delivered in an individualized progress note. The progress note must describe the treatment intervention provided, the beneficiary's response to the intervention, and must be placed in the beneficiary’s clinical record. Documentation must clearly reflect the implementation of the treatment and recovery plan. Discharge planning must be an essential part of the treatment and recovery plan and the documentation of the progress toward discharge must be documented in the clinical record.

.011.06 PROVIDER ENROLLMENT. Outpatient adult substance use disorder providers must comply with all applicable provider participation requirements. Providers of outpatient services must provide annual cost information as a requirement by Nebraska Medicaid at the time of enrollment and maintain any licensure requirements in order to continue participation with Nebraska Medicaid.

011.07 PRIOR AUTHORIZATION. Outpatient substance use disorder treatment services must be prior authorized by Nebraska Medicaid or its designee before treatment service delivery.

011.08 PAYMENT FOR COMMUNITY SUPPORT ABUSE TREATMENT SERVICES. Providers must bill community support services in 15-minute increments for a maximum of 144 units for 180 days.

History

• Effective 2026-06-28

Chapter 36 Hospice Services

Neb. Admin. Code tit. 471, ch. 36 Hospice Services {#sec-471-nac-36 omnilex-key=us-ne-regs-official--title-471--471 NAC 36}

001. SCOPE AND AUTHORITY . These regulations govern services provided under the Medical Assistance Act, Nebraska Revised Statute (Neb. Rev. Stat.) §§ 68-901 et seq.

002. DEFINITIONS . The following definitions apply:

002.01 ADVANCED DIRECTIVE. A legal document, including, but not limited to, a living will, signed by a competent person, to provide guidance for medical and health-care decisions in the event the client becomes incapable to make such decisions.

002.02 ASSISTED LIVING FACILITY. A facility licensed as an assisted living facility by the Department of Health and Human Services, Division of Public Health.

002.03 ATTENDING PHYSICIAN. A doctor of medicine or osteopathy who is legally authorized to practice medicine or surgery by the state in which they perform that function, and is identified by the client, at the time they elect to receive hospice care, as having the most significant role in the determination and delivery of the client’s medical care.

002.04 BENEFIT PERIOD. The dates that the certification or recertification request covers.

002.05 BEREAVEMENT COUNSELING. Emotional, psychosocial, and spiritual support and services provided before and after the death of the client to assist with issues related to grief, loss, and adjustment.

002.06 CAREGIVER. A friend, family member, or legal guardian who provides ongoing care for a client who is unable to care for themself.

002.07 CENTER FOR THE DEVELOPMENTAL DISABILITIES (CDD). A facility, including a group home, where shelter, food, care, advice, counseling, diagnosis, treatment, or related services are provided for a period of more than twenty-four consecutive hours to four or more persons residing at such facility who have developmental disabilities.

002.08 CLIENT. A Medicaid client who is:

(A) Diagnosed as terminally ill; and (B) Admitted into a hospice service, after giving informed consent.

002.09 CLIENT REPRESENATIVE. A person who is, because of the client’s mental or physical incapacity, authorized in accordance with state law to execute decisions about hospice services, or terminate medical care, on behalf of the terminally ill client.

002.10 DIETARY COUNSELING. Education and interventions provided to the client and family regarding appropriate nutritional intake as the client’s condition progresses. Dietary counseling is provided by qualified individuals, which may include a registered nurse (RN), dietitian, or nutritionist, when identified in the client’s plan of care.

002.11 ELECTION. A decision by the client, or client’s representative, to receive hospice care.

002.12 HOMEMAKER. A person employed by, or a volunteer of, a hospice provider to provide domestic services including, but not limited to, meal preparation, laundry, light housekeeping, errands, and chore services.

002.13 HOSPICE OR HOSPICE PROVIDER. A public agency, private organization, or subdivision of a public agency or private organization that is primarily engaged in providing hospice care as defined in this section.

002.14 HOSPICE AIDE. A person who is employed by a hospice to provide personal care, assistance with activities of daily living, and basic therapeutic care to the clients of the hospice.

002.15 HOSPICE CARE. A comprehensive set of services described in this chapter, identified, and coordinated by a hospice interdisciplinary group (IDG) to provide for the physical, psychosocial, spiritual, and emotional needs of a terminally ill client and family members, as delineated in a specific client plan of care.

002.16 HOSPICE INPATIENT FACILITY. A facility in which the hospice service provides inpatient care directly for respite and general inpatient care.

002.17 HOSPICE INTERDISCIPLINARY GROUP (IDG). The hospice medical director, nurse practitioner, licensed professional registered nurse (RN), certified social worker, pastoral or other counselor; and, as determined by the interdisciplinary plan of care, providers of special services such as counseling services, pharmacy services, hospice aides, trained volunteers, dietary services, and any other appropriate health services, to meet the physical, medical, psychosocial, spiritual, and emotional needs of clients and families, which are experienced during the final stages of illness, dying, and bereavement.

002.18 HOSPICE VOLUNTEER. An individual specifically trained and supervised to provide support and supportive services to the client and client’s family under the supervision of a designated hospice employee. This does not apply to any volunteers working on behalf of a hospice provider licensed under the Health Care Facility Licensure Act who, as part of their volunteer duties, provide care. Volunteers are unpaid persons who supplement other covered services. Volunteer services include, but are not limited to, caregiver relief, short term client companionship or running errands.

002.19 INITIAL ASSESSMENT. An evaluation of the client’s physical, psychosocial, and emotional status related to the terminal illness and related conditions to determine the client’s immediate care and support needs.

002.20 INSTITUTION FOR MENTAL DISEASES (IMD). A hospital, nursing facility (NF), or other institution of more than 16 beds that is primarily engaged in providing diagnosis, treatment, or care of persons with mental diseases, including medical attention, nursing care, and related services. For the purposes of this chapter, whether an institution is an institution for mental diseases is determined by its overall character as that of a facility established and maintained primarily for the care and treatment of individuals with mental diseases, whether or not it is licensed as such.

002.21 INTERMEDIATE CARE FACILITY FOR INVIDUALS WITH DEVELOPMENTAL DISABILITIES (ICF/DD). A facility, licensed by the Department of Health and Human Services Division of Public Health and certified to participate in Medicaid, where shelter, food, and training or habilitation services, advice, counseling, diagnosis, treatment, care, nursing care, or related services are provided for a period of more than 24 consecutive hours to four or more persons residing at such facility who have intellectual disability or related conditions, including epilepsy, cerebral palsy, or other developmental disabilities.

002.22 LICENSED NURSE. A person licensed as a registered nurse (RN) or as a practical nurse under the provisions of the Nurse Practice Act, Neb. Rev. Stat. §§ 38-2201 to 38-2238.

002.23 LICENSED PROFESSIONAL. A person licensed to provide patient care services by the state in which services are delivered.

002.24 MEDICAID REPRESENTATIVE. The client’s services coordinator or case manager.

002.25 MEDICAL DIRECTOR. A hospice provider employee, or contracted person, who is a doctor of medicine or osteopathy who is responsible for the overall coordination of medical care in the hospice.

002.26 MEDICATION. Any prescription or non-prescription drug or biological intended for treatment or prevention of disease or to affect body functions in humans.

002.27 NURSE PRACTITIONER. A registered nurse (RN) who performs such services as legally authorized to perform under the provisions of the Nurse Practice Act, Neb. Rev. Stat. §§ 38-2201 to 38-2238.

002.28 NURSING FACILITY (NF). A facility, or a distinct part of a facility, licensed by the Department of Health and Human Services Division of Public Health and certified for participation in the Medicaid program under Title XIX of the Social Security Act, where medical care, rehabilitation, or related services and associated treatment are provided for a period of more than 24 consecutive hours to persons residing at such facility who are ill, injured, or disabled.

002.29 ON-CALL SERVICES. Nursing services, physician services, and drugs and biologicals must be made routinely available on a 24-hour basis, seven days a week. Other covered services must be available on a 24-hour basis when reasonable and necessary to meet the needs of the client and family.

002.30 PALLIATIVE CARE. As defined in Neb. Rev. Stat. § 71-424.04.

002.31 PHYSICIAN. Any person licensed to practice medicine as provided in Neb. Rev. Stat. §§ 38-2001 to 38-2063.

002.32 PHYSICIAN DESIGNEE. A doctor of medicine or osteopathy designated by the hospice provider who assumes the same responsibilities and obligations as the medical director when the medical director is not available.

002.33 RESPITE CARE. Short-term inpatient care provided to the individual only when necessary to relieve the family members or other persons caring for the individual.

002.34 REVOCATION. The choice by the client, or client’s representative, to discontinue hospice services. Hospice services may be revoked in writing at any time.

002.35 SOCIAL WORKER, CERTIFIED. A person who has received a baccalaureate or master’s degree in social work from an approved educational program and holds a current certified social worker certificate issued by the Department of Health and Human Services Division of Public Health.

002.36 TERMINALLY ILL OR TERMINAL ILLNESS. The client is diagnosed with a medical prognosis that his or her life expectancy is six months or less if the illness runs its normal course.

002.37 TREATMENT. A therapy, modality, product, device, or other intervention used to maintain well-being or to diagnose, assess, alleviate, or prevent a disability, injury, illness, disease, or similar condition.

003. PROVIDER REQUIREMENTS .

003.01 GENERAL PROVIDER REQUIREMENTS. Providers must comply with all applicable provider participation requirements codified in 471 Nebraska Administrative Code (NAC) 2 and 3. In the event that participation requirements in 471 NAC 2 or 3 conflict with requirements outlined in this chapter, the participation requirements in this chapter will govern.

003.02 SERVICE SPECIFIC PROVIDER REQUIREMENTS. Hospice providers must participate in Medicare and meet the licensure and certification requirements of the Nebraska Department of Health and Human Services Division of Public Health.

003.02(A) STANDARDS OF CARE. The hospice provider must deliver services in accordance with the following standards:

(i) A hospice provider must be primarily engaged in providing the scope of services outlined in this chapter, and must do so in a manner that is consistent with accepted standards of practice; (ii) The hospice provider must designate a physician to serve as medical director. The medical director must be a doctor of medicine or osteopathy who is an employee or is under contract with the hospice. When the medical director is not available, a physician designated by the hospice provider assumes the same responsibilities and obligations as the medical director; (iii) The hospice provider must maintain clinical records containing past and current findings for each hospice client for the longer of six years, or the time period identified in 175 NAC 16. The clinical record must contain correct clinical information that is available to the client’s attending physician and hospice staff. The clinical record may be maintained electronically; (iv) Medical supplies and appliances, durable medical equipment, and drugs and biologicals related to the palliation and management of the terminal illness and related conditions, as identified in the hospice plan of care, must be provided by the hospice provider while the client is under hospice care; (v) The needs, preferences, cultural diversity, values, and expectations of client and caregiver are reflected in all aspects of service delivery; (vi) All service provision is done in a manner that is empowering to the client and caregiver; (vii) The client and caregiver feels safe and confident that their right to privacy is protected; (viii) The client and caregiver is treated with dignity and respect at all times; (ix) The hospice provider must assume full responsibility for the professional management of the client’s hospice care; (x) The hospice provider must conduct and document, in writing or electronically, a client-specific comprehensive assessment that identifies the client’s need for hospice care and services, and the client’s need for physical, psychosocial, emotional, and spiritual care. This assessment includes all areas of hospice care related to the palliation and management of the terminal illness and related conditions as outlined in this chapter; (xi) The hospice provider must maintain a certification that the client is terminally ill based on the clinical judgment of the hospice medical director or the physician member of the hospice interdisciplinary group (IDG), or the client’s attending physician if the client has an attending physician; (xii) Maintain the signed election statement in its files; (xiii) The hospice provider must designate a hospice interdisciplinary group (IDG) or groups as defined in this chapter which, in consultation with the client's attending physician, must prepare a written plan of care for each client. The plan of care must specify the hospice care and services necessary to meet the client and family-specific needs identified in the comprehensive assessment as such needs relate to the terminal illness and related conditions; (xiv) Provide on-call services 24 hours a day, seven days a week; (xv) Allow the Department staff to review agency policies regarding hiring and reporting to ensure that appropriate procedures regarding abuse, neglect, and law violations are in place; (xvi) Agree and assure that any suspected abuse or neglect must be reported to law enforcement and appropriate Department staff; (xvii) A hospice provider must routinely provide all core services directly by hospice provider employees. Any hospice employee or volunteer who is or will be ordering, referring, or prescribing items or services to clients, must be enrolled as a Medicaid provider in accordance with the provisions of 471 NAC 2; (xviii) All professionals who furnish services directly, under an individual contract, or under arrangements with a hospice provider, must be legally authorized, licensed, certified, or registered, in accordance with applicable federal, state, and local laws, and must act only within the scope of his or her state license, or state certification, or registration. All personnel qualifications must be kept current at all times; (xix) The hospice provider must organize, manage, and administer its resources to provide the hospice care and services which are reasonable and necessary for the palliation and management of the terminal illness and related conditions; (xx) The hospice provider must have a signed, written, non-resident-specific contract with each certified nursing facility (NF), intermediate care facility for individuals with developmental disabilities (ICF/DD), institution for mental diseases (IMD), assisted living facility (ALF), or center for the developmental disabilities (CDD); and (xxi) The hospice provider must maintain and document an effective infection control program that protects clients, families, visitors, and hospice personnel by preventing and controlling infections and communicable diseases.

003.02(B) PROVIDER AGREEMENT AND ENROLLMENT. The hospice provider must complete and submit Form MC-19, Service Provider Agreement. When enrollment by hospice is done to provide inpatient services in a facility, a copy of the hospice provider’s contract with the facility must be attached.

003.02(C) QUALITY ASSURANCE. The Department may refuse to execute or may cancel a contract or provider agreement with a hospice provider when the hospice provider:

(i) Does not meet the hospice requirements in this chapter; (ii) Consistently admits clients who do not meet the eligibility requirements for terminal illness or consistently exceed the six-month prognosis; (iii) Consistently refuses to provide, or is unable to provide, services identified in the assessment and on the hospice plan of care; (iv) Consistently bills the majority of claims at the continuous home care (CHC); or (v) Consistently discharges clients in conflict within this chapter.

003.02(D) HOSPICE AIDE AND HOMEMAKER COMPETENCY AND QUALIFICATIONS. All hospice aide and homemaker services must be provided by individuals who meet the personnel requirements specified in 42 Code of Federal Regulations (CFR) § 418.76. The hospice must maintain documentation that demonstrates the following requirements of this standard are being met:

(i) A hospice aide provides services that are:

(1) Ordered by the hospice interdisciplinary group (IDG); (2) Included in the plan of care; (3) Permitted to be performed under state law by such hospice aide; and (4) Consistent with the hospice aide training;

(ii) The duties of a hospice aide include the following:

(1) The provision of hands-on personal care; (2) The performance of simple procedures as an extension of therapy or nursing services; (3) Assistance in ambulation or exercises; and (4) Assistance in administering medications that are ordinarily self-administered;

(iii) Hospice aides must report changes in the client's medical, nursing, rehabilitative, and social needs to a registered nurse (RN), as the changes relate to the plan of care and quality assessment and improvement activities. Hospice aides must also complete appropriate records in compliance with the hospice's policies and procedures; (iv) Supervision of hospice aides must meet the following requirements:

(1) A registered nurse (RN) must act as the supervising nurse for hospice aides; (2) The supervising nurse must make an on-site visit to the client's home no less frequently than every 14 days to assess the quality of care and services provided by the hospice aide and to ensure that services ordered by the hospice interdisciplinary group (IDG) meet the client's needs; (3) The hospice aide does not have to be present during this visit:

(a) If an area of concern is noted by the supervising nurse, then the hospice must make an on-site visit to the location where the client is receiving care in order to observe and assess the aide while he or she is performing care; and (b) If an area of concern is verified by the hospice during the on-site visit, then the hospice must conduct, and the hospice aide must complete, a competency evaluation in accordance with hospice federal regulations;

(4) The supervising nurse must make an annual on-site visit to the location where a client is receiving care in order to observe and assess each aide while he or she is performing care; and (5) The supervising nurse must assess an aide's ability to demonstrate initial and continued satisfactory performance in meeting outcome criteria that include, but is not limited to:

(a) Following the client's plan of care for completion of tasks assigned to the hospice aide by the registered nurse (RN); (b) Creating successful interpersonal relationships with the client and family; (c) Demonstrating competency with assigned tasks; (d) Complying with infection control policies and procedures as outlined in 175 NAC 16; and (e) Reporting changes in the client's condition.

003.02(E) ATTENDING PHYSICIAN REQUIREMENTS. Services of an attending physician who is not an employee of the hospice are covered, billed, and reimbursed in accordance with 471 NAC 18. An attending physician who is not an employee of the hospice must be enrolled as a Medicaid provider in accordance with the provisions of 471 NAC 2 and 18.

004. SERVICE REQUIREMENTS .

004.01 GENERAL REQUIREMENTS.

004.01(A) CLIENT ELIGIBILITY. The Medicaid hospice benefit is available to clients who meet the following criteria:

(i) The client is currently eligible for Medicaid; (ii) The client is diagnosed as terminally ill by the hospice medical director or the physician member of the hospice interdisciplinary group (IDG), and the attending physician, if any; and (iii) The client is an adult and has elected to receive palliative or comfort care to manage symptoms of terminal illness, and has chosen not to receive curative treatment or disease management; or (iv) The client is a child and his or her parent or guardian has elected to receive palliative or comfort care to manage symptoms of terminal illness. Such election by a child’s parent or guardian must not constitute a waiver of any rights of the child to be provided with, or receive Medicaid payment for, concurrent services related to the treatment of the child’s condition for which a diagnosis of terminal illness has been made.

004.01(B) ELECTION OF HOSPICE SERVICES. A client, or the client’s representative, must file a voluntary, written expression to choose hospice care, called an election statement, designating the Medicaid hospice benefit as the care preference for terminal illness. The election statement must include:

(1) The effective date for the election period that begins with the first day of hospice care or any subsequent day of hospice care. This date may not be earlier than the date the election is made; (2) The name of the hospice provider; (3) The client’s or representative’s acknowledgement that he or she has been given a full understanding of hospice care; (4) The client’s or representative’s acknowledgement that he or she understands that the Medicaid services listed in this chapter are waived by the election; and (5) The client’s signature. If the client is physically or mentally incapacitated, his or her representative may file the election statement. If signed by the client’s representative, the reason the client cannot sign the election statement must be documented.

004.01(B)(i) HOSPICE RESPONSIBILITIES AT ELECTIONS. When a client elects to receive hospice services, the hospice program must:

(1) Explain the scope of benefits the client must receive as a part of the hospice program; (2) Explain the benefits the client is waiving; (3) Give the client or legal representative a copy of the signed statement; (4) Retain the signed statement in its files; and (5) Inform the client of his or her rights, and the hospice must protect and promote the exercise of these rights.

004.01(B)(ii) BENEFIT PERIODS. Medicaid provides two 90-day benefit periods during the client’s lifetime. If additional benefit periods are needed, Medicaid provides an unlimited number of 60-day benefit periods as elected by the client. The benefit periods may be used consecutively or at intervals. An election to receive hospice care will be considered to continue through the initial certification period and the subsequent election periods without a break in care as long as the client remains in the care of the hospice and does not revoke the election in accordance with this chapter.

004.01(B)(ii)(1) CERTIFICATION. The client must be certified as terminally ill by the hospice medical director, or the physician member of the hospice interdisciplinary group (IDG), and the attending physician, if any, at the beginning of the first benefit period, and by the hospice medical director for all subsequent benefit periods. The initial certification must be signed by both the medical director, or physician member of the hospice interdisciplinary group (IDG), and the attending physician. Subsequent certifications must include a new statement regarding life expectancy and be signed by the attending physician.

004.01(B)(ii)(1)(a) INITIAL CERTIFICATION AND SUBSEQUENT BENEFIT PERIODS. The initial written certification must be made within two calendar days of the start of hospice care; however, if verbal certification is provided within the first two calendar days, written certification may be provided within eight days after hospice care is initiated. Additionally, the initial certification may be completed no more than 15 calendar days prior to the effective date of the election. If these time periods are not met, coverage will not be provided for hospice care rendered before certification. For subsequent benefit periods, written certification must be made within two calendar days of the start of the subsequent period. Additionally, the certification for subsequent benefit periods may be completed no more than 15 calendar days prior to the start of each subsequent benefit period.

004.01(B)(ii)(1)(b) DECLINE IN CLINICAL STATUS. Clients will be considered to have a life expectancy of six months or less only when there is documented evidence of a decline in clinical status. A requirement of the certification process for hospice is the physician narrative explanation of the clinical findings that support a life expectancy of six months or less. This brief narrative is to be part of the certification and recertification forms or as an addendum to the certification and recertification forms. Baseline data is established on admission to hospice through nursing assessment in addition to utilization of existing information from records. It is essential that baseline and follow-up determinations are documented thoroughly to establish a decline in clinical status. Coverage of hospice care for clients not meeting the guidelines may be denied.

004.01(B)(ii)(2) CONCURRENT CARE FOR CHILDREN UNDER THE AGE OF 21. Terminally ill children who are enrolled in a Medicaid or state Children’s Health Insurance Plans (CHIP) hospice benefit, may receive curative and hospice services related to their terminal health condition.

004.01(B)(ii)(3) GUIDELINES FOR 180-DAY RECERTIFICATION OF HOSPICE SERVICES. A hospice physician must have a face-to-face encounter with each hospice client prior to, but no more than 30 days prior to, the beginning of the client’s third benefit period, and prior to each subsequent benefit period. Failure to meet the face-to-face encounter requirements specified in this section results in a failure by the hospice to meet the client’s recertification of terminal illness eligibility requirement. The client would cease to be eligible for the benefit until the face-to-face visit is completed.

004.01(B)(iii) WAIVER OF MEDICAID BENEFITS FOR ADULT CLIENTS. Upon signing the hospice election statement, an adult client must be deemed to have waived all rights to the following:

(1) Medicaid payment for treatment associated with the terminal illness; (2) Hospice care provided by a hospice provider that was not designated by the client; and (3) All services that are equivalent to, or duplicative of, hospice care.

004.01(B)(iii)(1) WAIVER DURATION. This waiver remains in effect for the duration of the election of hospice care. Medicaid services provided for conditions or illnesses that are unrelated to the terminal illness may be covered by Medicaid separate from the hospice benefit. These services must be based on individual assessed need and medical necessity as specified in the appropriate chapters of Title 471 NAC. If the client or representative revokes election of the Medicaid hospice benefit, Medicaid coverage of the benefits deemed to have been waived is restored.

004.01(B)(iv) REVOCATION OF ELECTION OF HOSPICE BENEFIT. A client or representative may revoke election of hospice care at any time. To revoke the election of hospice care, the client must file a document with the hospice that includes a signed statement that he or she revokes the election for Medicaid coverage of hospice care, and the date the revocation is to be effective. The client may not designate an effective date prior to the date the revocation document is signed. The individual forfeits coverage for any remaining days in that election period. The client may initiate re-election of the Medicaid hospice benefit if eligibility criteria are met.

004.01(B)(iv)(1) REVOCATION OF ELECTION. When the hospice election is ended due to revocation, the hospice must file a notice of revocation of election with Medicaid within five calendar days after the effective date of the revocation, unless it has already filed a final claim for that beneficiary.

004.01(B)(v) CHANGE OF HOSPICE. The client or representative may choose to change from one hospice provider to another hospice provider. A change of hospice provider may occur only once in each benefit period. To change the designation of hospice providers, the individual must file, with the hospice from which he or she has received care and with the newly designated hospice, a signed statement that includes the following information:

(1) Name of the hospice from which the individual has received care; (2) Name of the hospice from which the individual plans to receive care; and (3) Date the change is effective.

004.01(B)(vi) DUALLY ELIGIBLE. A client who is Medicare and Medicaid eligible must elect and revoke hospice care simultaneously under both the Medicare and the Medicaid program.

004.01(B)(vii) ADMISSION TO HOSPICE CARE. The hospice admits a client only on the recommendation of the medical director in consultation with, or with input from, the client's attending physician, if any.

004.01(B)(viii) ADVANCE DIRECTIVES. Medicaid-participating hospice agencies must comply with applicable state and federal requirements.

004.01(C) INITIAL ASSESSMENT. An initial assessment must be completed within 48 hours after Medicaid eligibility is established and the election statement is signed, unless the physician, client, or representative requests that the initial assessment be completed in less than 48 hours. The nurse completes the assessment to collect comprehensive information concerning the client’s preferences, goals, health status, and to determine strengths, priorities, and resources. The assessment must be completed by a designated registered nurse (RN) from the hospice provider and coordinated with the client’s Medicaid representative. Ongoing assessments must be completed and updated with each client visit.

004.01(D) PRIOR AUTHORIZATION. All hospice services must be prior authorized. The hospice must submit prior authorization requests to the Department within three business days of the initial assessment. Prior authorization may be retroactive for up to seven days, based on the client’s entry date into the hospice program. Claims may be denied when prior authorization is not completed. Re-authorization is required for each subsequent benefit period. To request prior authorization, the hospice must submit:

(i) Agency name and provider number; (ii) The client’s Medicaid number. When the client’s Medicaid eligibility is pending at the time of admission to hospice and the client later becomes eligible, the hospice agency must submit the request for prior authorization once the client is determined Medicaid eligible; (iii) Signed election statement; (iv) Physician certification of terminal illness; (v) Hospice plan of care; and (vi) List of all medications, biologicals, supplies, and equipment for which the hospice is responsible.

004.01(E) INDIVIDUALIZED HOSPICE PLAN OF CARE. An individualized hospice plan of care must be written to identify specific individual services to be provided in a coordinated and organized manner. The hospice must have up to three business days from the initial assessment to develop the plan of care, with involvement from the client, caregiver, attending physician, medical director, and hospice interdisciplinary group (IDG). The hospice plan of care must be established prior to services being provided.

004.01(E)(i) ADDITIONAL PLAN OF CARE REQUIREMENTS. The hospice plan of care must be culturally appropriate, and identify in detail the services that will address the needs identified in the assessment. The hospice plan of care must state in detail the scope and frequency of services that will meet the client’s and family’s needs. The care provided must be in accordance with the written plan of care. In the event of disagreement between the client and in-home caregiver, the client must make the final decision about care, service needs, preferences, and choices. The hospice interdisciplinary group (IDG), in collaboration with the client’s attending physician, if any, must review, revise, and document the individualized plan as frequently as the client's condition requires, but no less frequently than every 15 calendar days. A revised plan of care must include information from the client's updated comprehensive assessment and must note the client's progress toward outcomes and goals specified in the plan of care.

004.01(F) COORDINATION OF CARE. The hospice provider must designate a registered nurse (RN) to coordinate the implementation of the hospice plan of care with the client’s Medicaid representative. Coordination of care must include connections to needed services and resources and must ensure that client choices and concerns are represented. Coordination requires sharing of information to prevent gaps in service, duplication of services, and duplication of payment. A request for additional Medicaid services, or a determination of denial of hospice services, for a Medicaid client by the hospice provider must be coordinated with the client’s Medicaid representative. The hospice provider must notify the client’s Medicaid representative when a Medicaid client elects hospice services.

004.01(G) DISCHARGE FROM HOSPICE. Coverage of the Medicaid hospice benefit depends on a physician’s certification that a client is terminally ill. The client must be discharged from the Medicaid hospice benefit when the client improves or stabilizes enough that he or she no longer meets the definition of a terminal illness. The client may be re-enrolled for a new benefit period when a decline in the clinical status leads to a new certification that the client is terminally ill.

004.01(G)(i) DISCHARGE BY THE HOSPICE. A hospice provider may discharge a client if:

(a) The client moves out of the hospice's service area or transfers to another hospice; (b) The hospice determines that the client is no longer terminally ill; or (c) The hospice determines, under a policy set by the hospice for the purpose of addressing discharge for cause, that the client's, or other persons in the client's home, behavior is disruptive, abusive, or uncooperative to the extent that delivery of care to the client, or the ability of the hospice to operate effectively, is seriously impaired. The hospice must do the following before it seeks to discharge a client for cause:

(1) Advise the client that a discharge for cause is being considered; (2) Make a serious effort to resolve the problems presented by the client's behavior or situation; (3) Ascertain that the client's proposed discharge is not due to the client's use of necessary hospice services; and (4) Document the problems and efforts made to resolve the problems and enter this documentation into its medical records.

004.01(G)(i)(1) DISCHARGE ORDER. Prior to discharging a client for any reason listed in this section, the hospice must obtain a written physician's discharge order from the hospice medical director. If a client has an attending physician involved in his or her care, this physician should be consulted before discharge and his or her review and decision included in the discharge note.

004.01(G)(ii) EFFECT OF DISCHARGE. A client, upon discharge from the hospice during a particular election period for reasons other than immediate transfer to another hospice:

(1) Is no longer covered under Medicaid for hospice care; (2) Resumes Medicaid coverage of benefits waived; and (3) May at any time elect to receive hospice care if he or she is again eligible for the hospice benefit.

004.01(H) SERVICES PROVIDED FOR CLIENTS ENROLLED IN NEBRASKA MEDICAID MANAGED CARE. See 471 NAC 1.

004.01(I) HEALTH CHECK SERVICES. See 471 NAC 33.

004.02 COVERED SERVICES. These services are offered based on individually assessed needs and choices of terminally ill clients and their families for palliative care and support. The client has the right to be informed of his or her rights, and the hospice must protect and promote the exercise of these rights. A hospice must be primarily engaged in providing the following care and services and must do so in a manner that is consistent with accepted standards of practice:

(1) Nursing services; (2) Physician services; (3) Medical social services; (4) Counseling services, including spiritual counseling, dietary counseling, and bereavement counseling; (5) Hospice aide, volunteer, and homemaker services; (6) Medical supplies, including drugs and biologicals, and medical appliances; (7) Physical therapy, occupational therapy, and speech language pathology services; and (8) Short-term inpatient care.

004.02(A) NURSING SERVICES. The hospice provider must assure that nursing services require the skills of a registered nurse (RN), or licensed practical nurse (LPN) under the supervision of a registered nurse (RN) and must be reasonable and necessary for the palliation and management of the client’s terminal illness and related conditions. Services must be provided in accordance with recognized standards of practice. A nurse practitioner may serve as an attending physician. If the nurse practitioner serves as the attending physician, the nurse practitioner must comply with the requirements outlined in this chapter. The nurse practitioner may not serve as or replace the medical director or physician designee. Nursing services include, but are not limited to:

(i) Required visits by a registered nurse (RN) or licensed practical nurse (LPN) to monitor condition, provide care, and maintain comfort based on assessment of individual needs and as identified in the hospice plan of care; (ii) At a minimum, the required visits by a registered nurse (RN) or licensed practical nurse (LPN) occur weekly, or more frequently as needed. The registered nurse (RN) must visit at least every two weeks; (iii) Education based on the needs of the client, caregiver, and family about the changes to be expected with the dying process; the appropriate use of medications, therapies, equipment, and supplies; what hospice does and does not do; and emphasis on the importance of realistic goals; (iv) An initial assessment; (v) An individualized hospice plan of care; and (vi) Coordination of care.

004.02(B) HOSPICE AIDE and HOMEMAKER. The hospice provider must assure that hospice aide and homemaker services are provided to promote client care and comfort and are completed at the direction of the client and caregiver based on client’s individualized hospice plan of care. Services must be available and adequate to meet the needs of the client. Hospice aide and homemaker services include:

(i) Personal care services, as indicated in the client’s individualized hospice plan of care and at the direction of the client and caregiver; and (ii) Hospice aides may perform household services to maintain a safe and sanitary environment in areas of the home used by the client. Hospice aide services must be provided under the general supervision of a registered nurse (RN). Homemaker services may include assistance in maintenance of a safe and healthy environment and services to enable the client’s family to carry out the plan of care.

004.02(C) MEDICAL SOCIAL SERVICES. The hospice provider must assure that medical social services are provided by a certified social worker for the client, caregiver, and family under the direction of the physician. Medical social services include:

(i) Crisis intervention for the client, caregiver, and family; (ii) Psychosocial assessment to address needs identified by the client and caregiver and to develop plans for intervention; (iii) Counseling to assist the client, caregiver, and family including children, to cope with serious illness and death; (iv) Client advocacy to assure the client and caregiver have choices in care, and understands their right to refuse treatment; (v) Act as a liaison between client and needed community resources; (vi) Fostering human dignity and personal worth; and (v) Coordination of services with the Medicaid representative, when applicable.

004.02(D) MEDICAL EQUIPMENT AND SUPPLIES INCLUDING DRUGS AND BIOLOGICALS. The hospice is responsible for providing any and all services indicated in the plan of care as reasonable and necessary for the palliation and management of the terminal illness and related conditions. The hospice provider must assure that medical equipment and supplies, including drugs, are provided for relief of pain and symptom control related to the client’s terminal illness and related conditions. This includes both prescription and over-the-counter drugs. All equipment, supplies, medications, and biologicals must be provided as prescribed by the client’s physician, as needed, and at the direction of the client and caregiver, as indicated in the client’s individualized hospice plan of care. These services include:

(i) Medication for the relief of pain and related symptoms; (ii) Durable medical equipment related to palliation; and (iii) Personal comfort items related to the palliation and management of the client’s terminal illness.

004.02(E) OTHER COUNSELING SERVICES. The hospice provider must assure that other counseling services are available for the client, caregiver, and family. Services include:

(i) Dietary counseling; (ii) Spiritual counseling. The hospice must:

(1) Advise the client and family of the service; (2) Provide an assessment of the client's and family's spiritual needs; (3) Provide spiritual counseling to meet these needs in accordance with the client's and family's acceptance of this service, and in a manner consistent with client and family beliefs and desires; and (4) Make all reasonable efforts to facilitate visits by local clergy, pastoral counselors, or other individuals who can support the client's spiritual needs to the best of its ability; and

(iii) Bereavement counseling provided through an organized program of bereavement services under the supervision of a qualified professional. The hospice provider must make bereavement services available to the family and other individuals in the bereavement plan of care up to one year following the death of the patient and ensure bereavement services reflect the needs of the bereaved. It is the choice of the family to accept bereavement services.

004.02(F) VOLUNTEER SERVICES. The hospice provider must sponsor a volunteer program and must assure that volunteers participate in an initial volunteer education program. Opportunities for ongoing education must be available for volunteers.

004.02(G) PHYSICIAN SERVICES. Physician services must be performed in accordance with 471 NAC 18. The services of the hospice medical director or the physician member of the hospice interdisciplinary group (IDG) must be performed by a doctor of medicine or osteopathy. Nurse practitioners may not serve as a medical director or as the physician member of the hospice interdisciplinary group (IDG). The hospice face-to-face encounter is an administrative requirement related to certifying the terminal illness.

004.02(H) PHYSICAL THERAPY, OCCUPATIONAL THERAPY, AND SPEECH LANGUAGE PATHOLOGY SERVICES. The hospice provider must assure that physical therapy, occupation therapy, and speech language pathology services are provided to control symptoms, or to enable the client to maintain activities of daily living and basic functional skills. These services must be provided under the direction of the attending physician or medical director and must be included in the hospice plan of care. The client and caregiver make the final decision regarding acceptance or refusal of a therapy program.

004.02(I) SHORT-TERM INPATIENT RESPITE CARE. May be provided only on an intermittent, nonroutine, and occasional basis and may not be provided consecutively over longer than five days.

004.02(J) MEDICAL INTERVENTIONS. The hospice provider must assure that medical interventions are provided when the interventions related to the terminal illness, either in use or planned, have been evaluated by the attending physician, hospice medical director, hospice team, client, caregiver, and family, based on the quality of life, value of the treatment to the client, and the service’s congruence with the palliative care goals of the client, caregiver, family, and hospice. Planned interventions must be included in the hospice plan of care. A hospice may use chemotherapy, radiation therapy, and other modalities for palliative purposes if it determines that these services are needed. This determination is based on the client’s condition and the individual hospice’s caregiving philosophy. No additional Medicaid payment may be made regardless of the cost of the services.

004.02(K) HOSPICE SERVICES IN CERTAIN FACILITIES. A client who meets the eligibility requirements in this chapter and resides in an intermediate care facility for individuals with developmental disabilities (ICF/DD), a nursing facility (NF), an institution for mental disease (IMD), an assisted living facility (ALF), or a center for the developmental disabilities (CDD) may elect to receive hospice services where he or she lives. The Medicaid hospice benefit is available to Medicaid eligible persons in an institution for mental diseases (IMD) who are age 20 or younger, or 65 or older. The facility must agree to the provision of hospice services, and the hospice provider must have a signed contract with the facility before provision of hospice services.

004.02(K)(i) FACILITY REPONSIBILITIES. The facility must:

(1) Provide room and board for the client; (2) Perform personal care; (3) Assist with activities of daily living; (4) Administer medications; (5) Provide social activities; (6) Provide housekeeping; (7) Supervise and assist with the use of durable medical equipment and prescribed therapies; and (8) Develop a plan of care in collaboration with the hospice provider, client, caregiver, and providers, including the case manager, service coordinator, and eligibility workers, and adhere to responsibilities outlined in the plan.

004.02(K)(ii) HOSPICE RESPONSIBILITIES. The hospice provider may not require the client to move from the facility as long as the client’s needs can be appropriately and safely met. The hospice provider must:

(1) Assess the client’s needs in coordination with the designated facility representative, client, and caregiver; (2) Develop a hospice plan of care in collaboration with client, caregiver, facility caregivers, and providers, including the case manager, service coordinator, and eligibility workers, and adhere to responsibilities outlined in the hospice plan of care; (3) Assume the professional management responsibility for ensuring the implementation of the hospice plan of care at the direction of the client and caregiver; (4) In collaboration with the facility representative, coordinate the responsibilities of the facility and the responsibilities of the hospice provider, and document these responsibilities in all client records; (5) Involve family and facility personnel in assisting with provision of services as designated by the hospice plan of care, and at the direction of the client and caregiver. The same level of services that would be provided in the home must be provided in the facility; and (6) Provide social services and counseling utilizing hospice personnel. This service may not be delegated to the facility’s personnel.

004.02(L) HOME AND COMMUNITY-BASED WAIVER SERVICES (HCBS). Clients who elect the hospice benefit while receiving home and community-based waiver services (HCBS) may continue to receive home and community-based waiver services (HCBS) that are based on assessed need and medical necessity. All medical services related to the terminal illness, or the hospice plan of care are the responsibility of the hospice, and all services must be coordinated with the waiver services coordinator. The waiver services coordinator retains full responsibility for waiver planning and service authorization.

005. BILLING AND PAYMENT FOR HOSPICE SERVICES .

005.01 BILLING.

005.01(A) GENERAL BILLING REQUIREMENTS. Providers must comply with all applicable billing requirements in 471 NAC 3. In the event that billing requirements in 471 NAC 3 conflict with billing requirements outlined in this chapter, the billing requirements in this chapter will govern.

005.01(B) SPECIFIC BILLING REQUIREMENTS. The hospice provider must bill for services provided using Form CMS-1450 or the standard electronic health care claim. Healthcare Common Procedure Coding System (HCPCS) and Current Procedural Terminology (CPT) procedure codes used by Medicaid are listed in the Nebraska Medicaid Fee Schedule.

005.02 PAYMENT.

005.02(A) GENERAL PAYMENT REQUIREMENTS. Medicaid will reimburse the provider for services rendered in accordance with the applicable payment regulations codified in 471 NAC 3. In the event that payment regulations in 471 NAC 3 conflict with payment regulations outlined in this chapter, the payment regulations in this chapter will govern.

005.02(B) SPECIFIC PAYMENT REQUIREMENTS. Medicaid pays for services provided under the Medicaid hospice benefit using the Medicaid hospice payment rates established by Centers for Medicare and Medicaid services (CMS).

005.02(B)(i) ROUTINE HOME CARE (RHC). Medicaid pays the routine home care (RHC) rate to the hospice provider for every day the client is at home, under the care of hospice, and not receiving continuous home care (CHC). This rate is paid without regard to the volume or intensity of routine home care (RHC) services provided on any given day. Medicaid pays two separate rates for routine home care (RHC) depending on the length of stay. For the first 60 days of care, routine home care (RHC) will be paid at an increased rate, with a reduced routine home care (RHC) rate applicable to services provided on day 61 and greater.

005.02(B)(i)(1) SERVICE INTENSITY ADD-ON (SIA). In addition to the per diem rate for routine home care (RHC) level of care, Medicaid will include a service intensity add-on (SIA) payment for direct client care services provided by a registered nurse (RN) or social worker during the last seven days of a client’s life. The service intensity add-on (SIA) payment will equal the continuous home care (CHC) hourly rate multiplied by the hours of nursing or social work service, for at least 15 minutes and up to four hours total, that occurred on a routine home care (RHC) day during the last seven days of life.

005.02(B)(ii) CONTINUOUS HOME CARE (CHC). A continuous home care (CHC) day is a day on which an individual who has elected to receive hospice care is not in an inpatient facility, hospital, short term nursing facility, or hospice inpatient unit and receives hospice care consisting predominantly of nursing care on a continuous basis at home. Continuous home care (CHC) is only furnished during brief periods of crisis and only as necessary to maintain the terminally ill client at home. Medicaid pays the continuous home care (CHC) rate to the hospice provider to maintain a client at his or her place of residence when a period of medical crisis occurs. A period of medical crisis is a time when a client requires continuous care which is primarily nursing care to achieve palliation or management of acute medical symptoms. A registered nurse (RN) or licensed practical nurse (LPN) must provide nursing care. A nurse must be providing more than one half of care given in a 24-hour period. A minimum of eight hours of care must be provided in a 24-hour period, which begins and ends at midnight. When the number of hours is less than 24, Medicaid pays the hourly rate. The hours may be split over the 24 hours to meet the needs of the client. Routine home care (RHC) must be billed when fewer than eight hours of nursing care are provided.

005.02(B)(iii) INPATIENT HOSPITAL OR NURSING FACILITY (NF) RESPITE CARE. Inpatient respite care may be necessary to relieve the caregiver who normally cares for the client at home.

005.02(B)(iii)(1) INPATIENT RESPITE CARE FOR ADULT CLIENTS. Medicaid pays the inpatient respite care rate to the hospice provider for each day the client is in an inpatient facility and receiving respite care. Payment may be made for a maximum of five days per month counting the day of admission but not the day of discharge. The discharge day for inpatient respite care is billed as routine home care (RHC) unless the client is discharged as deceased. When the client dies under inpatient respite care, the day of death is paid at the inpatient respite care rate.

005.02(B)(iii)(2) INPATIENT RESPITE CARE FOR CHILD CLIENTS. Medicaid payment for hospital and nursing facility (NF) services must be made directly to the hospital or nursing facility (NF) for inpatient respite care.

005.02(B)(iv) GENERAL INPATIENT CARE. General inpatient care may be necessary for pain control or acute or chronic symptom management that cannot be provided in any other setting. Care must be provided in a hospital or a contracted hospice inpatient facility that meets the hospice standards regarding staffing and client care. The hospice must have a written contract and retain professional management of hospice services and care.

005.02(B)(iv)(1) GENERAL INPATIENT CARE FOR ADULT CLIENTS. Medicaid pays the general inpatient care rate to the hospice provider during a period of acute medical crisis.

005.02(B)(iv)(2) GENERAL INPATIENT CARE FOR CHILD CLIENTS. Medicaid payment for hospital and nursing facility (NF) services must be made directly to the hospital or nursing facility (NF) for general inpatient care.

005.02(B)(iv)(3) GENERAL INPATIENT CARE HOSPICE FACILITY REQUIREMENTS. A hospice that provides general inpatient care directly in its own facility must demonstrate compliance with the following standards:

(a) The hospice is responsible for ensuring that staffing for all services reflects its volume of clients, their acuity, and the level of intensity of services needed to ensure that plan of care outcomes are achieved and negative outcomes are avoided; and (b) The hospice facility must provide 24-hour nursing services that meet the nursing needs of all clients and are furnished in accordance with each client's plan of care. Each client must receive all nursing services as prescribed and must be kept comfortable, clean, well-groomed, and protected from accident, injury, and infection.

005.02(B)(iv)(4) GENERAL INPATIENT CARE RATE RESTRICTIONS. When a severe breakdown in caregiving occurs, the general inpatient care rate must be paid until other arrangements can be made, up to a maximum of 10 days per month. The discharge day for general inpatient care is billed as routine home care (RHC) unless the client is discharged as deceased. When the client dies under general inpatient care, the day of death is paid at the general inpatient care rate.

005.02(B)(v) HOSPITAL SERVICES UNRELATED TO TERMINAL DIAGNOSIS. In accordance with 471 NAC 10, Medicaid pays all costs for hospital services provided when a client receiving the Medicaid hospice benefit is hospitalized for an acute medical condition that is not related to the terminal illness or complications secondary to the terminal illness. Determination of the cause of hospitalization must be made by the hospice interdisciplinary group (IDG) with consultation from the Department. Payment for hospital services must be made directly to the hospital.

005.02(B)(vi) SERVICES RECEIVED IN FACILITIES.

005.02(B)(vi)(1) ADULT CLIENTS. Medicaid pays the hospice provider for both the hospice services provided, and for the residential services provided by the facility.

005.02B(vi)(1)(a) PAYMENT FOR THE MEDICAID HOSPICE BENEFIT WHEN PROVIDED IN AN INTERMEDIATE CARE FACILITY FOR INDIVIDUALS WITH DEVELOPMENTAL DISABILITIES (ICF/DD), A NURSING FACILITY (NF), OR AN INSTITUTION FOR MENTAL DISEASES (IMD). Payment for the Medicaid hospice benefit can be found in the applicable chapters in Title 471 NAC.

005.02(B)(vi)(1(b) PAYMENT AND MEDICAID MANAGED CARE. When a client permanently residing in a nursing facility (NF) is enrolled in managed care and elects the hospice benefit all services not covered under the Medicaid hospice benefit are covered as part of the benefits of the managed care plan. The Medicaid hospice benefit, services covered under the hospice benefit, and nursing facility (NF) room and board payments will be paid outside of the managed care plan.

005.02(B)(vi)(2) CHILD CLIENTS. Medicaid payment for hospital and nursing facility (NF) services must be made directly to the hospital or nursing facility (NF).

005.02(B)(vii) MEDICARE COVERAGE. A client who has Medicare coverage must use Medicare coverage as primary payer until Medicare benefits are exhausted. Medicaid pays the Medicare co-insurance and deductible when the client is covered by both Medicare and Medicaid as indicated in 471 NAC 3.

History

• Effective 2024-06-02

Chapter 37 Program of All-Inclusive Care for the Elderly

Neb. Admin. Code tit. 471, ch. 37 Program of All-Inclusive Care for the Elderly {#sec-471-nac-37 omnilex-key=us-ne-regs-official--title-471--471 NAC 37}

37-001 INTRODUCTION : This chapter regulates Nebraska’s Program of All-Inclusive Care for the Elderly (PACE) provided under Nebraska Medicaid.

37-001.01 Definitions:

Appeal: The process by which a participant may seek and obtain a review and reversal with respect to enrollment denial; involuntary disenrollment; or non-coverage of, or nonpayment for, a service including denials, reductions, or termination of services.

External appeal: The State Administering Agency’s or Medicare’s formal appeal processes.

Grievance: A complaint, either written or oral, by participants, their family members, and/or representatives expressing dissatisfaction with service delivery or the quality of care furnished.

Internal appeal: A PACE organization’s appeal process.

PACE organization: An entity that has a PACE program agreement in effect to operate a PACE program.

PACE program: A program of all-inclusive care for the elderly that is operated by an approved PACE organization and that provides comprehensive healthcare services to PACE participants in accordance with a PACE program agreement.

PACE program agreement: An agreement between a PACE organization, CMS, and the State Administering Agency for the operation of a PACE program.

Participant: An individual who is enrolled in a PACE program.

Premium: The monthly amount that a PACE organization charges a participant as determined by the participant’s eligibility status for Medicare and Medicaid pursuant to 42 CFR 460.186.

State Administering Agency (SAA): The State agency responsible for administering the PACE program agreement. In Nebraska the SAA is the Nebraska Department of Health and Human Services, Division of Medicaid and Long-Term Care.

37-001.02 Legal Basis: PACE is authorized by Sections 1894 and 1934 of the federal Social Security Act. Federal PACE regulations are located at 42 CFR, Part 460.

37-002 PARTICIPANT ELIGIBILITY

37-002.01 Eligibility Criteria: Participation in PACE is voluntary. PACE eligibility criteria include the following:

1. Be 55 years of age or older;

2. Meet the nursing facility level of care (NF LOC) criteria (See 471 NAC 12);

3. Live in the service area of the PACE organization; and

4. Be able to safely live in a community setting, at the time of enrollment, with PACE services.

37-002.02 Eligibility Determinations: The PACE organization shall be responsible for determining eligibility based on the criteria set forth in section 37-002.01 of this chapter.

37-002.03 Denial of Eligibility: A potential participant shall be denied enrollment if he/she does not meet the eligibility criteria as set forth in section 37-002.01 of this chapter.

37-002.03A Nursing Facility Level of Care Not Met: If a potential participant does not meet NF LOC, the SAA will notify the PACE organization, and the potential participant shall receive a notice of adverse action. Upon receipt of adverse action, potential participants may appeal using the SAA’s appeal process (See 465 NAC 2-001.02).

37-002.03B Unsafe: If a potential participant is determined to be unable to safely live in a community setting, the PACE organization shall:

1. Notify the potential participant in writing of the reason for the denial;

2. Refer the potential participant to alternative services, as appropriate;

3. Maintain supporting documentation of the reason for the denial; and

4. Notify CMS and the SAA and make the documentation available for review.

37-002.03B1 Appeal Process: Upon receipt of the PACE organization’s written denial based on the inability to safely live in the community, potential participants have the right to appeal using the SAA’s appeal process (465 NAC 2-001).

37-002.03C Appeal Process for Medicare-only Beneficiaries: Medicare does not have an appeal process that permits challenges of enrollment denials for Medicare-only beneficiaries within PACE. Medicare-only eligible participants, as well as private pay participants, must use the appeals process provided by the SAA (71 Fed. Reg. 71244, 71303, 71312, 71317 (Dec. 8, 2006)).

37-002.04 Annual Nursing Facility Level of Care Recertification: A PACE participant’s NF LOC shall be documented by the PACE organization and recertified by the SAA within 12 months of each previous recertification.

37-002.05 Waiver of Annual Nursing Facility Level of Care Recertification: The annual recertification requirement may be permanently waived by the SAA at the PACE organization’s request. The PACE organization shall provide to the SAA the participant’s diagnosis, medical record and plan of care for review for waiver and will be notified of the SAA’s determination.

37-002.06 Deemed Continued Eligibility: If a participant no longer meets NF LOC at the time of annual recertification, he/she may be allowed to continue eligibility until the next annual recertification upon the request of the PACE organization. The PACE organization shall provide information to the SAA to be reviewed under the following criteria:

1. The participant can reasonably be expected to meet NF LOC eligibility again within six months in the absence of continued coverage under the program; and

2. The participant’s medical record and plan of care support continued eligibility.

37-003 PARTICIPANT ENROLLMENT

37-003.01 Participant Enrollment: A PACE organization shall receive direct inquiries from potential participants. The PACE organization shall verify that the potential participant meets all eligibility criteria as set forth in section 37-002 of this chapter.

37-003.02 Duration of Enrollment: Enrollment continues until the PACE participant’s death, regardless of changes in health status, unless the participant voluntarily disenrolls or is involuntarily disenrolled by the PACE organization under section 37-006.01 or 37-006.02 of this chapter.

37-004 PACE BENEFITS

37-004.01 Benefits: The PACE benefit package for all participants, regardless of source of payment, shall include the following:

1. All Medicare-covered items and services;

2. All Medicaid-covered items and services as specified in Nebraska’s approved Medicaid State Plan; and

3. Other services determined necessary by the PACE organization’s interdisciplinary team to improve and maintain the participant’s overall health status.

37-004.02 Benefit Conditions: If a Medicare beneficiary or Medicaid recipient chooses to enroll in the PACE program, the following conditions apply:

1. Medicare and Medicaid benefit limitations and conditions relating to amount, duration, scope of services, deductibles, copayments, coinsurance, or other cost-sharing do not apply (Note: Participants who have been determined to have a Medicaid share of cost remain responsible to meet their share of cost as per 469 NAC 4); and

2. The participant, while enrolled in the PACE program, shall receive all Medicare and Medicaid benefits, as well as other services determined necessary by the PACE organization interdisciplinary team, solely through the PACE organization.

37-004.03 Excluded Benefits: The following services are excluded from coverage under PACE:

1. Any service that is not authorized by the interdisciplinary team.

2. In an inpatient facility, a private room and private duty nursing services, unless medically necessary, as well as non-medical items for personal convenience unless specifically authorized by the interdisciplinary team as part of the participant’s plan of care.

3. Cosmetic surgery, not including surgery that is required for improved functioning of a malformed part of the body resulting from an accidental injury or for reconstruction following mastectomy.

4. Experimental medical, surgical, or other health procedures.

5. Services furnished outside of the United States, including the Commonwealth of Puerto Rico, the Virgin Islands, Guam, American Samoa, and the Northern Mariana Islands, except under particular circumstances and as permitted under the Medicaid State Plan.

37-005 PARTICIPANT RIGHTS

37-005.01 Written Explanation: Upon enrollment, a PACE participant shall be informed, in writing, of his/her rights and responsibilities and all rules and regulations governing participation according to 42 CFR 460.110 and 460.112.

37-005.02 Grievance Process: Upon enrollment and at least annually thereafter, the PACE organization supply participants written information about its grievance process. In the event of a grievance, the PACE organization shall:

1. Discuss with and provide to the participant in writing the specific steps, including timeframes for response, that will be taken to resolve the participant’s grievance;

2. Continue to furnish all required services to the participant during the grievance process.

37-005.03 Appeal Processes for Non-Coverage or Non-Payment of a Service: The PACE organization shall give enrolled participants written information on available appeal processes upon enrollment, at least annually thereafter, and whenever a participant takes action with respect to the PACE organization’s non-coverage or non-payment of a service including denials, reductions, or terminations of services. (See section 37-002.04 of this chapter for appeals of denial of enrollment and section 37-006.04 of this chapter for appeals of involuntary disenrollments.)

37-005.03A Available Appeal Processes:

1. The PACE organization’s internal appeal process.

2. The SAA’s appeal process (external appeal process).

3. Medicare’s appeal process through the Independent Review Entity (IRE) that contracts with CMS (external appeal process).

37-005.03B PACE Organization Internal Appeal Process: Participants shall first access the PACE organization’s internal appeal process prior to using the SAA’s or Medicare’s appeal process for all decisions pertaining to non-coverage of, or non-payment for, a service including denials, reductions, or terminations of services.

37-005.03C PACE Organization Third Party Review: The PACE organization must appoint an appropriately credentialed and impartial third party who was not involved in the original action and who does not have a stake in the outcome of the appeal to review the participant’s appeal.

37-005.03C1 Notice of Internal Appeal Outcome: The PACE organization shall notify a participant of the outcome of his/her appeal in writing no later than 30 calendar days after the organization receives the verbal or written appeal, unless the appeal has been expedited as described in section 37-005.03C2 of this chapter.

37-005.03C2 Expedited Appeal Process: A PACE organization shall have an expedited appeal process for situations in which the participant believes that his or her life, health, or ability to regain or maintain maximum function could be seriously jeopardized, absent provision of the services in dispute.

37-005.03C2a Expedited Appeal Notice: The PACE organization must respond in writing to an expedited appeal no later than 72 hours after it receives the appeal.

37-005.03C2b Expedited Appeal Extension: The PACE organization may extend the 72-hour timeframe by up to 14 calendar days for either of the following reasons:

1. The participant requests the extension; or

2. The PACE organization justifies to the SAA the need for additional information and how the delay is in the interest of the participant.

37-005.03C3 Favorable Determination: If a determination is made in favor of the participant on appeal, the PACE organization must furnish the disputed service as expeditiously as the participant’s health condition requires.

37-005.03C4 Adverse Determination: For a determination that is wholly or partially adverse to a participant, the PACE organization must notify the participant, the SAA, and CMS.

37-005.03D External Appeals: If dissatisfied with the outcome of their internal appeal to the PACE organization, participants may appeal as follows:

37-005.03D1 Participants Eligible for Both Medicaid and Medicare: Participants who are eligible for both Medicare and Medicaid have the choice of using either the SAA’s or Medicare’s appeal process; however, they may only choose one route by which to exercise their external appeal rights. The PACE organization shall assist the participant in choosing which process to pursue if both are applicable, and the PACE organization must forward the appeal to the appropriate external agency.

37-005.03D2 Participant Eligible Only for Medicare: Participants who are only eligible for Medicare shall appeal through the Independent Review Entity (IRE).

37-005.03D3 Participants Eligible Only for Medicaid: Participants who are only eligible for Medicaid shall appeal using the SAA’s appeal process.

37-005.03D4 Private Pay Participants: Participants who are private pay shall appeal using the SAA’s appeal process.

37-005.03E Services Provided During the Appeals Process: During the appeals process, the PACE organization shall continue to provide non-disputed services to a participant.

37-005.03E1 Medicaid Recipient: For a participant who is a Medicaid recipient, the PACE organization shall continue to provide the disputed service until the final determination is issued if the following conditions are met:

1. The PACE organization is proposing to terminate or reduce a service currently being furnished to the participant; and

2. The participant requests continuation of the provision of services with the understanding that he or she may be liable for the cost of the contested services if the determination is not made in his/her favor.

37-006 PARTICIPANT DISENROLLMENT Reasons for disenrollment, either voluntary or involuntary, shall be documented by the PACE organization.

37-006.01 Voluntary Disenrollment: A participant may voluntarily disenroll from the program without cause at any time, including if he/she no longer meets NF LOC criteria.

37-006.02 Involuntary Disenrollment: A PACE organization may involuntarily disenroll a participant for any of the following reasons:

1. The participant fails to pay, or make satisfactory arrangements to pay, any premium due the PACE organization after a 30-day grace period.

2. The participant engages in disruptive or threatening behavior. Disruptive or threatening behavior is either of the following:

a. Behavior that jeopardizes a participant’s health or safety or the safety of others; or

b. Consistent refusal to comply with an individual plan of care or the terms of the PACE enrollment agreement while having decision-making capacity.

3. The participant moves out of the PACE program service area or is out of the service area for more than 30 consecutive days, unless the PACE organization agrees to a longer absence due to extenuating circumstances.

4. The participant is determined to no longer meet nursing facility level of care and is not deemed eligible under section 37-002.06 of this chapter.

5. The PACE organization’s agreement with CMS and the SAA is not renewed or is terminated.

6. The PACE organization is unable to offer required services because of the loss of State licenses or outside provider contracts.

37-006.02A SAA Review and Final Determination: Before an involuntary disenrollment is effective, it shall be reviewed by the SAA and a determination made that acceptable grounds for disenrollment have been documented by the PACE organization.

37-006.02B Reinstatement in PACE: A previously disenrolled PACE participant may re-enroll but shall do so as a new applicant.

A participant scheduled to be disenrolled for failure to pay his/her premium may be reinstated with no break in coverage if payment is made prior to the effective date of disenrollment. If payment is received after the effective date of disenrollment, the participant shall re-enroll as a new applicant.

37-006.03 Transition from PACE: Upon either voluntary or involuntary disenrollment, the PACE organization shall:

1. Facilitate a participant’s reinstatement in other Medicare and Medicaid programs for which the participant is eligible;

2. Coordinate the disenrollment date between Medicare and Medicaid for participants who are eligible for both programs;

3. Give reasonable advance notice of the disenrollment date to the participant; and

4. Continue to furnish all needed services as identified in the participant’s plan of care until the disenrollment date.

37-006.03A Effective Date: The participant shall be allowed to continue to use PACE organization services and will remain liable for any premiums due until the disenrollment date.

37-006.04 Appeals of Involuntary Disenrollment: Participants who are involuntarily disenrolled may appeal using the SAA’s appeal process (465 NAC 2-001).

37-006.04A Appeal Process for Medicare-only Beneficiaries: Medicare does not have an appeals process that permits challenges of disenrollment determinations of Medicare-only beneficiaries within PACE. Medicare-only eligible participants, as well as private pay participants, must use the appeals process provided by the SAA (71 Fed. Reg. 71244, 71303, 71312, 71317 (Dec. 8, 2006)).

37-007 PACE ORGANIZATIONS

37-007.01 Agreement: PACE organizations shall have an agreement with CMS and the SAA for the operation of a PACE program. The agreement specifies the prospective monthly capitated Medicaid payment amount as negotiated by the PACE organization and the SAA. The monthly capitated payment may be renegotiated on an annual basis as pursuant to 42 CFR 460.182.

37-007.02 Licenses or Credentials: PACE organizations must hold appropriate licenses or credentials as required under state licensing laws.

37-007.03 Federal Requirements: In addition to the requirements in this chapter, PACE organizations must also meet all applicable federal requirements, including those set forth in 42 CFR, Part 460.

History

• Effective 2013-04-03

Chapter 38 Estate Recovery

Neb. Admin. Code tit. 471, ch. 38 Estate Recovery {#sec-471-nac-38 omnilex-key=us-ne-regs-official--title-471--471 NAC 38}

001. SCOPE AND AUTHORITY . Medicaid estate recovery is mandated by §1917(b) of the Social Security Act and Nebraska Revised Statute (Neb. Rev. Stat.) §68-919.

002. RESERVED .

003. RESERVED .

004. UNDUE HARDSHIP WAIVER .

004.01 PURPOSE. Waivers granted by the Department based on undue hardship are a rare and extraordinary remedy intended to prevent the impoverishment of the deceased recipient’s family if the Department were to pursue an estate-recovery claim. Anticipating or expecting an inheritance, or being inconvenienced economically by the lack of an inheritance, is not a valid basis for an undue-hardship waiver.

004.02 HEIR. Any person who could be considered an heir of the now-deceased Medicaid recipient under the Probate Code may apply for an undue-hardship waiver.

004.03 CRITERIA. Any of the following circumstances may constitute an undue hardship that results in a complete or partial waiver of claim:

(A) An heir of the recipient resided in the recipient’s home for two years prior to the recipient’s entry into a nursing home and during that time provided the type and quantity of unreimbursed care that delayed the recipient’s entry into a nursing home;

(B) An heir of the recipient resided in the recipient’s home for two years prior to the recipient’s receipt of recoverable medical services and during that time provided the type and quantity of unreimbursed care that delayed the recipient’s receipt of those services;

(C) Payment of the Department’s claim would cause an heir of the deceased recipient to become eligible for public assistance;

(D) Waiver of the Department’s claim would allow an heir to discontinue eligibility for public assistance for a substantial time period; or

(E) Other situations that the Department, in its discretion and on a case-by-case basis upon consideration of all facts and circumstances, determines constitutes an undue hardship.

004.04 LIMITATION. An undue hardship does not exist if action taken by the recipient, whether directly or by another person pursuant to sufficient authorization, impermissibly divested or diverted assets to avoid estate recovery.

004.05 APPLICATION AND REVIEW PROCESS. An undue-hardship waiver application must be submitted in writing to the Department within 30 days of the creditor’s claim-filing deadline or 90 days from the recipient’s date of death if there is no probate proceeding. The application must explain:

(A) How the applicant is related to the now-deceased Medicaid recipient, and include documents or other evidence of this relationship; and

(B) The specific reason(s) why the application should be granted, according to 471 Nebraska Administrative Code (NAC) 38-004.03, and include documents or other evidence to support the application.

The applicant will receive a written decision within 90 days after the Department has received the application. If the application is completely or partially denied, the decision will include general information about appealing the decision.

005. LONG-TERM CARE PARTNERSHIP PROGRAM . Neb. Rev. Stat. §68-1095.01 established Nebraska’s Long-Term Care Partnership Program.

Resources equal to the amount of benefits paid out by a long-term care partnership policy are disregarded for an individual applying for Medicaid if the policy was issued on July 1, 2006 or later and the individual is otherwise Medicaid eligible. The amount of the resource disregard is also excluded from estate recovery.

The Department accepts the Department of Insurance’s approval of the policy.

005.01 RECIPROCITY WITH OTHER STATES. The Department will accept partnership policies issued in other states with Qualified Long-Term Care Partnership Programs that meet the criteria established in §1917(b)(1)(C) of the Social Security Act.

History

• Effective 2019-07-01

Chapter 39 Nebraska Alternative Benefit Plan (abp)

Neb. Admin. Code tit. 471, ch. 39 Nebraska Alternative Benefit Plan (abp) {#sec-471-nac-39 omnilex-key=us-ne-regs-official--title-471--471 NAC 39}

001. SCOPE AND AUTHORITY . The regulations govern the services provided under Nebraska’s Medicaid program as defined by Nebraska Revised Statute (Neb. Rev. Stat.) §§ 68-901 et seq.

002. OVERVIEW . This chapter details the benefit plan and services offered to eligible adults aged 19 through 64 enrolled in the Heritage Health Adult (HHA) program as described in 477 NAC 29. This benefit plan begin October 1, 2021.

003. BENEFIT PLAN AND SERVICES .

003.01 NEBRASKA ALTERNATIVE BENEFIT PLAN. The Nebraska Alternative Benefit Plan offers all services as described in the Title XIX Plan and listed in 471 NAC 1.

003.01(A) NEBRASKA ALTERNATIVE BENEFIT PLAN SERVICES. For the purposes of the Nebraska Alternative Benefit Plan, these services are grouped as follows:

(i) Ambulatory patient services as set forth in 471 NAC 5, 9, 10, 18, 26, 36, and 34;

(ii) Emergency services as set forth in 471 NAC 4 and 10;

(iii) Hospitalization as set forth in 471 NAC 10;

(iv) Maternity and newborn care as set forth in 471 NAC 9, 10, 18, 26, 34, 36, and 42;

(v) Mental health and substance use disorder services as set forth in 471 NAC 9, 10, 18, 20, 26, 34, 35, and 36;

(vi) Prescription drugs/pharmacy as set forth in 471 NAC 16;

(vii) Rehabilitative and habilitative services and devices as set forth in 471 NAC 7, 9, 14, 21, and 23;

(viii) Laboratory services as set forth in 471 NAC 10;

(ix) Preventative and wellness services and chronic disease management as set forth in 471 NAC 10, 18, and 33;

(x) Early periodic screening, diagnosis, and treatment (EPSDT) as set forth in 471 NAC 33;

(xi) Other services as follows:

(1) Rural Health Clinic as set forth in 471 NAC 34;

(2) Federally Qualified Health Center (FQHC) as set forth in 471 NAC 29;

(3) Certified pediatric & family nurse practitioner services as set forth in 471 NAC 10;

(4) Podiatrists' services as set forth in 471 NAC 19;

(5) Case management as set forth in 477 NAC 4;

(6) Inpatient psychiatric services under age 21 as set forth in 471 NAC 20;

(7) Telehealth as set forth in Title 471 NAC;

(8) Non-emergency transportation as set forth in 471 NAC 27;

(9) Respiratory care services as set forth in 471 NAC 22;

(10) Abortion services as set forth in 471 NAC 10 and 18;

(11) Family planning services and supplies as set forth in 471 NAC 10 and 18;

(12) Critical care hospital as set forth in 471 NAC 10;

(13) Intermediate care facility services as set forth in 471 NAC 12;

(14) Program or All-Inclusive Care (PACE) services as set forth in 471 NAC 37;

(15) Long term nursing facility services as set forth in 471 NAC 12;

(16) 915 (C) Home and Community Based Services (HCBS) waivers as set forth in Title 480 NAC;

(17) Personal assistance services as set forth in 471 NAC 15;

(18) Private duty nursing services as set forth in 471 NAC 13;

(19) Medically-monitored inpatient withdraw management as set forth in 471 NAC 20;

(20) Opioid treatment program as set forth in 471 NAC 20;

(21) Dental services as set forth in 471 NAC 6;

(22) Dentures as set forth in 471 NAC 6;

(23) Optometrists' services as set forth in 471 NAC 24;

(24) Eyeglasses as set forth in 471 NAC 24; and

(25) Over-the-counter (OTC) pharmacy services as set forth in 471 NAC 16.

004. PARTICIPATION IN THE HEALTH INSURANCE PREMIUM PAYMENT (HIPP) PROGRAM . Clients eligible to receive benefits under the Heritage Health Adult (HHA) program may voluntarily participate in the Health Insurance Premium Payment (HIPP) program as described in 471 NAC 30.

005. COPAYMENTS . Clients receiving services through the Heritage Health Adult (HHA) program will be subject to copayment requirements as described in 471 NAC 3-008.01.

History

• Effective 2021-09-27

Chapter 42 Freestanding Birth Centers

Neb. Admin. Code tit. 471, ch. 42 Freestanding Birth Centers {#sec-471-nac-42 omnilex-key=us-ne-regs-official--title-471--471 NAC 42}

42-001 STANDARDS FOR PARTICIPATION : Medicaid covers facility services provided by non-hospital freestanding birth centers. To participate in Medicaid, a freestanding birth center must:

1. Be licensed by the Department of Health and Human Services, Division of Public Health, as a facility providing labor and delivery services and not licensed as another type of health care facility and maintain standards of care required by the Department of Health and Human Services, Division of Public Health for licensure.

2. The center must have a written agreement for emergency care with a hospital that provides obstetrical services or each medical practitioner practicing at the facility must have admitting privileges at a transferring hospital.

3. Admissions to the facility must be restricted to uncomplicated (low-risk) patients. Planned caesarean section procedures are prohibited.

4. Each mother and newborn must be discharged within 24 hours after admission, in a condition which will allow or not endanger the well-being of either. If the condition of mother or newborn does not allow discharge within 24 hours, then transfer to a hospital must occur.

5. The birth center must be enrolled and approved by the Department or its designee for participation in Medicaid.

6. The birth attendant must be licensed at the time and place the services are provided and must be enrolled and approved by the Department or its designee for participation in Medicaid.

42-001.01 Definition of a Freestanding Birth Center: A Freestanding Birth Center means a health facility-

1. That is not a hospital;

2. Where childbirth is planned to occur away from the pregnant woman’s residence;

3. That is licensed or otherwise approved by the State to provide prenatal labor and delivery or postpartum care and other ambulatory services; and

4. That complies with such other requirements relating to the health and safety of individuals furnished services by the facility as the State shall establish.

42-001.02 Definition of a Birth Attendant: A birth attendant means an individual who is licensed by the State to provide health care at childbirth and who provides such care within the scope of practice under which the individual is legally authorized to perform such care under State law.

42-001.03 Provider Agreement: The provider must complete and sign Form MC-19, “Medical Assistance Provider Agreement,” (see 471-000-90) and submit it to the Department to be approved for provider enrollment.

42-002 COVERED BIRTH CENTER FACILITY SERVICES : Coverage of birth center facility services is limited to certain birth services provided by the center and determined by the birth attendant to be necessary for the care of the mother and live newborn child following the mother’s normal, uncomplicated pregnancy. Reimbursable services are limited to facility services provided during the labor and delivery. These items and services are those that would otherwise be covered by Medicaid if provided on an inpatient or outpatient basis in a hospital in connection with the services provided by the center. Birth center facility services furnished prior to or after the above described period are not considered birth center facility services and are not covered or reimbursed.

Services provided by the birth attendant are not considered to be birth center facility services. The fee for the birth center facility services does not include payment for medical or other health services such as the birth attendant’s services.

42-003 (RESERVED)

42-004 BILLING REQUIREMENTS

42-004.01 Required Forms: When billing Medicaid, the Birth Center must submit using the paper Form CMS-1500 or the standard electronic Health Care Claim: Professional transaction (ASC X12N 837) (see Claim Submission Table at 471-000-49).

42-004.02 Procedure Codes: To bill the Birth Center facility fee, the Birth Center must use the appropriate HCPCS/CPT procedure codes. Birth Centers may only be reimbursed by Medicaid for their facility labor and delivery services. Birth attendants’ services or other services not directly related to the labor and delivery services, along with prenatal or family planning services in the birth center setting must be submitted on separate claims. Claims for non-facility services need to be submitted utilizing the appropriate HCPCS/CPT procedure codes on the paper Form CMS-1500 or the standard electronic Health Care Claim: Professional transaction (ASC X12N 837).

42-005 PAYMENT FOR BIRTH CENTER SERVICES

42-005.01 Fee for Birth Center Facility Services: Birth Centers may only be reimbursed for facility labor and delivery services. The department will establish maximum reimbursement fees for birth center services based upon the average of published rates from the State Medicaid Programs of other states that have published rates for such services. Rates may also be adjusted in accordance with legislative appropriations or budget directives from the Nebraska Legislature, which may result in Medicaid payment rate increases or decreases.

42-005.02 Payment for Services Not Included in the Birth Center Facility Services Fee: The fee for facility services does not include payment for birth attendants’ services or other services not directly related to the labor and delivery services.

History

• Effective 2013-02-26

Chapter 43 Nursing Facility Level of Care Determination for Children

Neb. Admin. Code tit. 471, ch. 43 Nursing Facility Level of Care Determination for Children {#sec-471-nac-43 omnilex-key=us-ne-regs-official--title-471--471 NAC 43}

001. SCOPE AND AUTHORITY . The regulations govern the services provided under Nebraska’s Medicaid program as defined by Nebraska Revised Statute (Neb. Rev. Stat.) §§ 68-901 et seq. (the Medical Assistance Act).

002. DEFINITIONS . The definitions set out in Neb. Rev. Stat. § 68-907 and the following definitions apply:

002.01 ACTIVITIES OF DAILY LIVING (ADL). Activities related to personal care. They include bathing or showering, dressing, getting in and out of bed or a chair, walking, using the toilet, and eating.

002.02 AGE APPROPRIATE. Reflective of the developmental abilities of the child taking into account any cultural traditions that are within the boundaries of state and federal law.

002.03 BATHING. A person’s ability to take a full-body bath or shower. Includes how a person transfers in and out of tub or shower and the ability to bathe each part of the body.

002.04 DRESSING. A person’s ability to put on and remove clothing from upper and lower body. This includes the ability to put on or remove physician ordered prosthetic or orthotic devices.

002.05 EATING. A person’s ability to eat and drink. Includes intake of nourishment by other means, such as tube feeding or total parenteral nutrition.

002.06 PERSONAL HYGIENE. A person’s ability to manage personal hygiene including combing hair, brushing teeth, and washing and drying self.

002.07 HOME AND COMMUNITY-BASED WAIVER SERVICES FOR AGED PERSONS OR ADULTS OR CHILDREN WITH DISABILITIES. An array of community-based services available to individuals who are eligible for nursing facility (NF) services under Medicaid but choose to receive services at home. The purpose of the waiver services is to offer options to Medicaid clients who would otherwise require nursing facility (NF) services.

002.08 HOSPICE. Hospice or hospice services shall meet the definition in 471 Nebraska Administrative Code (NAC) 36.

002.09 LEGAL REPRESENTATIVE. Any person who has been vested by law with the power to act on behalf of an individual. The term includes a guardian appointed by a court of competent jurisdiction in the case of an incompetent individual or minor, or a parent in the case of a minor, or a person acting under a valid power of attorney.

002.10 LEVEL OF CARE (LOC) DETERMINATION. Medicaid’s nursing facility (NF) screening for medical necessity.

002.11 LIMITATION. A person is determined to have a limitation if they have difficulty performing age appropriate tasks associated with an activity of daily living by himself or herself, or is unable to perform the activity of daily living at all.

002.12 LEVEL II EVALUATION. See 471 NAC 12.

002.13 MEDICAID-ELIGIBLE. See 471 NAC 12.

002.14 MOBILITY. The ability to move from place to place indoors or outside, walking or other locomotion between locations on the same floor on a building.

002.15 NURSING FACILITY (NF). See 471 NAC 12.

002.16 REHABILITATION. See 471 NAC 12.

002.17 REHABILITATIVE SERVICES. See 471 NAC 12.

002.18 TERMINALLY ILL OR TERMINAL ILLNESS. The client is diagnosed with a medical prognosis that his or her life expectancy is six months or less if the illness runs its normal course.

002.19 TOILETING. How a person uses the toilet room, commode, bedpan, or urinal. How a person cleanses self after toilet use or incontinent episode(s), manages ostomy or catheter, and adjusts clothes.

002.20 TRANSFERRING. The ability to move from one place to another, including bed to chair and back, and into and out of a vehicle. Includes the ability to move on and off toilet or commode.

003. LEVEL OF CARE .

003.01 NURSING FACILITY LEVEL OF CARE (NF LOC) CRITERIA. The client or his or her authorized representative must provide information needed to determine nursing facility level of care (NF LOC). In order to make a determination, the client or representative must be assessed on the basis of activities of daily living (ADLs), risk factors, medical conditions and interventions, and cognitive function, to be determined via in-person discussion and observation of the client; reports from caregivers, family, and providers; and current medical records.

003.01(A) LEVEL OF CARE (LOC) DETERMINATION FOR CHILDREN AGE 17 OR YOUNGER. To meet nursing facility level of care (NF LOC) eligibility, a child must have assessed limitations in the child level of care (LOC) categories as follows:

(1) Children age 0-47 Months: To be eligible, the child must have needs related to a minimum of one defined medical condition or treatment as listed in this chapter; and

(2) Children age 48 months through 17 years: Nursing facility level of care (NFLOC) eligibility can be met in one of three ways:

(a) At least one medical condition or treatment need;

(b) Limitations in at least six activities of daily living (ADL); or

(c) Limitations in at least four activities of daily living (ADL) and the presence of at least two other considerations.

003.01(A)(i) AGE. For purposes of this section, the age of the child is his or her age on the last day of the month in which the level of care (LOC) determination is made.

003.01(A)(ii) LEVEL OF CARE (LOC) CRITERIA. The client or his or her authorized representative must provide the nursing facility level of care (NF LOC) information for use in the level of care determination which is obtained through in-person discussion, standardized assessment, and observation of the child; reports from parents or legal representative or informal caregivers; documentation from the child’s individualized family service plan (IFSP) or individual education plan (IEP); and current medical records. Children with disabilities meet nursing facility level of care (NF LOC) eligibility based on the assessment categories of medical conditions and treatments, activities of daily living (ADL), and other considerations.

003.01(A)(ii)(1) DETERMINATION OF MEDICAL CONDITIONS AND MEDICAL TREATMENTS. To qualify with a limitation in this category, a child must have a defined, documented medical condition or receipt of treatment, which satisfies the requirements of this chapter.

003.01(A)(ii)(1)(a) DEFINED MEDICAL TREATMENT AND MEDICAL CONDITIONS. The following medical conditions and treatments are considered in determining nursing facility level of care (NF LOC)eligibility:

(i) Defined medical treatments:

(1) Chemotherapy;

(2) Hemodialysis;

(3) Peritoneal dialysis;

(4) IV medication;

(5) Routine oxygen therapy;

(6) Radiation;

(7) Nasopharyngeal suctioning;

(8) Tracheotomy care;

(9) Transfusion;

(10) Ventilator or respirator;

(11) Wound care;

(12) Urinary catheter care;

(13) Continuous positive airway pressure (CPAP) or bi-level positive airway pressure (BiPAP);

(14) Percussion vest;

(15) Urinary collection device;

(a) Condom catheter;

(b) Indwelling catheter; or

(c) Cystostomy, nephrostomy, ureterostomy;

(16) Inadequate pain control;

(17) Mode of nutritional intake;

(a) Combined oral and parenteral or tube feeding;

(b) Nasogastric tube feeding;

(c) Abdominal feeding tube;

(d) Parenteral feeding; or

(18) Other treatment(s) that may require management through a nursing facility or hospitalization, evaluated through clinical review by the Department;

(ii) Defined medical conditions:

(1) Epilepsy;

(2) Conditions or diseases which make cognitive, activity of daily living, mood, or behavior patterns unstable including fluctuating, precarious, or deteriorating;

(3) End-stage disease, six or fewer months to live;

(4) Severe pressure ulcer;

(5) Deep craters in the skin;

(6) Breaks in skin exposing muscle or bone;

(7) Spinal cord dysfunction;

(8) Comatose or persistent vegetative state;

(9) Cerebral palsy;

(10) Macro or microcephaly;

(11) Muscular dystrophies;

(12) Seizure disorder;

(13) Traumatic brain injury;

(14) Congenital heart disorder;

(15) Cystic fibrosis;

(16) Cancer;

(17) Explicit terminal prognosis;

(18) Failure to thrive;

(19) Renal failure; or

(20) A fluctuating, inconsistent medical condition that has required the child to receive hospitalization related to a single medical condition:

(a) One or more times in the past 90 days; or

(b) For at least 30 days, if the child is less than 12 months old; or

(iii) A condition which a licensed medical provider has documented as terminal or a persistent condition in which the absence of active treatment would result in hospitalization.

003.01(A)(ii)(1)(b) ADDITIONAL CRITERIA FOR MEDICAL CONDITIONS AND TREATMENTS. In addition to having a medical condition or treatment identified above, the present medical condition or treatment must:

(1) Impact the child’s functioning or independence on a daily basis; and

(2) Require physical assistance of another person:

(a) To prevent a decline in health status; or

(b) When the child is physically or cognitively unable to self-perform the medically necessary treatments.

003.01(A)(ii)(1)(b)(i) 48 MONTHS THROUGH 17 YEARS. For children ages 48 months through 17 years, documentation of the daily effect of a defined medical condition or treatment on the child’s functioning or independence is required.

003.01(B) ACTIVITIES OF DAILY LIVING (ADL) FOR CHILDREN AGE 48 MONTHS THROUGH 17 YEARS. Information about limitations in activities of daily living (ADL) is obtained from observation of the child in the home setting, reports from parents, guardians or caregivers, current medical records, school records, and standardized assessments. Activities in daily living (ADL) are considered a limitation when the child, due to their physical disabilities, requires physical assistance from another person on a daily basis, or supervision, monitoring, or direction to complete the age appropriate tasks associated with each activity of daily living (ADL) defined in this section. For the purposes of this section, the term “ability” must be interpreted to include the physical ability, cognitive ability, age appropriateness, and endurance necessary to complete identified activities. The following activities of daily living (ADL) are considered for nursing facility level of care (NF LOC) eligibility:

(1) Bathing;

(2) Dressing;

(3) Personal Hygiene;

(4) Eating;

(5) Mobility;

(6) Toileting; and

(7) Transferring.

003.01(B)(i) OTHER CONSIDERATIONS FOR CHILDREN AGE 48 MONTHS THROUGH 17 YEARS. The below are the considerations for use with 003.01(A)(2)(c) of this chapter.

(1) Vision: The child has a documented visual impairment that is defined as a visual acuity of 20/200 or less in the better eye with the use of a correcting lens. When the child is not able to participate in testing using the Snellen or comparable methodology, documentation of an alternate method that demonstrates visual acuity is required;

(2) Hearing: The child has a documented hearing impairment that is defined as the inability to hear at an average hearing threshold of 1000, 2000, 3000 and 4000 hertz (Hz) with the high fence set at an average of 65 decibels (dB) or higher in the better ear;

(3) Communication: The child is not able to make themselves understood. This includes expressing information content, both verbal and nonverbal; and

(4) Behavior: The child requires interventions based on a documented behavior management program developed and monitored by a psychiatrist, psychologist, mental health practitioner, or school counselor.

003.02 PERSONS ELIGIBLE. To be eligible for a level of care (LOC) determination, a person must:

(1) The person must be determined to be eligible for Medicaid, or under consideration for Medicaid eligibility;

(a) The person must be requesting Medicaid funding to cover nursing facility (NF) services or Home and Community-Based Waiver Services for Aged Persons or Adults or Children with Disabilities.

003.02(A) SPECIAL CIRCUMSTANCES NOT EVALUATED OR SCREENED. Level of care (LOC) will not be evaluated or reevaluated for Medicaid clients who:

(i) Have previously been determined to meet nursing facility level of care (NF LOC) and return to the same nursing facility (NF) after discharge to a hospital, other nursing facility (NF), or swing bed. This exception does not apply for clients who have previously been discharged to an alternative level of care, or to the community;

(ii) Are Medicaid-eligible clients who admit to the nursing facility (NF) under hospice care;

(iii) Are nursing facility (NF) residents who elect hospice upon becoming Medicaid eligible;

(iv) Are receiving nursing facility (NF) care which is currently being paid by Medicare. Level of care (LOC) evaluation referral must be completed after Medicare coverage has ended;

(v) Direct transfer from one nursing facility (NF) to another nursing facility (NF);

(vi) Are currently, or were previously eligible the month prior to nursing facility (NF) admission, for the Aged and Disabled Waiver program through the Department;

(vii) Are admitted to a special needs nursing facility (NF) unit; or

(viii) Are seeking out-of-state nursing facility (NF) admission.

003.02(B) EVALUATION FORMAT. Evaluations will be conducted using common evaluation tools. The evaluation tools reflect each area of nursing facility level of care (NF LOC) criteria, the amount of assistance required, and the complexity of the care.

003.02(C) REFERRAL.

003.02(C)(i) MINIMUM REFERRAL INFORMATION. The following is the minimum information required to process a referral for level of care (LOC) determination:

(1) The name, position, and telephone number of the person making the referral;

(2) The name of the nursing facility (NF) involved, if different than the referral source;

(3) The name, date of birth, and social security number of the person to be evaluated; and

(4) The date and time the referral is being made.

003.02(C)(ii) RECEIVING REFERRALS. When the Department or its agent receives a referral to evaluate an applicant for admission to a nursing facility (NF), they will begin to collect the information outlined in the evaluation tool. Information may be collected either in person or through telephone interviews. Based on the information gathered through the evaluation, the Department determines whether the applicant meets nursing facility level of care (NF LOC).

003.02(C)(iii) APPLICABLE TIME FRAMES. A referral will only be accepted if it is verified by the Department that an application has been received and is under consideration or if an individual is determined eligible for Medicaid. The Department must complete a level of care (LOC) evaluation within 48 hours. If the evaluation is not completed by the Department within 48 hours, the applicant for admission must be deemed by the Department to be appropriate for admission until a level of care (LOC) determination is completed and any required notice is given.

003.02(C)(iii)(1) RETROACTIVE MEDICAID LEVEL OF CARE (LOC) DETERMINATION. If a current nursing facility (NF) resident applies for Medicaid without informing the nursing facility (NF) and a level of care (LOC) referral is not completed during the Medicaid eligibility consideration period, the nursing facility (NF) must make an immediate referral to the Department when information is received that Medicaid has been approved. If the following conditions are met, Medicaid coverage will be retroactive to the date of Medicaid eligibility:

(a) The nursing facility (NF) has a process in place to inform private pay clients and their families that the nursing facility (NF) must be informed when a Medicaid application is made;

(b) The nursing facility (NF) makes a referral to the Department immediately upon receipt of information about the opening of the Medicaid case. At the time of this referral, the nursing facility (NF) must provide information on the date and means by which information about Medicaid eligibility was obtained; and

(c) The resident meets the nursing facility level of care (NF LOC) criteria.

003.02(C)(iii)(2) LEVEL OF CARE (LOC) REFERRAL 14-DAY POST-MEDICAID DETERMINATION. A level of care (LOC) approval determination will be effective as of the date of Medicaid eligibility if the referral is completed by the 14th calendar day following the Medicaid eligibility determination date.

003.02(C)(iii)(3) REFERRAL AFTER DEATH OR DISCHARGE. A level of care (LOC) referral will also be accepted and a medical records-based level of care (LOC) determination will be completed if Medicaid eligibility is not approved until after the recipient dies or is discharged from the facility. To qualify, the referral must be completed within 14 days of the Medicaid eligibility determination date, and the recipient must meet level of care (LOC) criteria. If the required conditions are met, the level of care (LOC) determination will be effective to the date of Medicaid eligibility.

003.02(C)(iii)(4) DETERMINATION OTHERWISE REQUIRED. A level of care (LOC) determination will be required in all other cases for nursing facility (NF) admission.

003.02(D) OUTCOMES OF THE EVALUATION.

003.02(D)(i) NURSING FACILITY LEVEL OF CARE (NF LOC) MET. If the Department determines that the applicant meets nursing facility level of care (NF LOC) and the client chooses to receive nursing facility (NF) services, the Department will make appropriate notifications.

003.02(D)(ii) NURSING FACILITY LEVEL OF CARE (NF LOC) NOT MET. If the Department determines that the applicant does not meet nursing facility level of care (NF LOC), notification of the determination is issued to the applicant, the facility, and the managed care organization. Persons who are found to be ineligible for Medicaid reimbursement for nursing facility (NF) service will be sent a notice of denial by the Department.

003.02(D)(iii) POSSIBLE OPTIONS. Medicaid payment for nursing facility (NF) services will only be available to those clients who are determined to require nursing facility level of care (NF LOC). They will have the option of entering a nursing facility (NF) or exploring home and community-based care services. If the evaluation determines that there is a need for post-hospitalization rehabilitative or convalescent care, the Department may indicate that short-term or time-limited nursing facility (NF) care is medically necessary. Prior to the end of the short-term or time-limited stay, the nursing facility (NF) must contact Medicaid to review the client’s condition and determine future nursing facility level of care (NF LOC).

003.02(E) NOTICES AND APPEALS.

003.02(E)(i) LEVEL OF CARE (LOC) DETERMINATION NOTIFICATION. Medicaid staff send notification to each client, family, or applicable parties, to inform the client of the level of care (LOC) decision. Nursing facility (NF) residents with Medicaid funding, who no longer meet the criteria for nursing facility level of care (NF LOC), must be allowed to remain in the facility up to 30 days from the date of the notice.

003.02(E)(ii) APPEALS. The client or his or her authorized representative may appeal any action or inaction of the Department by following standard Medicaid appeal procedures as defined in 465 NAC 6.

History

• Effective 2020-12-23

Chapter 44 Nursing Facility Level of Care Determination for Adults

Neb. Admin. Code tit. 471, ch. 44 Nursing Facility Level of Care Determination for Adults {#sec-471-nac-44 omnilex-key=us-ne-regs-official--title-471--471 NAC 44}

001. SCOPE AND AUTHORITY . The regulations govern the services provided under Nebraska’s Medicaid program as defined by Nebraska Revised Statute (Neb. Rev. Stat.) § 68-901 et seq. (the Medical Assistance Act).

002. DEFINITIONS . The definitions set out in Neb. Rev. Stat. § 68-907 and the following definitions apply:

002.01 ACTIVITIES OF DAILY LIVING (ADL). Activities related to personal care, including but not limited to bathing or showering, continence, dressing, grooming, transferring to and from a bed or chair, mobility, toileting, and eating.

002.02 BATHING. A person’s ability to take a full-body bath or shower, including but not limited to transferring in and out of tub or shower and bathing each part of the body.

002.03 CONTINENCE. A person’s ability to control their body to empty the bladder or bowel on time or change incontinence pads or briefs, cleansing, or disposing of soiled articles.

002.04 DRESSING. A person’s ability to put on and remove clothing from upper and lower body, including but not limited to the ability to put on or remove physician ordered prosthetic or orthotic devices.

002.05 EATING. A person’s ability to eat and drink, including but not limited to intake of nourishments by other means, such as tube feeding or total parenteral nutrition.

002.06 GROOMING. A person’s ability to manage personal hygiene, including but not limited to combing hair, brushing teeth, and washing and drying self.

002.07 HOME AND COMMUNITY-BASED WAIVER SERVICES FOR AGED PERSONS OR ADULTS OR CHILDREN WITH DISABILITIES. An array of community-based services available to individuals who are eligible for nursing facility (NF) services under Medicaid but choose to receive services at home. The purpose of the waiver services is to offer alternative service delivery options to Medicaid recipients who would otherwise receive services in a nursing facility (NF) or other institutional setting.

002.08 HOSPICE. Hospice or hospice services shall meet the definition in 471 Nebraska Administrative Code (NAC) 36.

002.09 LEGAL REPRESENTATIVE. Any person who has been vested by law with the power to act on behalf of an individual. The term includes a guardian appointed by a court of competent jurisdiction in the case of an incompetent individual or minor, or a person acting under a valid power of attorney.

002.10 LEVEL OF CARE (LOC) DETERMINATION. Medicaid’s evaluation to determine whether an individual requires the supports typically provided by a nursing facility (NF) or other institutional setting.

002.11 LIMITATION. When a person has difficulty performing tasks associated with an activity of daily living (ADL) by themselves, or is unable to perform the tasks at all.

002.12 LEVEL II EVALUATION. See 471 NAC 12.

002.13 MEDICAID-ELIGIBLE. See 471 NAC 12.

002.14 MOBILITY. A person’s ability to move from place to place indoors or outside, by walking or other locomotion.

002.15 NURSING FACILITY (NF). See 471 NAC 12.

002.16 PROGRAM OF ALL-INCLUSIVE CARE FOR THE ELDERLY (PACE). A program that provides comprehensive, coordinated health care and long-term services and supports for voluntarily enrolled individuals. Program of All-inclusive Care for the Elderly (PACE) provides another alternative along the continuum of available long-term care services and supports to enable participants to continue to live in their homes and communities.

002.17 TOILETING. A person’s ability to use the toilet, commode, bedpan, or urinal, including but not limited to how a person cleanses self after toilet use, manages ostomy or catheter, and adjusts clothes.

002.18 TRANSFERRING. A person’s ability to move from one place to another, including but not limited to bed to chair and back, into and out of a vehicle, and on and off toilet or commode.

003. LEVEL OF CARE .

003.01 NURSING FACILITY LEVEL OF CARE (NF LOC) CRITERIA. The person or his or her legal representative must provide information needed to determine nursing facility level of care (NF LOC). In order to make a determination, the person or representative must be addressed on the basis of activities of daily living (ADL), risk factors, medical conditions and interventions, and cognitive function, to be determined via discussion and observation of the person; reports from caregivers, family, and providers; and current medical records.

003.01(A) LEVEL OF CARE DETERMINATION FOR ADULTS AGE 18 OR OLDER. A person must satisfy one of the four following categories to meet nursing facility level of care (NF LOC) eligibility:

(1) A limitation in at least three activities of daily living (ADL) and one or more risk factors;

(2) A limitation in at least three activities of daily living (ADL) and one or more medical conditions and treatments;

(3) A limitation in at least three activities of daily living (ADL) and one or more areas of cognitive limitation; or

(4) A limitation in at least one activity of daily living (ADL) and at least one risk factor and at least one area of cognitive limitation.

003.01(A)(i) ACTIVITIES OF DAILY LIVING (ADL). Information about limitations in activities of daily living (ADL) is obtained from observation of the person in the home setting, reports from guardians or caregivers, current medical records, school records, and standardized assessments. Activities in daily living (ADL) are considered a limitation when the person, due to their physical disabilities, requires physical assistance from another person on a daily basis, or supervision, monitoring, or direction to complete the tasks associated with each activity of daily living (ADL) defined in this section. For the purposes of this section, the term “ability” must be interpreted to include the physical ability, cognitive ability, and endurance necessary to complete identified activities. The following activities of daily living (ADL) are considered for nursing facility level of care (NF LOC) eligibility:

(1) Bathing;

(2) Continence;

(3) Dressing or grooming;

(4) Eating;

(5) Mobility;

(6) Toileting; and

(7) Transferring.

003.01(A)(ii) RISK FACTORS. Risk factors must cause significant impact to the person’s life and functional abilities and require significant intervention in a timely manner. Risk factors to be considered are:

(1) Behavior: The inability to act on one's own behalf, including but not limited to lack of interest or motivation to eat, not taking medications, not caring for one's self, not maintaining personal safety, wandering, avoiding social activities, and relating to others in a socially-inappropriate manner;

(2) Frailty: The inability to function independently without the presence of a support person, including but not limited to mismanaging finances or using poor judgment in understanding abilities and health factors to safeguard well-being and avoid inappropriate safety risk such as risk of falling; and

(3) Safety: The lack of adequate housing, including the absence of home modification or adaptive equipment to assure safety and accessibility, the lack of a formal or informal support system, or presence of abuse, neglect, or exploitation in the home.

003.01(A)(iii) MEDICAL CONDITIONS AND TREATMENTS. Medical conditions and treatments to be considered are:

(1) A medical condition is present which requires observation and assessment to evaluate the person's need for treatment modification or additional medical procedures to prevent destabilization when a person has demonstrated an inability to self-observe or evaluate the need to contact skilled medical professionals;

(2) Due to the complexity created by multiple, interrelated medical conditions, there exists potential for the person's medical condition to be unstable; and

(3) The person requires at least one ongoing medical or nursing service.

003.01(A)(iv) COGNITIVE FUNCTION. Limitations in cognitive function to be considered are:

(1) Memory: Lack of short-term recall, unable to perform all or almost all steps in a multitask sequence without cues, inability to recognize frequently encountered caregivers’ names or faces or know location of regularly visited places in residential setting;

(2) Orientation: Easily distracted, episodes of disorganized speech, or variation in mental function over the course of a day; behavior must be inconsistent with usual functioning;

(3) Communication: Inability to make oneself understood, including inability to express information content, both verbal and nonverbal, or the inability to understand information conveyed;

(4) Judgment: Inability to independently make decisions regarding tasks of daily life, except in new situations with only some difficulty; and

(5) Dementia: Dementia diagnosis, including Alzheimer’s disease.

003.02 PERSONS ELIGIBLE. A Level of Care (LOC) determination will be completed when a person is:

(1) Determined to be eligible for Medicaid, or is under consideration for Medicaid eligibility; and

(2) Requesting Medicaid funding to cover nursing facility (NF) service or Home and Community-Based Waiver Services for Aged Persons or Adults or Children with Disabilities.

003.02(A) SPECIAL CIRCUMSTANCES NOT EVALUATED OR SCREENED. Level of care (LOC) will not be evaluated or reevaluated for Medicaid recipients who:

(i) Have previously been determined to meet nursing facility level of care (NF LOC) and return to the same nursing facility (NF) after discharge to a hospital, other nursing facility (NF), or swing bed. This exception does not apply for persons who have previously been discharged to an alternative level of care, or to the community;

(ii) Are Medicaid-eligible persons who admit to the nursing facility (NF) under hospice care;

(iii) Are nursing facility (NF) residents who elect hospice upon becoming Medicaid eligible;

(iv) Are receiving nursing facility (NF) care which is currently being paid by Medicare;

(v) Direct transfer from one nursing facility (NF) to another nursing facility (NF);

(vi) Have a preadmission screening and resident review (PASRR) Level II level of care (LOC) determination indicating the resident meets nursing facility level of care (NF LOC);

(vii) Are currently, or were previously eligible the month prior to nursing facility (NF) admission, for the Aged and Disabled Waiver program through the Department;

(viii) Are admitted to a special needs nursing facility (NF) unit;

(ix) Are currently eligible for the Program of All-Inclusive Care for the Elderly (PACE) through the Department; or

(x) Are seeking out-of-state nursing facility (NF) admission.

003.02(B) EVALUATION FORMAT. Evaluations will be conducted using common evaluation tools. The evaluation tools reflect each area of nursing facility level of care (NF LOC) criteria, the amount of assistance required and the complexity of the care.

003.02(C) REFERRAL.

003.02(C)(i) MINIMUM REFERRAL INFORMATION. The following is the minimum information required to process a referral for level of care (LOC) determination:

(1) The name, position, and telephone number of the person making the referral;

(2) The name of the nursing facility (NF) involved, if different than the referral source;

(3) The name, date of birth, and social security number of the person to be evaluated; and

(4) The date and time the referral is being made.

003.02(C)(ii) RECEIVING REFERRALS. When the Department or its agent receives a referral to evaluate an applicant for admission to a nursing facility (NF), they will begin to collect the information and supporting documentation established in the evaluation tool. Information may be collected either in person or through telephone interviews. Based on the information gathered through the evaluation, the Department determines whether the applicant meets nursing facility level of care (NF LOC) criteria.

003.02(C)(iii) APPLICABLE TIME FRAMES. A referral will only be accepted if it is verified by the Department that an application has been received and is under consideration or if an individual is determined eligible for Medicaid. The Department must complete a level of care (LOC) evaluation within forty-eight (48) hours. If the evaluation is not completed by the Department within forty-eight (48) hours, the applicant for admission must be deemed by the Department to be appropriate for admission until a level of care (LOC) determination is completed and any required notice is given.

003.02(C)(iii)(1) RETROACTIVE MEDICAID LEVEL OF CARE (LOC) DETERMINATION. If a current nursing facility (NF) resident applies for Medicaid without informing the nursing facility (NF) and a level of care (LOC) referral is not completed during the Medicaid eligibility consideration period, the nursing facility (NF) must make an immediate referral to the Department when information is received that Medicaid has been approved. If the following conditions are met, Medicaid coverage will be retroactive to the date of Medicaid eligibility:

(a) The nursing facility (NF) has in place a process to inform private pay clients and their families that the nursing facility (NF) must be informed when a Medicaid application is made;

(b) The nursing facility (NF) makes a referral to the Department immediately upon receipt of information about the opening of the Medicaid case. At the time of this referral, the nursing facility (NF) must provide information on the date and means by which information about Medicaid eligibility was obtained; and

(c) The resident meets the nursing facility level of care (NF LOC) criteria.

003.02(C)(iii)(2) LEVEL OF CARE (LOC) REFERRAL 14-DAY POST-MEDICAID DETERMINATION. A level of care (LOC) approval determination will be effective as of the date of Medicaid eligibility if the referral is completed by the 14th calendar day following the Medicaid eligibility determination date.

003.02(C)(iii)(3) REFERRAL AFTER DEATH OR DISCHARGE. A level of care (LOC) referral will also be accepted and a medical records-based level of care (LOC) determination will be completed if Medicaid eligibility is not approved until after the person dies or is discharged from the facility. To qualify, the referral must be completed within 14 days of the Medicaid eligibility determination date, and the person must meet level of care (LOC) criteria. If the required conditions are met, the level of care (LOC) determination will be effective to the date of Medicaid eligibility.

003.02(C)(iii)(4) PROGRAM OF ALL-INCLUSIVE CARE FOR THE ELDERLY (PACE) LEVEL OF CARE (LOC) DETERMINATION. A Program of All-inclusive Care for the Elderly (PACE) level of care (LOC) determination may be used to substantiate nursing facility level of care (NF LOC) in the following cases:

(a) A Program of All-inclusive Care for the Elderly (PACE) recipient immediately admits to, or already resides in, a nursing facility (NF) following their disenrollment from the Program of All-inclusive Care for the Elderly (PACE); or

(b) A Program of All-inclusive Care for the Elderly (PACE) recipient admits to a nursing facility (NF) the month after disenrollment from the Program of All-inclusive Care for the Elderly (PACE).

003.02(C)(iii)(5) DETERMINATION OTHERWISE REQUIRED. A level of care (LOC) determination will be required in all other cases for nursing facility (NF) admission.

003.02(D) OUTCOMES OF THE EVALUATION.

003.02(D)(i) NURSING FACILITY LEVEL OF CARE (NF LOC) MET. If the Department determines that the applicant meets nursing facility level of care (NF LOC) criteria and the person chooses to receive nursing facility (NF) services, the Department will make appropriate notifications.

003.02(D)(ii) NURSING FACILITY LEVEL OF CARE (NF LOC) NOT MET. If the Department determines that the applicant does not meet nursing facility level of care (NF LOC), notification of the determination is issued to the applicant, the facility, and the managed care organization. Persons who are found to be ineligible for Medicaid reimbursement for nursing facility (NF) services will be sent a notice of denial by the Department.

003.02(D)(iii) POSSIBLE OPTIONS. Medicaid payment for nursing facility (NF) services will only be available to those persons who are determined to require nursing facility level of care (NF LOC). They will have the option of entering a nursing facility (NF) or exploring home and community-based care services. If the evaluation determines that there is a need for post-hospitalization rehabilitative or convalescent care, the Department may indicate that short-term or time-limited nursing facility (NF) care is medically necessary. Prior to the end of the short-term or time-limited stay, the nursing facility (NF) must contact Medicaid to review the person’s condition and determine future nursing facility level of care (NF LOC).

003.02(E) NOTICES AND APPEALS.

003.02(E)(i) LEVEL OF CARE (LOC) DETERMINATION NOTIFICATION. Medicaid staff send notification to each person, family, or applicable parties, to inform the person of the level of care (LOC) decision. Nursing facility (NF) residents with Medicaid funding, who no longer meet the criteria for nursing facility level of care (NF LOC), must be allowed to remain in the facility up to 30 days from the date of the notice.

003.02(E)(ii) APPEALS. The person or his or her authorized representative may appeal any action or inaction of the Department by following standard Medicaid appeal procedures as defined in 465 NAC 6.

History

• Effective 2022-05-11

Chapter 45 Rates for Nursing Facility Services

Neb. Admin. Code tit. 471, ch. 45 Rates for Nursing Facility Services {#sec-471-nac-45 omnilex-key=us-ne-regs-official--title-471--471 NAC 45}

001. SCOPE AND AUTHORITY . The regulations govern the services provided under Nebraska’s Medicaid program as defined by Nebraska Revised Statute (Neb. Rev. Stat.) §§ 68-901 et seq. (the Medical Assistance Act).

002. DEFINITIONS . The following definitions apply:

002.01 ALLOWABLE COST. Those facility costs which are included in the computation of the facility's Per Diem. The facility's reported costs may be reduced because they are not allowable under Medicaid or Medicare regulation, or because they are limited under 471 Nebraska Administrative Code (NAC) 45-006.

002.02 ASSISTED LIVING RATES. Standard rates, single occupancy, rural or urban, per day equivalent, paid under the Home and Community-Based Waiver Services for Aged Persons or Adults or Children with Disabilities.

002.03 DEPARTMENT. As defined in Neb. Rev. Stat. § 68-907.

002.04 DIVISION. The Division of Medicaid and Long-Term Care.

002.05 FAIR MARKET VALUE. The price that the asset would bring by bona fide bargaining between well-informed buyers and sellers at the date of acquisition.

002.06 INDIAN HEALTH SERVICES NURSING FACILITY PROVIDER. An Indian Health Services nursing facility or a tribal nursing facility designated as an Indian Health Services provider and funded by the Title I or ill of the Indian Self-Determination and Education Assistance Act, Public Law 93-638.

002.07 LEVEL OF CARE. The classification of each resident based on his or her acuity level.

002.08 MEDIAN. A value or an average of two values in an ordered set of values, below and above which there is an equal number of values.

002.09 NURSING FACILITY. An institution, or a distinct part of an institution, which meets the definition and requirements of Title XIX of the Social Security Act, Section 1919.

002.10 RATE DETERMINATION. Per Diem rates calculated under provisions of this chapter. These rates may differ from rates actually paid for nursing facility services for Levels of Care 201 and 202.

002.11 RATE PAYMENT. Per Diem rates paid under provisions of 471 NAC 45. The payment rate for Levels of Care 201 and 202 is the applicable rate in effect for assisted living services under the Home and Community-Based Waiver Services for Aged Persons or Adults or Children with Disabilities adjusted to include the Nursing Facility Quality Assessment Component and the Quality Measures Component.

002.12 REVISIT FEES. Fees charged to health care facilities by the Secretary of Health and Human Services to cover the costs incurred under Centers for Medicare & Medicaid Services for conducting revisit surveys on health care facilities cited for deficiencies during initial certification, recertification, or substantiated complaint surveys.

002.13 STRAIGHT-LINE METHOD. A depreciation method in which the cost or other basis of the asset, less its estimated salvage value, if any, is determined and the balance of the cost is distributed in equal amounts over the assigned useful life of the asset class.

002.14 URBAN. Douglas, Lancaster, Sarpy, and Washington Counties. Rural means all other Nebraska counties.

002.15 WAIVERED FACILITY. Facilities for which the State Certification Agency has waived professional nurse staffing requirements of omnibus budget reconciliation act of 1987 are classified as waivered if the total number of waivered days exceeds 90 calendar days at any time during the reporting period.

002.16 WEIGHTED RESIDENT DAYS. A facility's inpatient days, as adjusted for the acuity level of the residents in that facility.

003. GENERAL INFORMATION . Wherever applicable, the principles of reimbursement for provider's cost and the related policies under which the Medicare extended care facility program functions Medicare's Provider Reimbursement Manual, HIM-15, updated by provider reimbursement manual revisions in effect as of the beginning of each applicable cost report period are used in determining the cost for Nebraska nursing facilities with exceptions noted in this section. Chapter 15, Change of Ownership, of HIM-15 is excluded in its entirety. That portion of a provider's allowable cost for the treatment of Medicaid patients is payable under Medicaid except as limited in this section. The aggregate payments by the Department do not exceed amounts which would be paid under Title XVIII principles of reimbursement for extended care facilities. Except for Indian Health Services nursing facility providers, a provider with 1,000 or fewer Medicaid inpatient days during a complete fiscal year report period will not file a cost report.

004. ALLOWABLE COSTS . The following items are allowable costs under Medicaid:

004.01 COST OF MEETING LICENSURE AND CERTIFICATION STANDARDS. Allowable costs for meeting licensure and certification standards are those costs incurred in order to:

(A) Meet the definition and requirements for a nursing facility of Title XIX of the Social Security Act, Section 1919; (B) Comply with the standards prescribed by the Secretary of the Federal Health and Human Services for nursing facilities in 42 Code of Federal Regulations (CFR) 442; (C) Comply with requirements established by the Nebraska Department of Health and Human Services Division of Public Health standards, under 42 CFR 431.610; and (D) Comply with any other state law licensing requirements necessary for providing nursing facility services, as applicable.

004.02 ROUTINE SERVICES. Routine nursing facility services include regular room, dietary, and nursing services; social services where required by certification standards; minor medical supplies; oxygen and oxygen equipment; the use of equipment and facilities; and other routine services.

004.03 ANCILLARY SERVICES. Ancillary services are those services which are either provided by or purchased by a facility and are not properly classified as routine services. The facility must contract for ancillary services not readily available in the facility. If ancillary services are provided by a licensed provider or another licensed facility, the ancillary service provider must submit a separate claim for each client served. Allowable costs paid to physical, occupational, and speech therapists are limited to reasonable amounts paid for general consulting services plus reasonable transportation costs not covered through direct billing. General consulting services are not client specific, but instead, are staff related. These services include staff education, in-services, and seminars. Respiratory therapy is an allowable cost. Department-required independent qualified mental retardation professional assessments are considered ancillary services.

004.04 PAYMENTS TO OTHER PROVIDERS. Items for which payment may be authorized to non-nursing facility providers and are not considered part of the facility's Medicaid Per Diem are listed below. To be covered, the client's condition must meet the criteria for coverage for the item as outlined in the appropriate Medicaid provider chapter. The provider of the service may be required to request prior authorization of payment for the service. Items for which payment may be authorized are:

(A) Legend drugs, over the counter drugs, and compounded prescriptions, including intravenous solutions and dilutants. Bulk supply over the counter drugs may be provided by the facility in accordance with physician orders and then become an allowable cost on the facility’s cost report; (B) Personal appliances and devices, if recommended in writing by a physician; (C) Orthoses, lower and upper limb, foot and spinal; (D) Prostheses, breast, eye, lower and upper limb; (E) Ambulance services required to transport a client to obtain and after receiving Medicaid-covered medical care;

(i) To be covered, ambulance services must be medically necessary and reasonable. Medical necessity is established when the client's condition is such that use of any other method of transportation is contraindicated. In any case in which some means of transportation other than an ambulance could be used without endangering the client's health, whether or not such other transportation is actually available, Medicaid will not make payment for ambulance service; or (ii) Non-emergency ambulance transports to a physician or practitioner’s office, clinic, or therapy enter are covered when the client is bed confined before, during and after transport and when the services cannot or cannot reasonably be expected to be provided at the client’s residence, including the nursing facility.

004.05 PAYMENTS TO NURSING FACILITY PROVIDER SEPARATE FROM PER DIEM RATES. Items for which payment may be made to nursing facility providers and are not considered part of the facility's Medicaid per diem are listed below. To be covered, the client's condition must meet the criteria for coverage for the item outlined in the appropriate Medicaid provider chapter. Reimbursement to nursing facility providers separate from per diem rates is based on a Medicaid fee schedule. Except as otherwise noted in the plan, state-developed fee schedule rates are the same for both governmental and private providers of nursing facility services. The agency’s fee schedule rate was set as of October 1, 2017, and is effective for services provided on or after that date. Items for which payment may be made are:

(A) Non-standard wheelchairs, including power-operated vehicles, and wheelchair seating systems, including certain pressure reducing wheelchair cushions, needed for the client's permanent and full-time use; (B) Air fluidized bed units and low air loss bed units; and (C) Negative pressure wound therapy.

005. UNALLOWABLE COSTS . The following costs are specifically unallowable:

(A) Provisions for income tax; (B) Fees paid board of directors; (C) Non-working officers' salaries; (D) Promotion expenses, except for promotion and advertising as allowed in HIM-15. Yellow Page display advertising is not allowable; one Yellow Page informational listing per local area telephone directory is allowable; (E) Travel and entertainment, other than for professional meetings and direct operations of facility; (F) Donations; (G) Expenses of non-nursing home facilities and operations included in expenses; (H) Insurance or annuity premiums on the life of the officer or owner; (I) Bad debts, charity, and courtesy allowances; (J) Costs and portions of costs which are determined by the Department not to be reasonably related to the efficient production of service because of either the nature or amount of the particular expenditure; (K) Services provided by the clients' physicians, therapists or dentists, drugs, laboratory services, radiology services, or services provided by similar independent licensed providers, except services provided by state operated facilities. These exclusions are paid separately; (L) Return on equity; (M) Carry-over of costs lost due to any limitation in this system; (N) Expenses for equipment, facilities, and programs provided to clients which are determined by the Department not to be reasonably related to the efficient production of service because of either the nature or amount of the particular service; and (O) Revisit fees.

006. LIMITATIONS FOR RATE DETERMINATION . The Department applies the following limitations for rate determination.

006.01 EXPIRATION OR TERMINATION OF LICENSE OR CERTIFICATION. The Department does not make payment for care provided 30 days after the date of expiration or termination of the provider's license or certificate to operate under Medicaid. The Department does not make payment for care provided to individuals who were admitted after the date of expiration or termination of the provider's license or certificate to operate under Medicaid.

006.02 TOTAL INPATIENT DAYS. In computing the provider's allowable per diem rates, total inpatient days are used. Payment for holding beds for patients in acute hospitals or on therapeutic home visits is permitted if the policy of the facility is to hold beds for private patients and if the patient's bed is actually held. Bed holding is allowed for 15 days per hospitalization and for up to 18 days of therapeutic home visits per calendar year. Both bed hold days and therapeutic leave days for in-state nursing facilities are reimbursed equal to the resident’s applicable level of care classification. Medicaid inpatient days are days for which claims or electronic Standard Health Care Claim: Institutional transaction, ASC X12N 837, from the provider have been processed by the Department. The Department will not consider days for which a claim has not been processed unless the provider can show justification to the Department's satisfaction. Days for which the client's Medicaid eligibility is in a spenddown category are considered Medicaid inpatient days in compiling inpatient days. A facility may not impose charges that exceed the payment rate established under this chapter for these days. An inpatient day is:

(A) A day on which a patient occupies a bed at midnight. When a client is admitted to a facility and dies before midnight on the same day, one day is counted and paid; or (B) A day on which the bed is held for hospital leave or therapeutic home visits.

006.03 START-UP COSTS. All new providers entering Medicaid must capitalize and amortize their allowable start-up costs. Only those costs incurred three months before the admission of the first resident, private or Medicaid, may be capitalized and amortized. These costs must be documented and submitted with the provider's initial cost report. Amortization of these costs begins on the date of the first admission and must extend over at least 36 months but must not exceed 60 months.

006.04 COMMON OWNERSHIP OR CONTROL. Costs applicable to services, facilities, and supplies furnished to a provider by organizations related to the provider by common ownership or control must not exceed the lower of the cost to the related organization or the price of comparable services, facilities, or supplies purchased elsewhere. An exception to the general rule applies if the provider demonstrates by convincing evidence to the Department's satisfaction that:

(A) The supplying organization is a bona fide separate organization; (B) A substantial part of the supplying organization's business activity is transacted with other than the provider and organizations related to the supplier by common ownership or control, and there is an open competitive market for the type of services, facilities, or supplies furnished by the organization; (C) The services, facilities, or supplies are those which commonly are obtained by institutions like the provider from other organizations and are not a basic element of patient care ordinarily furnished directly to patients by similar institutions. Costs of contracted labor obtained from a related party are limited to the salaries paid to the individual workers for their time working at the facility, plus applicable payroll taxes and employee benefits. The exception to the related party rule does not apply; and (D) The charge to the provider is in line with the charge for those services, facilities, or supplies in the open market, and is no more than the charges made under comparable circumstances to others by the organization for those services, facilities, or supplies.

006.05 LEASED FACILITIES. Allowable costs leased facilities including all personal property covered in the lease, entered into after July 31, 1982, must not exceed the actual cost of the lessor for depreciation, interest on lessor's mortgage, and other costs of ownership incurred as a condition of the lease. If the lessor sells the facility, all provisions of this chapter will apply. All interest must be specifically identified or reasonably allocated to the asset. All actual costs to the lessor are computed according to the rate setting principles of this section. If costs are claimed for leases, the lease agreement must provide that the lessor will:

(A) Provide an itemized statement at the end of each provider's report period which includes depreciation, interest, and other costs incurred as a condition to the lease; and (B) Make records available for audit upon request of the Department, the federal Department of Health and Human Services, or their designated representatives.

006.06 HOME OFFICE COSTS - CHAIN OPERATIONS. A chain organization consists of a group of two or more health care facilities which are owned, leased, or through any other device, controlled by one organization. Chain organizations include, but are not limited to, chains operated by proprietary organizations and chains operated by various religious, charitable, and governmental organizations. A chain organization may also include business organizations which are engaged in other activities not directly related to healthcare. Home offices of chain organizations vary greatly in size, number of locations, staff, mode of operations, and services furnished to the facilities in the chain. The home office of a chain is not a provider in itself; therefore, its costs may not be directly reimbursed by the program. The relationship of the home office to the Medicaid program is that of a related organization to participating providers. To the extent the home office furnishes services related to patient care to a provider, the reasonable costs of such services are includable in the cost report. Costs allocated under HIM-15, Section 2150.3.B, are limited to direct patient care services provided at the facility and must be included in the applicable cost category. Costs allocated under HIM-15, Sections 2150.3C and 2150.3D, are included in the administration cost category. The Medicaid does not distinguish between capital related and non-capital related interest expense and interest income.

006.07 INTEREST EXPENSE. Interest cost will not be allowed on loan principal balances which are in excess of 80 percent of the fixed asset cost recognized by the Department for nursing facility care. This limitation does not apply to government owned facilities.

006.08 RECOGNITION OF FIXED COST BASIS. The fixed cost basis of real property, and personal property for facilities purchased on or after July 1, 2020, as an ongoing operation or for newly constructed facilities or facility additions is the lesser of, the acquisition cost of the asset to the purchaser; or for facilities purchased as an ongoing operation on or after July 1, 2020, the seller’s Medicaid net book value at the time of purchase. Costs, including legal fees, accounting and administrative costs, travel costs, and the costs of feasibility studies, attributable to the negotiation or settlement of the sale or purchase of any capital asset, by acquisition or merger, for which any payment has previously been made are not allowable.

006.09 SALARIES OF ADMINISTRATORS, OWNERS, AND DIRECTLY RELATED PARTIES. Compensation received by an administrator, owner, or directly related party is limited to a reasonable amount for the documented services provided in a necessary function. Reasonable value of the documented services rendered by an administrator is determined from Medicare regulations and administrator salary surveys for the Kansas City Region, adjusted for inflation by the federal Department of Health and Human Services. Beginning with the following calendar year base numbers for 12/31/2010, the Administrator Compensation Maximum Amounts can be calculated based on the following methodology.

006.09(A) 2010 BASE NUMBERS. The base numbers for 2010 to be used in the below calculation are: HIM%: 1.5%; Beds 0-74: 81,490; Beds 75-79: 82,954; Beds 100-149: 98,569; Beds 150-200: 99,544; Beds 200 or greater: 146,388.

006.09(B) CALCULATION. To determine the maximum amount for state fiscal year 2011, for each bed category, add 1 to the Calendar Year 2010 HIM % and multiply this amount by 50% of the Calendar Year 2010 bed total. To this amount add 50% of the Calendar Year 2010 bed total. For future years update the calendar year information above (A) by replacing the HIM % with the updated HIM % from HIM 15 Section 905.6.

006.09(C) COMPENSATION TO BE INCLUDED. All compensation received by an administrator is included in the administration cost category unless an allocation has prior approval from the Department. Reasonable value of the documented services rendered by an owner or directly related party who hold positions other than administrator is determined by comparison to salaries paid for comparable position or positions within the specific facility, if applicable, or, if not applicable, then comparison to salaries for comparable position or positions as published by the Department of Administrative Services, Division of State Personnel in the State of Nebraska Salary Survey.

006.10 ADMINISTRATION EXPENSE. In computing the provider's allowable cost for determination of the rate, administration expense is limited to no more than 14 percent of the total otherwise allowable direct nursing and support services components for the facility. This computation is made by dividing the total allowable direct nursing and support services Components, less the administration cost category, by 0.86. The resulting quotient is the maximum allowable amount for the direct nursing and support services components, including the administration cost category. If a facility's actual allowable cost for the two components exceeds this quotient, the excess amount is used to adjust the administration cost category.

006.11 DIRECT NURSING COSTS. Direct nursing costs include cost report lines 94 through 103.

006.12 PLANT RELATED COSTS. Plant related costs include cost report lines 129 through 163.

006.13 EQUIPMENT LEASE AND MAINTENANCE AGREEMENTS. Costs of equipment lease or maintenance agreements that include or are tied to usage or supplies must be reported in the operating cost category that most closely relates to the equipment.

006.14 OTHER LIMITATIONS. Other limitations to specific cost components of the rate are included in the rate determination provision of this system.

006.15 NURSING FACILITY QUALITY ASSESSMENT. The nursing facility quality assessment is an allowable cost addressed through the nursing facility quality assessment component.

007. RATE DETERMINATION . The Department determines rates for facilities under the following cost-based prospective methodology.

007.01 RATE PERIODS. The Rate Periods are defined as July 1 through December 31, and January 1 through June 30. Rates paid during the rate periods are determined from base year cost reports. For purposes of this section, base year cost reports means full and part-year cost reports filed with a base year report period ending date of June 30.

007.02 REPORT PERIOD. Each facility must file a cost report each year for the reporting period of July 1 through June 30 or part-year cost reports, when applicable.

007.03 CARE CLASSIFICATIONS. A portion of each individual facility's rate may be based on the urban or rural location of the facility.

007.04 PROSPECTIVE RATES. Subject to the allowable, unallowable, and limitation provisions of this chapter, the Department determines facility-specific prospective per diem rates, one rate corresponding to each level of care, based on the facility's allowable costs incurred and documented during the base year report period. The rates are based on financial, acuity, and statistical data submitted by facilities, and are subject to the component maximums and minimums. Component maximums and minimums are computed using audited data following the initial desk audits and are not revised based on subsequent changes to the data. Only cost reports with a full year's data are used in the computations. Cost reports from providers entering or leaving Medicaid during the immediately preceding report period are not used in the computations. Each facility's prospective rates are the sum of the following components; the direct nursing component adjusted by the inflation factor and weighted for level of care; the support services component adjusted by the inflation factor; the fixed cost component; the nursing facility quality assessment component; and the quality measures component. The direct nursing component and the support services component are subject to maximum and minimum per diem payments based on Median or Maximum computations. For each care classification, the median for the direct nursing component is computed using nursing facilities within that care classification with an average occupancy of 40 or more residents, excluding waivered, or facilities with partial or initial or final full year cost reports. For each care classification, the median for the support services component is computed using nursing facilities within that care classification with an average occupancy of 40 or more residents, excluding hospital based, waivered, or facilities with partial or initial or final full year cost reports. The Department will reduce the direct nursing component median by 2% for facilities that are waivered from the 24-hour nursing requirement to take into account those facilities’ lowered nursing care costs. The maximum per diem is computed as 105% of the median direct nursing component, and 100% of the median support services component. The Department will reduce the direct nursing component maximum by 2% for facilities that are waivered from the 24-hour nursing requirement to take into account those facilities’ lowered nursing care costs. The minimum per diem is computed as 77% of the median direct nursing component, and 72% of the median support services component. The fixed cost component is subject to a maximum Per Diem of $27.00, excluding personal property and real estate taxes.

007.04(A) DIRECT NURSING COMPONENT. This component of the prospective rate is computed by dividing the base year allowable direct nursing costs, lines 94 through 103 of Form FA-66, Long Term Care Cost Report, by the base year weighted resident days for each facility. The resulting quotient is the facility’s computed base year per diem. The computed base year per diem is subject to the component maximum per diem and minimum per diem for rate determination purposes.

007.04(B) SUPPORT SERVICES COMPONENT. This component of the prospective rate is computed by dividing the base year allowable costs for support services, lines 34, 63, 78, 93, 104 through 127, 163, 184, and 185 from the FA-66; Resident Transportation - Medical from the Ancillary Cost Center, line 219 from the FA-66; and respiratory therapy from the Ancillary Cost Center, line 210 from the FA-66, by the total base year inpatient days for each facility. The computed base year per diem is subject to the component maximum per diem and minimum per diem for rate determination purposes.

007.04(C) FIXED COST COMPONENT. This component of the prospective rate is computed by dividing the facility's base year allowable interest, depreciation, amortization, long-term rent or lease payments, personal property tax, real estate tax, and other fixed costs by the facility's total base year inpatient days. Rate determination for the Fixed Cost Component for an individual facility is computed using the lower of its own per diem as computed above, plus any prior approved increase under 471 NAC 45-007.05, or a maximum per diem of $27.00 excluding personal property and real estate taxes.

007.04(D) NURSING FACILITY QUALITY ASSESSMENT COMPONENT. The Nursing Facility Quality Assessment component shall not be subject to any cost limitation or revenue offset. For purposes of this section, facilities exempt from the quality assurance assessment are state-operated veterans’ homes; nursing facilities and skilled nursing facilities with twenty-six or fewer licensed beds; and continuing care retirement communities. the quality assessment component rate will be determined by calculating the anticipated tax payment’ during the rate year and then dividing the total anticipated tax payments by total anticipated nursing facility or skilled nursing facility patient days, including bed hold days and Medicare patient days. for each rate year, July 1 through the following June 30, total facility patient days, including bed hold days, less Medicare days, for the four most recent calendar quarters available at the time rates are determined will be used to calculate the anticipated tax payments. Total facility patient days, including bed hold days and Medicare days, for the same four calendar quarters will be used to calculate the anticipated nursing facility or skilled nursing facility patient days. For new providers entering the Medicaid program to operate a nursing facility not previously enrolled in Medicaid, for the rate period beginning on the Medicaid certification date through the following June 30, the quality assessment rate component is computed as the quality assurance assessment amount due from the provider’s first quality assurance assessment form covering a full calendar quarter, divided by total resident days in licensed beds from the same quality assurance assessment form. for existing providers changing from exempt to non-exempt status, for the rate period beginning on the first day of the first full month the provider is subject to the quality assurance assessment through the following June 30, the quality assessment rate component is computed as the quality assurance assessment amount due from the provider’s first quality assurance assessment form covering a full calendar quarter, divided by total resident days in licensed beds from the same quality assurance assessment form. For existing providers changing from non-exempt to exempt status, for rate periods beginning with the first day of the first full month the provider is exempt from the quality assurance assessment, the quality assessment rate component will be $0.00 (zero dollars).

007.04(E) BASE YEAR REPORT PERIOD AND INFLATION FACTOR. For the Rate Periods July 1 through December 31 and January 1 through June 30, the base year is updated no less frequently than every 5 years. The inflation factor is updated annually.

007.04(F) QUALITY MEASURES COMPONENT. This component of the prospective rate is based on the quality measures component of the Centers for Medicare & Medicaid nursing facility star rating system. The published rating as of May 1 is used to determine the rate component for the following July 1 through December 31 rate period. The published rating as of November 1 is used to determine the rate component for the following January 1 through June 30 rate period. Per Diem amounts corresponding to the quality measures rating are: 5-star rating = $10.00 a day; 4-star rating = $6.75 a day; 3- star rating = $3.50 a day; 1-star, 2-star, or NR (no rating) = $0.00 (zero dollars). This component applies to all nursing facility care levels (101-180).

007.05 EXCEPTION PROCESS. An individual facility may request, on an exception basis, the Medicaid Director or designee, to consider specific facility circumstance or circumstances, which warrant an exception to the facility's rate computed for its fixed cost component. For existing facilities, an exception may only be requested if the facility's total annualized fixed costs, total costs, not per diem rate, as compared to the annualized base year costs, have increased by twenty percent or more. Facilities without a base year cost report, and with 1,000 or more annualized Medicaid days, may only request an exception if the facility’s fixed costs per day, computed using an 85% minimum occupancy, exceeds the care classification average fixed cost component by 20% or more. In addition, the facility's request must include: Specific identification of the increased cost or costs that have caused the facility's total fixed costs to increase by 20% or more, with justification for the reasonableness and necessity of the increase; Whether the cost increase or increases are an ongoing or a one-time occurrence in the cost of operating the facility; and If applicable, preventive management action that was implemented to control past and future cause or causes of identified cost increase or increases. Approved increases from July 1 through December 31, will be effective the following January 1. Approved increases from January 1 through June 30, will be effective the following July 1.

007.06 RATE PAYMENT FOR ASSISTED LIVING LEVELS OF CARE. The payment rate for Levels of Care 201 and 202 is the applicable rate in effect for assisted living services under the Home and Community-Based Waiver Services for Aged Persons or Adults or Children with Disabilities adjusted to include the nursing facility quality assessment component and quality measures component.

007.07 OUT-OF-STATE FACILITIES. The Department pays out-of-state facilities participating in Medicaid at the rates established by that state’s Medicaid program for nursing facility days, bed hold days and therapeutic leave days at the time of establishment of the Medicaid provider agreement. The rates are periodically updated to align with the current and applicable rates assigned by the out-of-state facility’s State Medicaid program.

007.08 RATES FOR PROVIDERS WITHOUT A BASE YEAR COST REPORT. A provider without a base year cost report is an individual or entity which obtains their initial, facility-specific provider agreement to operate an existing nursing facility, meaning the business operation, not the physical property, due to a change in ownership, or to operate a nursing facility not previously enrolled in Medicaid, after the base year cost report end date; or a provider with 1,000 or fewer Medicaid inpatient days in the base year. Prospective Medicaid rates for providers without a base year cost report are the sum of the following components:

(A) The applicable urban or rural average direct nursing base rate component of all other providers in the same care classification, adjusted by the inflation factor; and weighted for level of care; (B) The applicable urban or rural average support services base rate component of all other providers in the same care classification, adjusted by the inflation factor; (C) The applicable urban or rural average fixed cost base rate component of all other providers in the same care classification; (D) The Nursing Facility Quality Assessment component; and (E) The quality measures component.

007.09 PROVIDERS LEAVING THE MEDICAID. Providers leaving Medicaid as a result of change of ownership or exit from the program shall comply with provisions of this chapter.

007.10 SPECIAL FUNDING PROVISIONS FOR GOVERNMENTAL FACILITIES. City and county-owned and operated nursing facilities are eligible to receive the federal financial participation share of allowable costs exceeding the rates paid for the direct nursing, support services, and fixed cost Components for all Medicaid residents. The reimbursement is subject to the payment limits of 42 CFR 447.272.

007.10(A) CITY OR COUNTY OWNED FACILITIES. City or county-owned facilities with a 40% or more Medicaid mix of inpatient days are eligible to receive the federal financial participation share of allowable costs exceeding the applicable maximums for the direct nursing, support services, and fixed cost components. This amount is computed after desk audit and determination of final rates for a report period by multiplying the current Medicaid federal financial participation percentage by the facility's allowable costs above the respective maximum for the direct nursing, support services, and fixed cost components. Verification of the eligibility of the expenditures for federal financial participation is accomplished during the audit process.

007.11 SPECIAL FUNDING PROVISIONS FOR INDIAN HEALTH SERVICES NURSING FACILITY PROVIDERS. Indian Health Services nursing facility providers are eligible to receive the federal financial participation share of allowable costs exceeding the rates paid for the direct nursing, support services, and fixed cost components for all Medicaid residents.

007.11(A) INDIAN HEALTH SERVICES. Indian Health Services providers may receive quarterly, interim Special Funding payments by filing quarterly cost reports, FA-66, for periods ending September 30, December 31, or March 31. Quarterly, interim special funding payments are retroactively adjusted and settled based on the provider’s corresponding annual cost report for the period ending June 30. Quarterly, interim payments and the retroactive settlement amount are calculated in accordance with section (ii) below. If the average daily census from a quarterly cost report meets or exceeds 85% of licensed beds, this shall be the final quarterly cost report filed by the provider. Subsequent quarterly, interim special funding payments shall be based on the final quarterly cost report. Quarterly, interim Special Funding payments may also be revised based on data from the annual cost reports.

(i) Quarterly, interim special funding payments shall be made within 30 days of receipt of the quarterly cost report or requested supporting documentation. Quarterly, interim special funding payments subsequent to the payment for the final quarterly cost report shall be made on or about 90-day intervals following the previous payment. (ii) The special funding amount is computed after desk audit and determination of allowable costs for the report period. The amount is calculated by adding the following two figures:

(1) The allowable federal medical assistance percentage for Indian Health Services-eligible Medicaid residents multiplied by the difference between the allowable costs for all Indian Health Services-eligible Medicaid residents and the total amount paid for all Indian Health Services-eligible Medicaid residents, if greater than zero; and (2) The allowable federal medical assistance percentage for non-Indian Health Services-eligible Medicaid residents multiplied by the difference between the allowable costs for all non-Indian Health Services-eligible Medicaid residents and the total amount paid for all non-Indian Health Services-eligible Medicaid residents, if greater than zero.

008. DEPRECIATION . This subsection replaces Medicare regulations on depreciation in their entirety, except those provisions concerning sale-leaseback and lease-purchase agreements, Medicare's Provider Reimbursement Manual, HIM-15, Section 110, are retained, subject to the following Medicaid depreciation regulations. At the time of an asset acquisition, the nursing facility must use the American Hospital Association Estimated Useful Lives of Depreciable Hospital Assets, 2004 edition, to determine the useful life span. In the event that the nursing facility determines a useful life shorter than a life shown in the tables, the facility must have documentation available to justify the unique circumstances that required the shorter life.

008.01 CAPITALIZATION GUIDELINES. Providers must devise and follow a written capitalization policy within the following guidelines. A copy of the policy must be available upon request by the Department.

008.01(A) CAPITALIZATION THRESHOLD. The capitalization threshold is a pre-determined amount at which asset purchases must be capitalized rather than expensed. Each provider determines the capitalization threshold for their facility, but the threshold amount must be at least $100 and no greater than $5,000.

008.01(B) ACQUISITIONS. If a depreciable asset has at the time of its acquisition an estimated useful life of at least two years and an allowable cost equal to or exceeding the capitalization threshold, its cost must be capitalized and written off ratably over the estimated useful life of the asset. If a depreciable asset has an allowable cost less than the capitalization threshold, or if the asset has a useful life of less than 2 years, its cost is allowable in the year it is acquired.

008.01(C) ACQUISITIONS UNDER $100. Acquisitions after July 1, 2005, with a per unit cost of less than $100 cannot be depreciated. Costs of these items are included in the applicable operating cost category on the cost report in the current period.

008.01(D) INTEGRATED SYSTEM PURCHASES. When items are purchased as an integrated system, all items must be considered as a single asset when applying the capitalization threshold.

008.01(E) MULTIPLE ITEMS WITH PER UNIT COST GREATER THAN OR EQUAL TO $100. Items that have a stand-alone functional capability may be considered on an item-by-item basis or as an aggregate single purchase. Each provider’s capitalization policy must describe how the provider elects to treat these items.

008.01(F) NON-CAPITAL PURCHASES. Purchases of equipment and furnishings over $100 per item and under the provider's capitalization threshold are included in the Plant Related cost category on the Cost Report in the current period.

008.01(G) BETTERMENTS AND IMPROVEMENTS. Betterments and improvements extend the life, increase the productivity, or significantly improve the safety of an asset as opposed to repairs and maintenance which either restore the asset to, or maintain it at, its normal or expected service life. Repair and maintenance costs are always allowed in the current accounting period.

008.02 BUILDINGS AND EQUIPMENT. An appropriate allowance for depreciation on buildings and equipment is an allowable cost. The depreciation must be:

(A) Identifiable and recorded in the provider's accounting records; (B) Based on book value of the asset or assets in use before July 1, 1976. Book value for these purposes is defined as cost less depreciation allowed or allowable per American Hospital Association or Internal Revenue Service guidelines; (C) Based on the lesser of cost or fair market value at the time of purchase for a facility purchased or constructed after June 30, 1976. The basis for facility purchases or new construction may be subject to limitation; (D) Based on the fair market value at the time of donation for donated assets without a prior Medicaid basis; or based on the donor’s Medicaid net book value at the time of the donation for donated assets with a prior Medicaid basis. Depreciation on donated assets must be funded in order to be allowed; this requires that money be segregated and specifically dedicated for the purpose of replacing the asset; and (E) Prorated over the estimated useful life of the asset using the straight-line method of depreciation.

008.03 OTHER GAINS AND LOSSES ON DISPOSITION OF ASSETS. Losses on the sale of real property are not recognized under Medicaid. Losses on the disposal of replaced building components that have been specifically identified in the nursing facility's depreciation schedule since acquisition will be included in the allowable fixed cost for the report period. Gains or losses on personal property will be reduced from or included in allowable fixed costs for the report period. Gains in excess of the other allowable fixed costs will result in a negative fixed cost component of the facility's rate.

008.04 SALE OR TRANSFER OF CORPORATE STOCK. Where the existing corporation continues after the sale or transfer of corporate stock, the depreciable basis of assets used under the program will be that of the then existing corporation. No revaluation of assets is allowed when only an acquisition of stock is involved.

009. REPORTING REQUIREMENTS AND RECORD RETENTION . Providers with greater than 1,000 Medicaid inpatient days for a full Report Period must submit cost and statistical data on Form FA-66, Report of Long-Term Care Facilities for Reimbursement. Data must be compiled on the basis of generally accepted accounting principles and the accrual method of accounting for the report period. If conflicts occur between generally accepted accounting principles and requirements of this regulation, the requirements of this regulation will prevail. Financial and statistical records for the period covered by the cost report must be accurate and sufficiently detailed to substantiate the data reported. All records must be readily available upon request by the Department for verification of the reported data. If records are not accurate, sufficiently detailed, or readily available, the Department may correct, reduce, or eliminate data. Providers are notified of changes. Each facility must complete the required schedules and submit the original, signed report to the Department within 90 days of the close of the reporting period, when a change in ownership or management occurs, or when terminated from participation in Medicaid. Under extenuating circumstances, an extension not to exceed 45 days may be permitted. Requests for extensions must be made in writing before the date the cost report is due. When a provider fails to file a cost report as due, the Department will suspend payment. At the time the suspension is imposed, the Department will send a letter informing the provider that if a cost report is not filed, all payments made since the end of the cost report period will be deemed overpayments. The provider must maintain levels of care if the Department suspends payment. If the provider takes no action to comply with the obligation, the Department may refer the case for legal action. If a required cost report has not been filed, the sum of the following is due: all prospective rate payments made during the rate period to which the cost report applies; all prospective rate payments made subsequent to the accounting rate period to which the cost report applies; and costs incurred by the department in attempting to secure reports and payments. If the provider later submits an acceptable cost report, the Department will undertake the necessary audit activities. Providers will receive all funds due them reflected under the properly submitted cost reports less any costs incurred by the Department as a result of late filing. Providers must retain financial records, supporting documents, statistical records, and all other pertinent records related to the cost report for a minimum of five years after the end of the report period or until an audit started within the five years is finalized, whichever is later. Records relating to the acquisition and disposal of fixed assets must be retained for a minimum of five years after the assets are no longer in use by the provider. The Department will retain all cost reports for at least five years after receipt from the provider. Facilities which provide any services other than certified nursing facility services must report costs separately, based on separate cost center records. As an alternative to separate cost center records and for shared costs, the provider may use a reasonable allocation basis documented with the appropriate statistics. All allocation bases must be approved by the Department before the rep ort period. A Medicare certified facility must not report costs for a level of care to the Department which have been reported for a different level of care on a Medicare cost report.

009.01 DISCLOSURE OF COST REPORTS. Cost reports for all report periods ending October 30, 1990, or thereafter, are available for public inspection by making a written request to the Division. The request must include the name, including an individual to contact, address, and telephone number of the individual or organization making the request; the nursing facility name, location, and report period for the cost report requested; and directions for handling the request, review the reports at the Department's Lincoln State Office Building address; pick up copies at that office; or mail copies. The total fee, based on current Department policy, must be paid in advance. The nursing facility will receive a copy of a request to inspect its cost report.

010. AUDITS . The Department will perform at least one initial desk audit and may perform subsequent desk audits or a periodic field audit of each cost report. Selection of subsequent desk audits and field audits will be made as determined necessary by the Department to maintain the integrity of the Nebraska Medical Assistance Program. The Department may retain an outside independent public accounting firm, licensed to do business in Nebraska or the state where the financial records are maintained, to perform the audits. Audit reports must be completed on all field audits and desk audits. All audit reports will be retained by the Department for at least three years following the completion and finalization of the audit. An initial desk audit will be completed on all cost reports. Care classification maximums and average base rate components are computed using audited data following the end of the Cost Report Period. Subsequent desk and field audits will not result in a revision of care classification maximums or average base rate components. All cost reports, including those previously desk audited but excluding those previously field audited, are subject to subsequent desk audits. The primary period or periods and subject or subjects to be desk-audited are indicated in a notification letter sent to the provider to initiate a subsequent desk audit. The provider must deliver copies of schedules, summaries, or other records requested by the Department as part of any desk audit. All cost reports, including those previously desk-audited but excluding those previously field-audited, are subject to field audit by the Department. The primary period or periods to be field-audited are indicated in a confirmation letter, which is mailed to the facility before the start of the field work. A field audit may be expanded to include any period otherwise open for field audit. The scope of each field audit will be determined by the Department. The provider must deliver to the site of the field audit, or an alternative site agreed to by the provider and the Department, any records requested by the Department as part of a field audit.

011. SETTLEMENT AND RATE ADJUSTMENTS . When an audit has been completed on a cost report, the Department will determine if an adjustment to the rate is required; if necessary, a settlement amount is determined. The facility will be notified of the settlement on a remittance advice. Payment or arrangements for payment of the settlement amount, by either the Department or the provider, must be made within 45 days of the settlement notice unless an administrative appeal filed within the appeal period is also filed within the 45-day repayment period. Administrative appeals filed after the 45-day payment period will not stay repayment of the settlement amount. The filing of an administrative appeal will not stay repayments to the Department for audit adjustments not included in the appeal request. The Department may adjust the interim rate for payments made after the audit completion. The Department will determine a final adjustment to the rate and settlement amount after the audit is final and all appeal options have been exhausted. Payment for any final settlement must be made within 30 days. If payment is not made, the Department will immediately begin recovery from future facility payments until the amount due is fully recovered. The Department will report an overpayment to the federal government on the appropriate form no later than the second quarter following the quarter in which the overpayment was found.

012. PENALTIES . Under federal law, the penalty for making a false statement or misrepresentation of a material fact in any application for Medicaid payments and for soliciting, offering, or accepting kickbacks or bribes, including the rebate of a portion of a fee or charge for a patient referral, is imprisonment up to five years, a fine of $25,000, or both. Similarly, making a false statement of material fact about conditions or operations of any institution is a felony punishable by up to five years imprisonment, a fine of not more than $25,000, or both.

013. APPEAL PROCESS . Final administrative decision or inaction in the allowable cost determination process is subject to administrative appeal. The provider may request an appeal in writing from the Division Director. The request for an appeal must include identification of the specific adjustments or determinations being appealed and basis or explanation of each item, or both. After the Division Director issues a determination in regard to the administrative appeal, the Department will notify the facility of the final settlement amount. Repayment of the settlement amount must be made within 30 days of the date of the letter of notification.

014. ADMINISTRATIVE FINALITY . Administrative decision or inaction in the allowable cost determination process for any provider, which is otherwise final, may be reopened by the Department within three years of the date of notice of the decision or inaction. Reopening means an action taken by the Division Director to reexamine or question the correctness of a determination or decision which is otherwise final. The Division Director is the sole authority in deciding whether to reopen. The action may be taken on the initiative of the Department within the three-year period; in response to a written request from a provider or other entity within the three-year period. Whether the Division Director will reopen a determination, which is otherwise final, depends on whether new and material evidence has been submitted, a clear and obvious error has been made, or the determination is found to be inconsistent with the law, regulations and rulings, or general instructions; or anytime fraud or abuse is suspected. A provider does not have the right to appeal a finding by the Division Director that a reopening or correction of a determination or decision is not warranted.

015. CHANGE OF HOLDER OF PROVIDER AGREEMENT . A holder of a provider agreement receiving payments under 12-011 must notify the Department 60 days before any change or termination regarding the holder of the provider agreement. If any known settlement is due the Department by that provider, payment must be made immediately. If the provider is subject to recapture of depreciation on the anticipated sale or if an audit is in process, the provider will be required to provide a guarantee of repayment of the Department's estimated settlement either by payment of that amount to the Department, providing evidence that another provider receiving payments under this chapter has assumed liability, or by surety bond for payment. All estimated or final amounts, regardless of appeal status, must be paid before the transfer of ownership. The Department will not enter into a provider agreement with a new provider if there is an unpaid settlement payable to the Department by a prior provider of services at the same facility unless the new provider has assumed liability for the unpaid amount. Parties to a facility provider change may receive information about unpaid settlement amounts owed to the Department by making a written request.

016. CLASSIFICATION OF RESIDENTS AND CORRESPONDING WEIGHTS .

016.01 RESIDENT LEVEL OF CARE. The Department will use a federally approved patient driven payment-model grouper to assign a level of care using the information from the minimum data set. Each level of care will be assigned the federally recommended weight. When no minimum data set assessment is available, the resident will be assigned to a default level of care, Level 280.

016.02 WEIGHTING OF RESIDENT DAYS USING RESIDENT LEVEL OF CARE AND WEIGHTS. Each facility resident is assigned to a level of care. Each resident's level of care is appropriately updated from each assessment to the next admission assessment, a significant change assessment, the quarterly review, the annual assessment, etc., and is effective for payment purposes on the first day of the month of the applicable assessment if it is received by the tenth day of the month of the applicable assessment. A change in resident level of care which results from an audit of assessments is retroactive to the effective date of the assessment which is audited. For purposes of the Medicaid case mix system, the Department does not change an assessment record. A record modification may replace an existing record in the Centers for Medicare & Medicaid Services minimum data set data base, but the Department will not replace the existing record in the Medicaid case mix system. The record modification will be processed by the Department as an original record. This means that the Department will process the record in the usual manner if the record is not already in the case mix system. The Department will reject the record as a duplicate if the record has already been accepted into the case mix system. The Department will inactivate a discharge or re-entry tracking record but not an assessment. For each reporting period, the total resident days, per the minimum data set system, at each care level are multiplied by the corresponding weight. The resulting products are summed to determine the total weighted resident days per the minimum data set system. This total is then divided by the minimum data set total resident days per the minimum data set system. This total is then divided by the minimum data set total resident days and multiplied by total resident days per the facility’s Medicaid cost report to determine the total number of weighted resident days for the facility, which is the divisor for the direct nursing component.

016.03 RESIDENT LEVEL OF CARE WEIGHTS. The following weighting factors must be assigned to each resident level of care, based on the Centers for Medicare and Medicaid Services Patient Driven Payment Model Nursing classifications:

(A) Level of care: 272; Case Mix Group: ES3; Description: Extensive Services 3, Tracheostomy and Ventilator; Case Mix Index Value: 4.06; (B) Level of care: 271; Case Mix Group: ES2; Description: Extensive Services 2, Tracheostomy or Ventilator; Case Mix Index Value: 3.07; (C) Level of care: 270; Case Mix Group: ES1; Description: Extensive Services 1, Infection Isolation; Case Mix Index Value: 2.93; (D) Level of care: 263; Case Mix Group: HDE2; Description: Special Care High, Depressed, Function Score 0-5; Case Mix Index Value: 2.40; (E) Level of care: 262; Case Mix Group: HDE1; Description: Special Care High, Not Depressed, Function Score 0-5; Case Mix Index Value: 1.99; (F) Level of care: 261; Case Mix Group: HBC2; Description: Special Care High, Depressed, Function Score 6-14; Case Mix Index Value: 2.24; (G) Level of care: 260; Case Mix Group: HBC1; Description: Special Care High, Not Depressed, Function Score 6-14; Case Mix Index Value: 1.86; (H) Level of care: 253; Case Mix Group: LDE2; Description: Special Care Low, Depressed, Function Score 0-5; Case Mix Index Value: 2.08; (I) Level of care: 252; Case Mix Group: LDE1; Description: Special Care Low, Not Depressed, Function Score 0-5; Case Mix Index Value: 1.73; (J) Level of care: 251; Case Mix Group: LBC2; Description: Special Care Low, Depressed, Function Score 6-14; Case Mix Index Value: 1.72; (K) Level of care: 250; Case Mix Group: LBC1; Description: Special Care Low, Not Depressed, Function Score 6-14; Case Mix Index Value: 1.43; (L) Level of care: 245; Case Mix Group: CDE2; Description: Clinically Complex, Depressed, Function Score 0-5; Case Mix Index Value: 1.87; (M) Level of care: 244; Case Mix Group: CDE1; Description: Clinically Complex, Not Depressed, Function Score 0-5; Case Mix Index Value: 1.62; (N) Level of care: 243; Case Mix Group: CBC2; Description: Clinically Complex, Depressed, Function Score 6-14; Case Mix Index Value: 1.55; (O) Level of care: 241; Case Mix Group: CA2; Description: Clinically Complex, Depressed, Function Score 15-16; Case Mix Index Value: 1.09; (P) Level of care: 242; Case Mix Group: CBC1; Description: Clinically Complex, Not Depressed, Function Score 6-14; Case Mix Index Value: 1.34; (Q) Level of care: 240; Case Mix Group: CA1; Description: Clinically Complex, Not Depressed, Function Score 15-16; Case Mix Index Value: 0.94; (R) Level of care: 221; Case Mix Group: BAB2; Description: Behavior SX Cognition, Restorative Nursing ≥ 2; Case Mix Index Value: 1.04; (S) Level of care: 220; Case Mix Group: BAB1; Description: Behavior SX Cognition, Restorative Nursing = 1 or 2; Case Mix Index Value: 0.99; (T) Level of care: 206; Case Mix Group: PDE2; Description: Reduced Physical Function, Restorative Nursing ≥ 2, Function Score 0-5; Case Mix Index Value: 1.57; (U) Level of care: 205; Case Mix Group: PDE1; Description: Reduced Physical Function, Restorative Nursing = 1 or 2, Function Score 0-5; Case Mix Index Value: 1.47; (V) Level of care: 204; Case Mix Group: PBC2; Description: Reduced Physical Function, Restorative Nursing ≥ 2, Function Score 6-14; Case Mix Index Value: 1.22; (W) Level of care: 202; Case Mix Group: PA2; Description: Reduced Physical Function, Restorative Nursing ≥ 2, Function Score 15-16; Case Mix Index Value: 0.71; (X) Level of care: 203; Case Mix Group: PBC1; Description: Reduced Physical Function, Restorative Nursing = 1 or 2, Function Score 6-14; Case Mix Index Value: 1.13; (Y) Level of care: 201; Case Mix Group: PA1; Description: Reduced Physical Function, Restorative Nursing = 1 or 2, Function Score 15-16; Case Mix Index Value: 0.66; or (Z) Level of care: 280; Casemix Index Value: STS; Casemix Index Description: Short-Term Stay; Casemix Index Value: 0.59; Level of Care 280, Short-Term Stay, is used for stays of less than 14 days when a client is discharged, and the facility does not complete a full minimum data set admission assessment of the client. This is effective for admissions on or after July 1, 2023.

016.04 VERIFICATION. Resident assessment information is audited as a procedure in the Department of Health and Human Services Division of Public Health, Survey and Certification process.

017. SPECIALIZED ADD-ON SERVICES PAYMENTS . Specialized add-on services are paid to the provider or providers of specialized add-on services. Payments to providers for medically necessary services, including specialized add-on services in excess of limitations for covered services identified elsewhere in the state plan, or not listed as specialized add-on services according to the state plan, require pre-authorization.

017.01 SPECIALIZED ADD-ON SERVICES. Except as otherwise noted in the plan, fee schedule rates are the same for both governmental and private providers of specialized add-on services provided in the nursing facility. The Medicaid agency’s rates were set as of June 30, 2018, and are effective for dates of services provided on and after that date.

017.02 HABILITATIVE SERVICES. Except as otherwise noted in the plan, fee schedule rates are the same for both governmental and private providers of habilitative services, provided to individuals residing in a nursing facility. The rates for these specialized add-on services were established using existing developmental disabilities waiver fee schedules. The rates were set as of June 30, 2018, and are effective for dates of service provided on and after that date and updated as specified by the Department.

017.03 SUPERVISORY ACTIVITIES. Payment excludes the supervisory activities rendered as a normal part of the employment support.

018. PAYMENT FOR SERVICES FOR LONG TERM CARE CLIENTS WITH SPECIAL NEEDS . Payment for services to all special needs clients must be prior authorized by Department staff in the Central Office.

018.01 NEBRASKA FACILITIES. To establish a Nebraska facility's payment rate for care of special needs clients:

(A) The facility must submit Form FA-66, Long Term Care Cost Report, to the Department for each fiscal year ending June 30. Medicare cost reporting forms may be substituted when Form FA-66 is not otherwise required to be submitted. Form FA-66 must be completed in accordance with this chapter, Completion of Form FA-66, Long Term Care Cost Report, Rates for Nursing Facility Services, as applicable. Medicare cost reports must be completed in accordance with Medicare's Provider Reimbursement Manual (HIM15). If the facility provides both nursing facility services and special needs services, direct accounting, or cost allocations necessary to distribute costs between the nursing facility and the special needs unit must be approved by the Department; (B) The Department shall compute the allowable cost per day from the most recent State fiscal year Form FA-66 or the most recent Medicare cost report, as applicable, which will be the basis from which a prospective rate is negotiated. Payment for fixed costs is limited to the lower of the individual facility's fixed cost per diem or a maximum per diem of $54.00 excluding personal property and real estate taxes. Negotiations may include, but are not limited to, discussion of appropriate inflation or deflation expectations for the rate period and significant increases or decreases in the cost of providing services that are not reflected in the applicable cost report; (C) If the facility has no prior cost experience in providing special needs services, the facility must submit a budget for the provision of the intended service. The Department must concur that the budgeted cost per day meets a reasonable expectation of the cost of providing said service, taking into account the cost per day of similar facilities providing similar services. Budgets will be used until the facility has at least six months of actual cost experience; (D) An incentive factor calculated at eight per cent of allowable costs is added to the allowable costs of proprietary facilities. An incentive factor calculated at four percent of allowable costs is added to the allowable costs of other than propriety facilities; (E) After a rate is agreed upon, the provider must sign a provider agreement addendum. The addendum originated by the Department, must include:

(i) The rate and its applicable dates; (ii) A description of the criteria for care; and (iii) A full description of the services to be provided under the established per diem as well as any services that are not provided under the per diem and are billed separately; and

(F) Reimbursement must reflect the facility’s actual reasonable cost of providing services to special needs clients and must be updated annually using an appropriate inflation adjustment.

018.02 OUT-OF-STATE FACILITIES. The Department pays out-of-state facilities participating in Medicaid at the rates established by that state’s Medicaid program for nursing facility days, bed hold days and therapeutic leave days at the time of establishment of the Medicaid provider agreement. The rates are periodically updated to align with the current and applicable rates assigned by the out-of-state facility’s State Medicaid program.

History

• Effective 2024-06-02

Chapter 46 Rates for Hospital Services

Neb. Admin. Code tit. 471, ch. 46 Rates for Hospital Services {#sec-471-nac-46 omnilex-key=us-ne-regs-official--title-471--471 NAC 46}

001. SCOPE AND AUTHORITY. These regulations govern the services provided under Nebraska’s Medicaid program as defined by the Medical Assistance Act, Nebraska Revised Statute (Neb. Rev. Stat.) §§ 68-901 et seq.

002. DEFINITIONS. The following definitions apply:

002.01 ALLOWABLE COSTS. Those costs as provided in the Medicare statutes and regulations for routine service costs, inpatient ancillary costs, capital-related costs, medical education costs, and malpractice insurance cost.

002.02 ALL-PATIENT REFINED DIAGNOSIS-RELATED GROUP (APR DRG). The All- Patient Refined Diagnosis-Related Group grouper (APR DRG) is a software application that assigns patients into categories based on severity of illness and risk of mortality.

002.03 ANCILLARY SERVICES. Ancillary services are supportive or diagnostic measures that supplement and support a primary physician, nurse, or other healthcare provider in treating a patient.

002.04 BASE YEAR. The period covered by the most recent settled Medicare cost report, which will be used for purposes of calculating prospective rates.

002.05 BUDGET NEUTRALITY. Payment rates are adjusted for budget neutrality such that estimated expenditures for the current rate year are not greater than expenditures for the previous rate year, trended forward.

002.06 CAPITAL-RELATED COSTS. Those costs, excluding tax-related costs, as provided in the Medicare regulations and statutes in effect for each facility's base year.

002.07 CASE-MIX INDEX. An arithmetical index measuring the relative average resource use of discharges treated in a hospital compared to the statewide average.

002.08 COST OUTLIER. Cases which have an extraordinarily high cost as established in this chapter to be eligible for additional payments above and beyond the initial diagnosis- related group payment.

002.09 CRITICAL ACCESS HOSPITAL (CAH). A hospital licensed as a critical access hospital (CAH) by the Department of Health and Human Services, Division of Public Health, and certified for participation by Medicare as a critical access hospital (CAH).

002.10 DIAGNOSIS-RELATED GROUP (DRG). A group of similar diagnoses combined based on patient age, birth weight, procedure coding, comorbidity, and complications.

002.11 DIRECT MEDICAL EDUCATION (DME) COST PAYMENT. An add-on to the operating cost payment amount to compensate for direct medical education (DME) costs associated with approved intern and resident programs.

002.12 DISPROPORTIONATE SHARE HOSPITAL (DSH). A hospital located in Nebraska is deemed to be a disproportionate share hospital (DSH) by having:

(A) A Nebraska Medicaid inpatient utilization rate equal to or above the mean Nebraska Medicaid inpatient utilization rate for hospitals receiving Nebraska Medicaid payments in Nebraska; or

(B) A low-income utilization rate of 25 percent or more.

002.13 DIAGNOSIS-RELATED GROUP (DRG) WEIGHT. A number that reflects relative resource consumption as measured by the relative costs by hospitals for discharges associated with each diagnosis-related group (DRG) and severity of illness.

002.14 DISTINCT PART UNIT. A Medicare-certified hospital-based substance use disorder, psychiatric, or physical rehabilitation unit that is certified as a distinct part unit for Medicare.

002.15 HOSPITAL MERGERS. Hospitals that have combined into a single entity, and have applied for and received a single inpatient Medicare provider number and a single inpatient Nebraska Medicaid provider number.

002.16 HOSPITAL-SPECIFIC BASE YEAR OPERATING COST. Hospital-specific operating allowable cost associated with treating Nebraska Medicaid beneficiaries . Operating costs include the major moveable equipment portion of capital-related costs, but exclude the building and fixtures portion of capital-related costs, direct medical education (DME) costs, indirect medical education (IME) costs, and graduate medical education costs.

002.17 HOSPITAL-SPECIFIC COST-TO-CHARGE RATIO (CCR). Hospital-specific cost-to-charge ratio (CCR) is based on total hospital aggregate costs divided by total hospital aggregate charges. Hospital-specific cost-to-charge ratios (CCR) used for outlier cost payments and transplant diagnosis-related group cost-to-charge ratio (CCR) payments are derived from the outlier cost-to-charge ratios (CCR) in the Medicare inpatient prospective payment system.

002.18 HOSPITAL QUALITY ASSURANCE AND ACCESS ASSESSMENT. A quality assurance and access assessment imposed on hospitals as defined in these regulations. The hospital quality assurance and access assessment shall be used to fund the non-federal share of hospital directed payments throughout the statutory period allowed by law.

002.19 INDIRECT MEDICAL EDUCATION (IME) COST PAYMENT. Payment for costs that are associated with maintaining an approved medical education program, but that are not reimbursed as part of direct medical education (DME) cost payments.

002.20 LONG-TERM ACUTE CARE HOSPITAL (LTACH). A hospital that is licensed as a general acute care hospital that focuses on treating patients requiring extended hospital-level care, typically following initial treatment at a general acute care hospital. Patients treated in a long-term acute care hospital (LTACH) are not generally appropriate for lower level of care (LOC) settings, but are expected to improve to lower level of care (LOC) status.

002.21 LOW-INCOME UTILIZATION RATE. For the cost reporting period ending in the calendar year preceding the Medicaid rate period, the sum of the fractions, expressed as a percentage, calculated from acceptable data submitted by the hospital as follows:

(A) The total Nebraska Medicaid inpatient revenues paid to the hospital, including fee-for-service, managed care, and primary care case management payments and excluding disproportionate share hospital (DSH) payments, plus the amount of cash subsidies received directly from state and local governments in a cost reporting period, divided by the total amount of revenues of the hospital for inpatient services in the same cost reporting period; and

(B) The total amount of the hospital's charges for hospital inpatient services attributable to uncompensated care and ending in the calendar year preceding the Nebraska Medicaid rate period, less the amount of any cash subsidies identified in this section in the cost reporting period reasonably attributable to hospital inpatient services, divided by the total amount of the hospital's charges for inpatient services in the hospital for the same period. The total inpatient charges attributed to uncompensated care does not include contractual allowances and discounts, other than for uncompensated patients not eligible for Nebraska Medicaid, that is, reductions in charges given to other third-party payors.

002.22 NEBRASKA MEDICAID ALLOWABLE INPATIENT CHARGES. The total claim submitted charges less claim non-allowable amount.

002.23 NEBRASKA MEDICAID ALLOWABLE INPATIENT DAYS. The total number of covered Nebraska Medicaid inpatient days.

002.24 NEBRASKA MEDICAID INPATIENT UTILIZATION RATE. The ratio of allowable Nebraska Medicaid inpatient days, as determined by Nebraska Medicaid, to total inpatient days, as reported by the hospital on its Medicare cost report ending in the calendar year preceding the Nebraska Medicaid rate period. Inpatient days for out-of-state Medicaid patients for the same time period will be included in the computation of the ratio if reported to Nebraska Medicaid prior to the beginning of the Nebraska Medicaid rate period.

002.25 NEBRASKA MEDICAID RATE PERIOD. The period of July 1 through the following June 30.

002.26 MEDICAL REVIEW. Review of Nebraska Medicaid claims, including validation of hospital diagnosis and procedure coding information; continuation of stay; completeness; adequacy; and quality of care; appropriateness of admission; discharge and transfer; and appropriateness of prospective payment outlier cases.

002.27 MEDICARE COST REPORT. The report filed by each facility with its Medicare fiscal intermediary. A hospital that does not participate in the Medicare program will complete the Medicare cost report in compliance with Medicare principles and supporting rules, regulations, and statutes. The hospital will file the completed form with Nebraska Medicaid within five months after the end of the hospital's reporting period. A 30-day extension of the filing period may be granted if requested in writing before the end of the five-month period. Completed Medicare cost reports are subject to audit by Nebraska Medicaid or its designees. If a nursing facility is affiliated with the hospital, the nursing facility cost report must be filed as outlined in these regulations.

002.28 NATIONAL WEIGHTS. The 3M All-Patient Refined Diagnosis-Related Group grouper (APR DRG) National Weights are calculated using the Nationwide Inpatient Sample released by the Healthcare Cost and Utilization Project.

002.29 NEW OPERATIONAL FACILITY. A new operational facility is created neither by virtue of a change in ownership nor by the construction of additional beds to an existing facility. A new operating facility provides inpatient hospital care that meets one of the following criteria:

(A) A licensed newly constructed facility, which either totally replaces an existing facility or which is built at a site where hospital inpatient services have not previously been provided;

(B) A licensed facility which begins providing hospital inpatient services in a building at a site where those services have not previously been provided; or

(C) A licensed facility which is reopened at the same location where hospital inpatient care has previously been provided but not within the previous 12 months.

002.30 NON-ACUTE ADMIN DAYS. Nebraska Medicaid coverage for hospital care when a Nebraska Medicaid beneficiary, who is an inpatient, no longer requires acute inpatient care and requires nursing facility level of care (LOC) upon discharge but is unable to be transferred to a nursing facility due to a lack of available nursing facility beds, or in cases when the transfer requires a guardian, and a guardian has not been appointed.

002.31 OPERATING COST PAYMENT AMOUNT. The calculated payment that compensates hospitals for operating cost, including the major moveable equipment portion of capital-related costs, but excluding the building and fixtures portion of capital-related costs, direct medical education (DME) costs, indirect medical education (IME) costs, and graduate medical educations costs.

002.32 PEER GROUP. A grouping of hospitals or distinct part units of a hospital for the purpose of determining payment amounts. Hospitals are grouped with similar characteristics, licenses, Medicare certification, and classifications in the Centers for Medicare & Medicaid Services (CMS) inpatient prospective payment system impact file. Hospitals are classified into the following Peer Groups:

(A) Peer Group 1: Metro Acute Care Hospitals;

(B) Peer Group 2: Urban Acute Care & Regional Rural Referral Hospitals;

(C) Peer Group 3: Rural Acute Care Hospitals;

(D) Peer Group 4: Indian Health Service (HIS) & Beatrice Development Center (BSDC) Hospitals;

(E) Peer Group 5: Mental Health and Psychiatric Inpatient Hospitals;

(F) Peer Group 6: Physical Rehabilitation Hospitals;

(G) Peer Group 7: Critical Access Hospitals (CAH);

(H) Peer Group 8: Rural Emergency Hospitals;

(I) Peer Group 9: Long-Term Acute Care Hospitals (LTACH); or

(J) Peer Group 10: Children’s Hospitals.

002.33 PEER GROUP BASE PAYMENT AMOUNT. A base payment per discharge or per diem amount used to calculate the operating cost payment amount. The hospitals in Peer Group 1 Metro Acute Care Hospitals, Peer Group 2 Urban & Regional Rural Referral Hospitals, Peer Group 3 Rural Acute Care Hospitals, Peer Group 5 Mental Health and Psychiatric Inpatient Hospitals, Peer Group 9 Long-Term Acute Care Hospitals (LTACH), and Peer Group 10 Children’s Hospitals will have the same base payment or per diem amount.

002.34 REPORTING PERIOD. Same reporting period as that used for the Medicare cost report.

002.35 RESOURCE INTENSITY. The relative volume and types of diagnostic, therapeutic, and bed services used in the management of a particular disease.

002.36 RISK OF MORTALITY (ROM). The likelihood of dying.

002.37 RURAL EMERGENCY HOSPITAL. A hospital licensed as a rural emergency hospital by the Department of Health and Human Services, Division of Public Health, and certified for participation by Medicare as a rural emergency hospital. A rural emergency hospital solely provides outpatient services, including emergency department services, observation care, and additional outpatient medical and health services that do not exceed an annual per patient length of stay of 24 hours on average.

002.38 SEVERITY OF ILLNESS LEVEL . The extent of physiologic decompensation or organ system loss of function.

002.39 SWING BED. Post-hospital 24-hour skilled nursing care services that must be provided by or under the direct supervision of professional or technical personnel and requires skilled knowledge, judgment observation, and assessment.

002.40 TAX-RELATED COSTS. Any real or personal property tax, sales tax, excise tax, tax enacted pursuant to federal public laws, or any amendments thereto, franchise fee, license fee, or hospital-specific tax, fee or assessment imposed by the local, state, or federal government, but not including income taxes.

002.41 TRANSPLANT DIAGNOSIS-RELATED GROUPS (DRG). Transplant diagnosis- related groups (DRG) are identified in the All-Patient Refined Diagnosis-Related Group grouper (APR DRG). Nebraska Medicaid does not recognize bone marrow transplant diagnosis-related groups in its classification with all other transplant diagnosis-related groups categorized by the All-Patient Refined Diagnosis-Related Group grouper (APR DRG). Bone marrow transplant diagnosis-related groups do not receive a transplant cost-to-charge ratio (CCR) or transplant direct medical education (DME) payment. The bone marrow transplant diagnosis-related groups per discharge payment is the sum of the operating cost payment amount, the capital-related cost payment, and when applicable a direct medical education (DME) cost payment, indirect medical education (IME) cost payment, and a cost outlier payment.

002.42 UNCOMPENSATED CARE. Uncompensated care includes the difference between costs incurred and payments received in providing services to Nebraska Medicaid beneficiaries and uninsured.

003. PAYMENT FOR PEER GROUPS 1 METRO, 2 URBAN AND REGIONAL RURAL REFERRAL, 3 RURAL, AND 10 CHILDREN’S. Payments for inpatient acute care services are made on a prospective per discharge basis. For inpatient services that are classified into a diagnosis-related group, the total per discharge payment is the sum of the operating cost payment amount; the capital-related cost payment; and when applicable direct medical education (DME) cost payment; indirect medical education (IME) cost payment; and a cost outlier payment. For inpatient services that are classified into a transplant diagnosis-related group, the total per discharge payment is the sum of the transplant cost-to-charge ratio (CCR) payment amount; and when applicable transplant direct medical education (DME) cost payment.

003.01 DETERMINATION OF OPERATING COST PAYMENT AMOUNT. The hospital operating cost payment amount for discharges are classified into a diagnosis-related group and is calculated by multiplying the Peer Group base payment amount by the applicable 3M All-Patient Refined Diagnosis-Related Group grouper (APR DRG) National Weight.

003.01(A) CALCULATION OF THE ALL-PATIENT REFINED DIAGNOSIS-RELATED GROUP GROUPER (APR DRG) WEIGHTS. Hospitals are expected to submit claims in compliance with All-Patient Refined Diagnosis-Related Groups grouper (APR DRG) standards. . .

003.01(B) CALCULATION OF NEBRASKA PEER GROUP BASE PAYMENT AMOUNTS. Peer Group base payment amounts are used to calculate payments for discharges for non-transplant diagnosis-related group. Peer Group base payment amounts are subject to annual adjustment as specified by Nebraska Legislative appropriations.

003.02 CALCULATION OF DIAGNOSIS-RELATED GROUP COST OUTLIER PAYMENT AMOUNTS. Additional payment is made for approved discharges classified into a diagnosis-related group meeting or exceeding Nebraska Medicaid criteria for cost outliers for each diagnosis-related group classification. Cost outliers may be subject to medical review. Discharges qualify as cost outliers when the costs of the service exceed the outlier threshold. The outlier threshold is the sum of the operating cost payment amount, the indirect medical education (IME) cost payment , and the capital-related cost payment , plus $30,000 for all neonate and nervous system All-Patient Refined Diagnosis-Related Groups grouper (APR DRG) at severity level 3 and at severity level 4. For all other All-Patient Refined Diagnosis-Related Groups grouper (APR DRG) , the outlier threshold is the sum of the operating cost payment amount, the indirect medical education (IME) cost payment , and the capital-related cost payment plus $51,800. Cost of the discharge is calculated by multiplying the Nebraska Medicaid allowed charges by the sum of the hospital-specific Medicare operating and capital outlier cost-to-charge ratios. Additional payment for cost outliers is 80% of the difference between the hospital’s cost for the discharge and the outlier threshold for all discharges except for burn discharges, which will be paid at 85% of the difference between the hospital’s cost for the discharge and the outlier threshold.

003.02(A) HOSPITAL-SPECIFIC MEDICARE OUTLIER COST-TO-CHARGE RATIOS (CCR). Hospitals excluded from the Medicare prospective payment system under federal regulations will have a provider-specific cost-to-charge ratio (CCR) calculated using all-payer data from their Medicare cost report. An out-of-state hospital’s outlier cost-to-charge ratio (CCR) is the average of in-state hospitals within the same Peer Group. The cost-to-charge ratio (CCR) outlier is not subject to Nebraska Legislative appropriations.

003.03 CALCULATION OF DIRECT MEDICAL EDUCATION (DME) COSTS.

003.03(A) CALCULATION OF DIRECT MEDICAL EDUCATION (DME) COST PAYMENTS. Direct medical education (DME) cost payments shall be made to eligible Nebraska teaching hospitals and are based on hospital-specific direct medical education (DME) cost payment rates determined each state fiscal year. The direct medical education (DME) cost payment amounts are subject to annual adjustment as specified by Nebraska Legislative appropriations.

003.03(B) CALCULATION OF INDIRECT MEDICAL EDUCATION (IME) COST PAYMENTS. . Indirect medical education (IME) cost payments shall be made to eligible Nebraska teaching hospitals and are calculated by multiplying an indirect medial education (IME) factor by the operating cost payment amount. Hospitals excluded from the Medicare prospective payment system under federal regulations will have a provider specific intern-to-bed ratio calculated using their Medicare cost report. The intern-to-bed ratio is then utilized in the following formula to calculate the annual indirect medical education (IME) factor: number of interns and residents divided by available beds; plus 1; to the power of 0.405; minus 1; multiplied by 1.35. The indirect medical education (IME) factor is not subject to Nebraska Legislative appropriations.

003.03(C) CALCULATION OF CAPITAL-RELATED COST PAYMENT. Capital-related cost payments for the building and fixtures portion of capital-related costs are paid on a per discharge basis. Per discharge amounts are calculated by multiplying the capital per diem cost by the statewide average length-of-stay for the diagnosis-related group. Capital-related payment per diem amounts are calculated for Peer Groups 1 Metro Acute Care Hospitals, 2 Urban Acute Care and Regional Rural Referral Hospitals, 3 Rural Acute Care Hospitals and 10 Children’s Hospitals. , The Peer Group specific capital-related payment per diem amounts shall be adjusted by the available funds appropriated by the Nebraska Legislature.

003.03(D) TRANSPLANT DIAGNOSIS-RELATED GROUP PAYMENTS. Transplant discharges, identified as discharges that are classified to a transplant diagnosis-related group, are paid a transplant diagnosis-related group cost-to-charge ratio (CCR) payment and, if applicable, a direct medical education (DME) payment. Transplant diagnosis-related group discharges do not receive separate cost outlier payments, indirect medical education (IME) cost payments or capital-related cost payments.

003.03(D)(i) TRANSPLANT DIAGNOSIS-RELATED GROUP COST-TO-CHARGE RATIO (CCR) PAYMENTS. Transplant diagnosis-related group cost-to-charge ratio (CCR) payments are calculated by multiplying the hospital-specific transplant diagnosis-related group cost-to-charge ratio (CCR) by Nebraka Medicaid-allowed claim charges. On July 1 of each year, Nebraska Medicaid will update the transplant diagnosis-related group cost-to-charge ratios (CCR) using the following method: divide the previous year outlier cost-to-charge ratio (CCR) by the current year outlier cost-to-charge ratio (CCR) to determine the percentage of change; then multiply this by the percentage of change by the previous state fiscal year transplant cost-to-charge ratio (CCR); then multiply the product by any applicable state legislative appropriations. Out-of-state hospital transplant cost-to-charge ratio (CCR) is the average of in-state hospitals within the same Peer Group.

003.03(D)(ii) TRANSPLANT DIAGNOSIS-RELATED GROUP DIRECT MEDICAL EDUCATION (DME) PAYMENTS. Transplant diagnosis-related group direct medical education (DME) cost payments are based on Nebraska hospital-specific direct medical education (DME) payment rates determined each state fiscal year. Bone marrow transplant diagnosis-related groups are excluded from transplant direct medical education (DME) rate and are reimbursed under the specific hospital direct medical education (DME) rate. Each state fiscal year Nebraska hospital-specific transplant direct medical education (DME) payment rates shall be adjusted by a percentage. This percentage shall be determined by Nebraska Legislature appropriations. The transplant direct medical education (DME) payment rates are adjusted annually and shall be effective each July 1. .

003.03(E) BUDGET NEUTRALITY FACTORS. Peer Group base payment amounts, are multiplied by budget neutrality factors in the process of setting payment rates.

003.03(E)(i) DEVELOP FISCAL SIMULATION ANALYSIS. Nebraska Medicaid will develop a fiscal simulation analysis using Nebraska Medicaid inpatient paid claims data . The fiscal simulation analysis includes discharges grouped into a diagnosis-related group and excludes all psychiatric, rehabilitation, and transplant discharges. In the fiscal simulation analysis, Nebraska Medicaid will apply all rate year payment rates before budget neutrality adjustments to the claims data and simulate payments.

003.03(E)(ii) DETERMINE BUDGET NEUTRALITY FACTORS. Nebraska Medicaid will set budget neutrality factors in fiscal simulation analysis such that simulated payments are equal to the claims data reported payments, inflated by Peer Group base payment amount increases approved by Nebraska Medicaid from the end of the claims data period to the rate year.

003.03(F) FACILITY SPECIFIC UPPER PAYMENT LIMIT. Facilities in Peer Groups 1, 2, 3, and 10 are subject to an upper payment limit for all cost reporting periods . For each cost reporting period, Nebraska Medicaid payment for inpatient hospital services shall not exceed 110% of Nebraska Medicaid cost. Nebraska Medicaid cost shall be the calculated sum of Nebraska Medicaid allowable inpatient routine and ancillary service costs. Nebraska Medicaid routine service costs are calculated by allocating total hospital routine service costs for each applicable routine service cost center. Nebraska Medicaid inpatient ancillary service costs are calculated by multiplying an overall ancillary cost-to-charge ratio (CCR) times the applicable Nebraska Medicaid program inpatient ancillary charges. The overall ancillary cost-to-charge ratio (CCR) is calculated by dividing the sum of the costs of all ancillary and outpatient service cost centers by the sum of the charges for all ancillary and outpatient service cost centers. Payments shall include all operating cost payments, capital related cost payments, direct medical education (DME) cost payments, indirect medical education (IME) cost payments, cost outlier payments, and all payments received from other sources for hospital care provided to Nebraska Medicaid eligible beneficiaries. Payment under Nebraska Medicaid shall constitute reimbursements under this subsection for days of service that occurred during the cost reporting period.

003.03(F)(i) RECONCILIATION TO FACILITY UPPER PAYMENT LIMIT. Facilities will be subject to a preliminary and a final reconciliation of Nebraska Medicaid payments to allowable Nebraska Medicaid costs. A reconciliation will be made within six months following receipt by Nebraska Medicaid of the facilities settled cost report. Facilities will have 60 days to make refunds to Nebraska Medicaid, when notified that an overpayment has occurred. Facilities will be notified when either the preliminary or final reconciliation indicates that the facility received Nebraska Medicaid payments more than 110% of Nebraska Medicaid costs. Nebraska Medicaid will identify the cost reporting period for Nebraska Medicaid payments, Nebraska Medicaid costs, and the amount of overpayment that is due to Nebraska Medicaid.

003.03(G) TRANSFERS. When a beneficiary is transferred to or from another hospital, Nebraska Medicaid shall make a transfer payment to the transferring hospital if the initial admission is determined to be medically necessary. For hospital inpatient services reimbursed on a prospective discharge basis, the transfer payment is calculated based on the average daily rate of the transferring hospital's payment for each day the beneficiary remains in that hospital, up to 100 % of the full diagnosis-related group payment. The average daily rate is calculated as the full diagnosis-related group payment, which is the sum of the operating cost payment amount, capital-related cost payment, and if applicable, direct medical education (DME) cost payment, divided by the statewide average length-of-stay for the related diagnosis-related group. For hospitals receiving a transferred beneficiary, payment is the full diagnosis-related group payment and, if applicable, cost outlier payment.

003.03(H) INPATIENT ADMISSION AFTER OUTPATIENT SERVICES. A beneficiary may be admitted to the hospital as an inpatient after receiving hospital outpatient services. When a beneficiary is admitted as an inpatient within three calendar days of the day that the hospital outpatient services were provided, all hospital outpatient services related to the principal diagnosis are considered inpatient services for billing and payment purposes. The day of the admission as an inpatient is the first day of the inpatient hospitalization.

003.03(I) READMISSIONS. Nebraska Medicaid adopts Medicare peer review organization regulations to control increased admissions or reduced services. All Nebraska Medicaid beneficiaries readmitted as an inpatient within 31 days will be reviewed by Nebraska Medicaid or its designee. Payment may be denied if either admissions or discharges are performed without medical justification as determined medical review.

003.03(J) INTERIM PAYMENT FOR LONG-STAY BENEFICIARIES. Nebraska Medicaid’s payment for hospital inpatient services is made upon the beneficiary’s discharge from the hospital. Occasionally, a beneficiary may have an extremely long stay, in which partial reimbursement to the hospital may be necessary. A hospital may request an interim payment if the beneficiary has been hospitalized 60 days and is expected to remain hospitalized an additional 60 days. To request an interim payment, the hospital shall send the appropriate completed Nebraska Medicaid approved health care claim form , for the hospital days for which the interim payment is being requested with an attestation by the attending physician that the beneficiary has been hospitalized a minimum of 60 days and is expected to remain hospitalized a minimum of an additional 60 days.

003.03(J)(i) FINAL PAYMENT FOR LONG-STAY BENEFICIARIES. When an interim payment is made for long-stay beneficiaries, the hospital shall submit a final billing for payment upon discharge of the beneficiary. The date of admission for the final billing must be the date the beneficiary was admitted to the hospital as an inpatient. The statement from and to dates must be the date the beneficiary was admitted to the hospital through the date the beneficiary was discharged. The total charges must be all charges incurred during the hospitalization. Payment for the entire hospitalization will be calculated at the same rate as all prospective discharge payments. The final payment will be reduced by the amount of the interim payment.

003.03(K) PAYMENT FOR CERTIFIED REGISTERED NURSE ANESTHETIST (CRNA) FEES. A certified registered nurse anesthetist (CRNA) provider may choose to retain their billing privileges and submit claims directly for certified registered nurse anesthetist (CRNA) charges, which would follow the anesthesia fee schedule. The critical access hospital (CAH) or rural emergency hospital may also elect one of the following two options to bill for certified registered nurse anesthetist (CRNA) professional fees on behalf of the certified registered nurse anesthetist (CRNA) provider. Certified registered nurse anesthetist (CRNA) providers in either circumstance must reassign billing privileges to the critical access hospital (CAH) or rural emergency hospital. In cases when Medicare is the primary payer, the provider must follow Medicare billing requirements. In either option below, the certified registered nurse anesthetist (CRNA) provider must not separately bill for charges that occurred in the critical access hospital (CAH) or rural emergency hospital for which they have reassigned billing privileges:

(i) A critical access hospital (CAH) may choose to bill on a professional claim form for both inpatient and outpatient certified registered nurse anesthetist (CRNA) services. A rural emergency hospital may choose to bill on a professional claim form for outpatient certified registered nurse anesthetist (CRNA) services. Reimbursement will follow the Nebraska Medicaid anesthesia fee schedule; or

(ii) The critical access hospital (CAH) may bill on an institutional claim form for both inpatient and outpatient professional certified registered nurse anesthetist (CRNA) costs using revenue code 964 for certified registered nurse anesthetist (CRNA) professional fees. Reimbursement will be based on critical access hospital (CAH) inpatient or outpatient applicable rates and are subject to cost settlement. A rural emergency hospital may bill on an institutional claim form for outpatient professional certified registered nurse anesthetist (CRNA) costs using revenue code 964 for certified registered nurse anesthetist (CRNA) professional fees. Reimbursement for rural emergency hospitals will be based on outpatient applicable rates.

004. NON-PAYMENT FOR HOSPITAL ACQUIRED CONDITIONS (HAC). Nebraska Medicaid will not make payment for conditions which are a result of avoidable inpatient hospital complications and medical errors that are identifiable, preventable, and serious in their consequences to beneficiaries. This means that Nebraska Medicaid will, at a minimum, identify as hospital acquired conditions (HAC), those diagnoses codes that have been identified as hospital acquired conditions (HAC) by the Centers for Medicare & Medicaid Services (CMS) when not present on hospital admission. Any diagnosis code(s) which are flagged as hospital acquired conditions (HAC) will be excluded from the final claim All-Patient Refined Diagnosis-Related Group grouper (APR DRG) determination.

005. PAYMENTS FOR PSYCHIATRIC INPATIENT SERVICES. Payments for psychiatric discharges are made on a prospective per diem basis. Tiered rates will be used for all acute psychiatric inpatient services. This includes services provided at a facility enrolled as a provider for psychiatric services which is not a licensed psychiatric hospital or a Medicare-certified distinct part unit. Payment for each discharge equals the per diem times the number of approved beneficiary days . Payment is made for the day of admission, but not the day of discharge. Tiered rates are subject to annual adjustment as specified by Nebraska Legislative appropriations.

005.01 PAYMENT FOR PSYCHIATRIC ADULT INPATIENT SUBACUTE HOSPITAL SERVICES. Payments for psychiatric adult inpatient subacute hospital services are made on a per diem basis. The subacute inpatient hospital per diem basis is not a tiered rate. Payment will be an all-inclusive per diem basis, with the exception of physician services. Per diem payment amounts are subject to annual adjustment as specified by Nebraska Legislative appropriations.

005.02 PAYMENT FOR HOSPITAL-SPONSORED PSYCHIATRIC RESIDENTIAL TREATMENT FACILITIES (PRTF). Reimbursement is capped at the psychiatric residential treatment facilities’ (PRTF) usual and customary daily charges billed for eligible beneficiaries. Public psychiatric residential treatment facilities (PRTF) will be cost-settled annually. Payment rates do not include costs of providing educational, pharmacy, and physician services. Rates are subject to annual adjustment as specified by Nebraska Legislative appropriations.

006. PAYMENT FOR IN-STATE OUTPATIENT HOSPITAL AND EMERGENCY ROOM SERVICES. The starting point for the outpatient hospital and emergency services rate shall be a rate which is determined by: Peer Groups 1 Metro Acute Care Hospitals, 2 Urban Acute Care & Regional Rural Referral Hospitals, 3 Rural Acute Care Hospitals, and 10 Children’s Hospitals Outpatient Rate is the Nebraska Medicaid percentage of cost to charge ratios (CCR), that is, cost divided by charges multiplied by Nebraska Medicaid percentage of allowable charges;Peer Groups 7 Critical Access Hospitals (CAH), and 8 Rural Emergency Hospitals Outpatient Rate is the ancillary and outpatient service cost center’s cost to charge ratio (CCR) up to 100 percent. All outpatient clinical laboratory services must be itemized and identified with the appropriate Healthcare Common Procedure Coding System (HCPCS) procedure codes. Nebraska Medicaid pays for clinical laboratory services at the fee schedule determined by the Centers for Medicare & Medicaid Services (CMS).

007. PAYMENTS FOR REHABILITATION SERVICES. Payments for rehabilitation discharges are made on a prospective per diem basis. All rehabilitation services, regardless of the type of hospital providing the service, will be reimbursed on a per diem basis. This includes services provided at a facility enrolled as a provider for rehabilitation services which is not a licensed rehabilitation hospital or a Medicare-certified distinct part unit. The per diem basis will be the sum of: the hospital-specific base payment per diem basis ; and the hospital's direct medical education (DME) cost payment , if applicable. Payment for each discharge equals the per diem basis times the number of approved beneficiary days. Payment is made for the day of admission but not for the day of discharge. Per diem payment amounts are subject to annual adjustment as specified by Nebraska Legislative appropriations.

007.01 ADJUSTMENT OF HOSPITAL-SPECIFIC BASE PAYMENT AMOUNT. The base payment amounts are subject to annual adjustment as specified by Nebraska Legislative appropriations.

008. PAYMENT FOR SERVICES FURNISHED BY A CRITICAL ACCESS HOSPITAL (CAH). Payment for inpatient services of a critical access hospital (CAH) is the reasonable cost of providing the services, as determined under applicable Medicare principles of reimbursement, except that the following principles do not apply: the lesser of costs or charges rule, ceilings on hospital operating costs, and the reasonable compensation equivalent limits for physician services to providers. Subject to the 96-hour average on inpatient stays in critical access hospitals (CAH), items and services that a critical access hospital (CAH) provides to its inpatients are covered if they are items and services of a type that would be covered if furnished by a hospital to hospital inpatients.

009. PAYMENT FOR LONG-TERM ACUTE CARE HOSPITAL (LTACH) SERVICES. Payments for long-term acute care hospitals (LTACH) discharges are made on a prospective per diem basis, depending on whether the beneficiary requires ventilator or non-ventilator services, whichever is applicable, as determined by prior authorization review. A prior authorization is required for all long-term acute care hospital (LTACH) services for either ventilator or non-ventilator services. The per diem will be the sum of long-term acute care hospital (LTACH) ventilator or non-ventilator services per diem; and direct medical education (DME) cost payment, if applicable. Payment for each discharge equals the per diem basis times the number of approved beneficiary days. Payment is made for the day of admission but not the day of discharge. Per diem payment amounts are subject to annual adjustment as specified by Nebraska Legislative appropriations.

010. PAYMENT FOR OUTPATIENT MENTAL HEALTH AND SUBSTANCE USE DISORDER SERVICES IN A HOSPITAL. Providers shall use Health Care Common Procedure Coding System (HCPCS) procedure codes and American Medical Association’s Current Procedural Terminology when submitting claims to Nebraska Medicaid. These codes are defined on the Mental Health Substance Use Disorder Fee Schedule. Nebraska Medicaid pays for covered outpatient mental health services, except for laboratory services, at the lower of: the provider’s submitted charge; or the allowable amount for that procedure code in the Nebraska Medicaid Mental Health Substance Use Disorder Fee Schedule for that date of service. Rates are subject to annual adjustment as specified by Nebraska Legislative appropriations.

011. RATES FOR STATE-OPERATED INSTITUTIONS FOR MENTAL DISEASE (IMD). Institutions for mental disease (IMD) operated by the State of Nebraska will be reimbursed for all reasonable and necessary costs of operation. State-operated institutions for mental diseases (IMD) will receive an interim per diem payment rate, with an adjustment to actual costs following the cost reporting period.

012. DISPROPORTIONATE SHARE HOSPITALS (DSH). A hospital qualifies as a disproportionate share hospital (DSH) if the hospital meets the definition of a disproportionate share hospital (DSH) and submits the required information completed, dated, and signed as follows with their Medicare cost report:

(A) The names of at least two obstetricians who have staff privileges at the hospital and who have agreed to provide obstetric services to individuals who are eligible for Nebraska Medicaid. This requirement does not apply to a hospital;

(i) The inpatients of which are predominantly individuals under 18 years of age;

(ii) Which does not offer non-emergency obstetric services to the general population ; or

(iii) For a hospital located in a rural area, the term obstetrician includes any physician with staff privileges at the hospital to perform non-emergency obstetric procedures;

(B) Only Nebraska hospitals which have a current enrollment with Nebraska Medicaid will be considered for eligibility as a disproportionate share hospital (DSH); and

(C) When notified by Nebraska Medicaid that the hospital qualifies as a disproportionate share hospital (DSH), each hospital must certify to Nebraska Medicaid that it has incurred costs for the delivery of uncompensated care which are equal to or exceed the amount of the disproportionate share hospital (DSH) payment.

012.01 DISPROPORTIONATE SHARE ELIGIBILITY CALCULATION. To calculate eligibility, proxy data will be used from each hospital's fiscal year ending in the calendar year preceding the state fiscal year. Eligibility as a disproportionate share hospital (DSH) will be calculated using the following data.

012.01(A) NEBRASKA MEDICAID INPATIENT UTILIZATION RATE. To determine the Nebraska Medicaid inpatient utilization rate, the denominator will be the total days as reported on the Medicare cost report. The numerator will be the sum of each hospital's Nebraska Medicaid days, which includes the Nebraska Medicaid management information system non-managed care claims file data run 150 days after each hospital's fiscal year end, managed care days for hospitals that submit a disproportionate share hospital (DSH) survey, and out-of-state days reported before the federal fiscal year for which the determination is made.

012.01(B) LOW INCOME UTILIZATION RATE. To determine the low-income utilization rate, data from the Nebraska accounting system will be used to calculate the low-income utilization rate for state-owned institutions for mental disease (IMD). For all other hospitals, the hospital's certified report of total revenue, Nebraska Medicaid inpatient revenue, cash subsidies, uncompensated care charges, and total inpatient charges minus any disproportionate share payment will be used.

012.02 DISPROPORTIONATE SHARE HOSPITAL (DSH) UPPER PAYMENT LIMIT AND UNCOMPENSATED CARE CALCULATION. The disproportionate share hospital (DSH) upper payment limit and the uncompensated care calculation is the sum of the Nebraska Medicaid shortfall plus the cost of uninsured care.

(A) Nebraska Medicaid will calculate the Nebraska Medicaid shortfall as follows:

(i) Nebraska Medicaid will determine the costs of Nebraska Medicaid fee-for-service and managed care inpatient services by:

(1) Calculating a hospital's routine cost per day for each cost center from the Centers for Medicare & Medicaid Services (CMS) cost report by dividing the total costs by the total days; and

(2) Multiplying the cost per day times the number of Nebraska Medicaid allowable days provided during the same fiscal year as the filed cost report and paid up to 150 days after the end of the fiscal year;

(ii) Nebraska Medicaid will determine costs of Nebraska Medicaid fee-for-service and managed care outpatient services by:

(1) Calculating a hospital's ancillary cost-to-charge ratio (CCR) from the Centers for Medicare & Medicaid Services (CMS) cost report; and

(2) Multiplying the total Nebraska Medicaid allowable charges times the ancillary cost-to-charge ratio (CCR);

(iii) The total Nebraska Medicaid cost is the sum of the inpatient and outpatient costs for each hospital; and

(iv) The Nebraska Medicaid shortfall is determined by subtracting the total allowable Nebraska Medicaid payments from the total Nebraska Medicaid cost.

(B) Nebraska Medicaid will calculate the cost of uninsured care by using each hospital's charges for services provided to uninsured beneficiaries as filed and certified to Nebraska Medicaid for the same fiscal year as the Centers for Medicare & Medicaid Services (CMS) cost report used in determining costs. Nebraska Medicaid will convert each hospital's charges to cost for uninsured patients by multiplying the charges by the overall cost-to-charge ratio (CCR) determined using each hospital's Centers for Medicare & Medicaid Services (CMS) report for the same fiscal year used in determining cost.

(C) The Nebraska Medicaid upper payment limit and the uncompensated care amount shall be the sum of the Nebraska Medicaid shortfall plus the cost of uninsured care.

012.03 DISPROPORTIONATE SHARE PAYMENTS. Disproportionate share payments will be made each federal fiscal year following receipt of all required data by Nebraska Medicaid. The total of all disproportionate share payments must not exceed the limits on disproportionate share hospital (DSH) funding established for this State by the Centers for Medicare & Medicaid Services (CMS) in accordance with federal law . Payments determined for each federal fiscal year will be considered payment for that year, and not for the year from which proxy data used in the calculation was taken. To calculate payment, proxy data will be used from each hospital's fiscal year ending in the calendar year preceding the state fiscal year which coincides most closely to the federal fiscal year for which the determination will be applied.

012.03(A) METHODS. Nebraska Medicaid will make a disproportionate share hospital (DSH) payment to hospitals that qualify for a payment under one of the following Pool distribution methods.

012.03(A)(i) BASIC DISPROPORTIONATE SHARE PAYMENT POOL 1. Pool 1 consists of eligible hospitals in Peer Groups 2 Urban Acute Care & Regional Rural Referral Hospitals, 3 Rural Acute Care Hospitals, and 7 Critical Access Hospitals (CAH) that are not eligible under Pool 6.

012.03(A)(i)(1) POOL 1 FUNDING. Total funding to Pool 1 will be $1,000,000. In federal fiscal year 2008 and following years, this amount will be increased by the percentage change in the consumer price index for all urban consumers, all items, United States city average. Nebraska Medicaid will calculate the payment for Pool 1 as follows: first, each hospital's Nebraska Medicaid days, which include days from the Nebraska Medicaid management information system claims file data run 150 days after each hospital's fiscal year end, managed care days, and out-of-state days reported before the federal fiscal year for which the determination is made, will be divided by the sum of the Nebraska Medicaid inpatient days of all hospitals which qualify for a payment in Pool 1. Second, the ratio resulting from such division will be multiplied times the total funding for Pool 1 to determine each hospital's payment. If payment to a hospital exceeds the federally determined disproportionate share hospital (DSH) payment limit, the payment will be reduced and the additional funds will be redistributed pro rata to eligible hospitals within Pool 1.

012.03(A)(ii) BASIC DISPROPORTIONATE SHARE PAYMENT POOL 2. Pool 2 consists of eligible hospitals in Peer Groups 1 Metro Acute Care Hospitals, 2 Urban Acute Care & Regional Rural Referral Hospitals, and 3 Rural Acute Care Hospitals that are also eligible under Pool 6.

012.03(A)(ii)(1) POOL 2 FUNDING. For federal fiscal year 2009 and following years, the total funding will be the amount for federal fiscal year 2008 with an annual increase by the percentage change in the consumer price index for all urban consumers, all items, United States city average. Nebraska Medicaid will calculate the payment for Pool 2 as follows. First, each hospital's Nebraska Medicaid days, which include days from the Nebraska Medicaid management information system claims file data run 150 days after each hospital's fiscal year end, managed care days, and out-of-state days reported before the federal fiscal year for which the determination is made, will be divided by the sum of the Nebraska Medicaid inpatient days of all hospitals which qualify for a payment in Pool 2. Second, the ratio resulting from such division will be multiplied times the total funding for Pool 2 to determine each hospital's payment. If payment to a hospital exceeds the federally determined disproportionate share hospital (DSH) payment limit, the payment will be reduced and the additional funds will be redistributed pro rata to eligible hospitals within Pool 2.

012.03(A)(iii) DISPROPORTIONATE SHARE PAYMENT FOR HOSPITALS THAT PRIMARILY SERVE CHILDREN POOL 3. Pool 3 consists of the eligible hospital in Peer Group 10 Children’s Hospitals that has the greatest number of Nebraska Medicaid days.

012.03(A)(iii)(1) POOL 3 FUNDING. For federal fiscal year 2009 and following years, the total funding will be the amount for federal fiscal year 2008 with an annual increase by the percentage change in the consumer price index for all urban consumers, all items, United States city average. A hospital eligible for payment under this Pool will not be eligible for payment under any other Pool. If payment to the hospital exceeds the federally determined disproportionate share hospital (DSH) payment limit, the payment will be reduced.

012.03(A)(iv) DISPROPORTIONATE SHARE PAYMENT FOR STATE OWNED INSTITUTIONS FOR MENTAL DISEASE (IMD) HOSPITALS AND FOR ELIGIBLE HOSPITALS IN PEER GROUP 5 POOL 4. Pool 4 consists of state-owned institutions for mental disease (IMD) and other eligible hospitals in Peer Group 5 Mental Health or Psychiatric Inpatient Hospitals .

012.03(A)(iv)(1) POOL 4 FUNDING. Total funding for Pool 4 will be $1,811,337 annually. Each eligible hospitals must certify in writing to the Nebraska Medical Assistance Program its charges for uncompensated care for the hospital's fiscal year ending in the calendar year preceding the federal fiscal year for which the determination is applied. Charges for uncompensated care will be converted to cost using the hospitals cost-to-charge ratio (CCR). Payment to each hospital will be equal to the cost of its uncompensated care. If the total of all disproportionate share payment amounts for Pool 4 exceeds the federally determined disproportionate share hospital (DSH) limit for Nebraska, the disproportionate share hospital (DSH) payments will be reduced pro rata.

012.03(A)(v) NON-PROFIT ACUTE CARE TEACHING HOSPITAL AFFILIATED WITH A STATE-OWNED UNIVERSITY MEDICAL COLLEGE POOL 5. Pool 5 consists of the non-profit acute care teaching hospital, subsequently referred to as the state teaching hospital, that has an affiliation with the University Medical College owned by the State of Nebraska. A hospital eligible for payment under this Pool may be eligible for payment under Pool 6.

012.03(A)(v)(1) POOL 5 FUNDING. Total funding to Pool 5 will be $15,000,000. For federal fiscal year 2008 and following years the funding will be increased annually by the percentage change in the consumer price index for all urban consumers, all items, United States city average. Nebraska Medicaid will calculate the disproportionate share hospital (DSH) payment to Pool 5 as an amount equal to the cost of its uncompensated care. If the payment to the hospital exceeds the federally determined disproportionate share payment limit, the payment will be reduced.

012.03(A)(vi) UNCOMPENSATED CARE POOL 6. Pool 6 consists of hospitals that provide services to low-income persons covered by a county administered general assistance program; or hospitals that provide services to low-income persons served by the behavioral health regions .

012.03(A)(vi)(1) POOL 6 FUNDING. Total funding to Pool 6 will be the remaining federal and state balance of the disproportionate share hospital (DSH) total funding minus the funding for Pools 1, 2, 3, 4, and 5. Nebraska Medicaid will calculate payments as follows: disproportionate share hospital (DSH) payments to a hospital under all other Pools will be subtracted from the hospital's disproportionate share hospital (DSH) upper payment limit before allocating payments under Pool 6. The costs for uncompensated care resulting from participation county administered general assistance program will be reported by the county; and costs for the state administered public behavioral health system will be reported by each hospital and funding will be transferred to Nebraska Medicaid. Reported costs will be subject to audit by Nebraska Medicaid. The total computable payment will be commensurate with the charges for uncompensated care resulting from participation in county administered general assistance program; or the behavioral health regions . If payment to the hospital exceeds the federally determined disproportionate share payment limit, the payment will be reduced to the payment limit. If payments to hospitals under this Pool exceed the total allotment to Nebraska, the payments will be reduced pro rata.

012.03(B) LIMITATIONS ON DISPROPORTIONATE SHARE PAYMENTS. No payments made under this section will exceed any federally determined applicable limitations upon such payments . Disproportionate share hospital (DSH) payments to all qualified hospitals for a year will not exceed the federally determined State disproportionate share hospital (DSH) payments limit.

.

013. OUT-OF-STATE HOSPITAL RATES. Out-of-state hospitals are paid for hospital inpatient services using the same methods described in this chapter for in-state hospitals, except that out-of-state hospitals do not receive direct medical education (DME) cost payments, indirect medical education (IME) cost payments or graduate medical education payments. Payments for services are determined by assigning out-of-state hospitals to the appropriate Peer Group.

(A) Peer Group 1: Metro Acute Care Hospitals, Peer Group 2: Urban Acute Care & Regional Rural Referral Hospitals, Peer Group 3: Rural Acute Care Hospitals, and Peer Group 10: Children’s Hospitals;

(i) Operating costs payment amounts are calculated based on the appropriate Peer Group base payment amount;

(ii) Capital-related cost payment are made based on the appropriate Peer Group capital per diem rate;

(iii) Outpatient rates will be the average of the in-state Peer Group;

(iv) Cost-to-charge ratio (CCR) outlier will be the average in-state by Peer Group; and

(v) Cost-to-charge ratio (CCR) transplant will be the average in-state by Peer Group;

(B) Peer Group 5: Mental Health or Psychiatric Hospitals: tiered rates per diem will be used for all psychiatric services and are the same of the in-state hospitals;

(C) Peer Group 6: Physical Rehabilitation Hospitals: payments are made on a prospective per diem for rehabilitation hospitals are based on average of the in-state rehabilitation hospitals per diem rates;

(D) Peer Group 7: Critical Access Hospitals (CAH);

(i) Acute per diem payment will be the average of in-state hospitals;

(ii) Bassinet or nursery per diem will be the average of in-state hospitals; and

(iii) Outpatient rates will be the average of in-state critical access hospitals (CAH);

(E) Peer Group 8: Rural Emergency Hospitals: outpatient rates will be the average of in-state rural emergency hospitals; and

(F) Peer Group 9: Long-Term Acute Care Hospitals (LTACH): payments are made on a prospective per diem for long term acute care hospitals are based on average of the in-state rehabilitation hospitals per diem rates.

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014. FREE-STANDING PSYCHIATRIC HOSPITALS. When a free-standing psychiatric hospital, in Nebraska or out of state, does not have ancillary services on-site, the provider of the ancillary service shall bill Nebraska Medicaid for the ancillary services provided to inpatients. The hospital shall not include these ancillary costs on its cost report.

015. PAYMENT FOR NON-ACUTE ADMIN DAYS. A per diem for hospital care is paid when a Nebraska Medicaid beneficiary, who is an inpatient, no longer requires acute inpatient care and requires nursing facility level of care (LOC) upon discharge but is unable to be transferred to a nursing facility due to a lack of available nursing facility beds, or in cases when the transfer requires a guardian, a guardian has not been appointed. Prior authorization for non-acute admin days is required by Nebraska Medicaid.

016. PAYMENT FOR SWING BED SERVICES. A per diem that includes post-hospital 24-hour skilled nursing care services that must be provided by or under the direct supervision of professional or technical personnel and requires skilled knowledge, judgment, observation, and assessment. This per diem payment includes all items and services aside from ancillary services and therapies. Prior authorization for admission to a swing bed is required by Nebraska Medicaid.

017. RATE-SETTING FOLLOWING A CHANGE IN OWNERSHIP. The rate-setting process for facilities with a change in ownership will be the same as the rate-setting process used prior to the change in ownership as described in this chapter .

018. RATE-SETTING FOLLOWING A HOSPITAL MERGER. Hospitals that have combined into a single entity shall be assigned a single combined weighted average for each of the following: direct medical education (DME) amount, if applicable, indirect medical education (IME) amount, if applicable, cost-to-charge ratio (CCR), outpatient percentage, capital amount, and any other applicable rates or add-ons. The weights shall equal each hospital's base year Nebraska Medicaid discharges as a proportion of total Nebraska Medicaid discharges for the merged hospitals and shall be applied to the current fiscal year rates which were calculated for each hospital.

019. RATE-SETTING FOR A NEW OPERATIONAL FACILITY. The prospective per discharge rate for a new operational facility . will be the average Peer Group rate for the respective Peer Group for the new facility.

020. DEPRECIATION. Nebraska Medicaid recognizes depreciation as an allowable cost as reported on each facility's Medicare cost report and as determined allowable by the Medicare intermediary through application of Medicare principles of reimbursement.

021. RECAPTURE OF DEPRECIATION FROM HOSPITAL. A hospital which is sold for a profit and has received Nebraska Medicaid payments for depreciation, shall refund to Nebraska Medicaid the lower of: the amount of depreciation allowed and paid by Nebraska Medicaid; or the product of the ratio of Nebraska Medicaid allowed inpatient days to total inpatient days; and the amount of gain on the sale as determined by the Medicare intermediary. The year or years for which depreciation is to be recaptured is determined by the Medicare intermediary according to Medicare principles of reimbursement.

022. ADJUSTMENT TO RATE. Changes to Nebraska Medicaid total allowable costs as a result of error, audit, or investigation may become the basis for adjusting current or prior prospective rates. The adjustment will be made back to the initial date of payment for the period affected based on the rate as determined by Nebraska Medicaid. Hospitals will receive written notice of any adjustment stating the amount of the adjustment and the basis for the adjustment. If the rate adjustment results in decreasing a hospital's rate, the hospital shall refund the overpayment amount as determined by Nebraska Medicaid . .

023. LOWER LEVELS OF CARE (LOC). When Nebraska Medicaid determines that a beneficiary no longer requires inpatient services but requires nursing facility care and there are no nursing beds available when the determination is made or when the transfer requires a guardian, Nebraska Medicaid will pay only for authorized medically necessary nursing care provided in an acute care hospital at a rate equal to the average rate per beneficiary day paid by Nebraska Medicaid to nursing facilities during the previous calendar year. A prior authorization is required.

024. ACCESS TO RECORDS. Hospitals shall make all records relating to the care of Nebraska Medicaid beneficiaries and all other cost information available to Nebraska Medicaid, its designated representatives or agents, or representatives of the federal Department of Health and Human Services, upon reasonable notice during regular business hours. Hospitals shall allow authorized representatives of Nebraska Medicaid , the federal Department of Health and Human Services, and state and federal fraud and abuse units to review and audit the hospital's data processing procedures and supportive software documentation involved in the production of computer-encoded claims submitted to Nebraska Medicaid.

025. AUDITS. Nebraska Medicaid periodically performs or receives cost report audits to monitor the accuracy of data used to set rates. Audits may be performed by the hospital's Medicare intermediary, Nebraska Medicaid, or an independent public accounting firm, licensed to do business in Nebraska and retained by Nebraska Medicaid. Audits will be performed as determined appropriate by Nebraska Medicaid.

026. PROVIDER APPEALS. A hospital may submit additional evidence and request prompt administrative review of its prospective rate within 90 days of the rate notification date according to the procedures in this title .

027. REQUEST FOR RATE ADJUSTMENTS. Requests for rate adjustments are subject to the rules contained in this section.

027.01 REQUESTS. Hospitals may submit a request to Nebraska Medicaid for an adjustment to their rates for the following:

(A) If the rate-setting methodology or principles of reimbursement established under the State Plan were incorrectly applied, or if incorrect data or erroneous calculations were used in the establishment of the hospital's rate;

(B) For extraordinary circumstances that are not faced by other Nebraska hospitals in the provision of hospital services. Extraordinary circumstances are limited to circumstances occurring since the base year that are not addressed by the reimbursement methodology. Extraordinary circumstances are limited to:

(i) Changes in routine and ancillary costs, which are limited to:

(1) Intern and resident related medical education costs; and

(2) Establishment of a subspecialty care unit; and

(ii) Extraordinary capital-related costs. Adjustment for capital-related costs will be limited to no more than a five percent increase; or

(C) If they incur allowable costs as a consequence of a natural or other catastrophe. The following circumstances must be met to be considered a catastrophic circumstance:

(i) One-time occurrence;

(ii) Less than twelve-month duration;

(iii) Could not have been reasonably predicted;

(iv) Not of an insurable nature;

(v) Not covered by federal or state disaster relief; and

(vi) Not a result of malpractice or negligence.

027.02 REQUIREMENTS. A request for adjustment for circumstances other than a correction of an error, the requesting hospital shall demonstrate the following: changes in costs are the result of factors generally not shared by other hospitals in Nebraska, such as improvements imposed by licensing or accrediting standards, the rate the hospital receives is insufficient to provide care and service that conforms to applicable state and federal laws, regulations, and quality and safety standards, or extraordinary circumstances beyond the hospital's control; and every reasonable action has been taken by the hospital to mitigate or contain resulting cost increases. Nebraska Medicaid may request that the hospital provide additional quantitative and qualitative data to assist in evaluation of the request. Nebraska Medicaid may require an on-site operational review of the hospital be conducted by Nebraska Medicaid or its designee. In all circumstances, requests for adjustments to rates must be calculable and auditable. Requests must specify the nature of the adjustment sought and the amount of the adjustment sought. The burden of proof is that of the requesting hospital.

027.03 SUBMISSION. Requests for rate adjustments must be submitted in writing to Nebraska Medicaid . Requests must be received within 45 days after one of the above circumstances occurs or the notification of the facility of its prospective rates. Upon receipt of the request, Nebraska Medicaid shall determine the need for a conference with the hospital and will contact the facility to arrange a conference if needed. The conference, if needed, must be held within 60 days of Nebraska Medicaid's receipt of the request. Regardless of Nebraska Medicaid's decision, the provider will be afforded the opportunity for a conference if requested for a full explanation of the factors involved and Nebraska Medicaid's decision. Following review of the matter, Nebraska Medicaid shall notify the facility of the action to be taken within 30 days of receipt of the request for review or the date of the conference, except in circumstances where additional information is requested or additional investigation or analysis is determined to be necessary by Nebraska Medicaid. If rate relief is granted because of a rate adjustment request, the relief applies only to the rate year for which the request is submitted, except for corrections of errors in rate determination. If the provider believes that continued rate relief is justified, a request in any subsequent year may be submitted. Under no circumstances shall changes in rates resulting from the request process result in payments to a hospital that exceed its actual Nebraska Medicaid cost, calculated in conformity with this Nebraska Medicaid cost calculation methodology. Nebraska Medicaid’s decision regarding rate adjustment requests is final and non-appealable.

028. HOSPITAL QUALITY ASSURANCE AND ACCESS ASSESSMENT. A hospital shall pay its quarterly assessment within 30 days after receipt of its quarterly directed payments.

028.01 DETERMINATION OF NET PATIENT REVENUE. The hospital cost reports, which are extracted from the Healthcare Cost Report Information System on Nebraska Medicaid’s extraction date, will be considered final for purposes of determining the hospital's net patient revenue for their prospective quality assurance assessment amount.

028.02 NON-PAYMENT OF QUALITY ASSURANCE AND ACCESS ASSESSMENT. Failure of a hospital to remit the assessments may result in penalties, interest, or legal action. Providers that fail to remit the assessments in 30 days are subject to sanctions listed in Nebraska regulations.

History

• Effective 2026-07-19

Chapter 47 Telehealth

Neb. Admin. Code tit. 471, ch. 47 Telehealth {#sec-471-nac-47 omnilex-key=us-ne-regs-official--title-471--471 NAC 47}

001. SCOPE AND AUTHORITY. The regulations govern the services provided under Nebraska’s Medicaid program as defined by Nebraska Revised Statute (Neb. Rev. Stat.) §§ 68-901 et seq.

002. DEFINITIONS. The following definitions apply to this chapter:

002.01 DISTANT SITE. The site at which the health care practitioner delivering the service is located at the time the service is provided via telehealth.

002.02 ESTABLISHED PATIENT. An established patient refers to a beneficiary who has received professional services, including services via telehealth, from the provider or another provider of the same specialty who belongs to the same group practice within the past three years.

002.03 ORIGINATING SITE. The site at which the client is located at the time the service is provided via telehealth.

002.04 STORE-AND-FORWARD. Asynchronous services involving the acquisition and storage of medical information at one site that is then forwarded to or retrieved by a health care practitioner at another site for medical evaluation which is then reported back to the referring provider.

002.05 TELEHEALTH. The use of telecommunications and information technology to electronically exchange medical information from one site to another at different physical locations, whether synchronously or asynchronously, in order to aid a health care practitioner in the diagnosis or treatment of a client. Telehealth encompasses telemedicine, store-and-forward, and telemonitoring. The term also includes audio-only services for the delivery of individual behavioral health services for an established client when appropriate, and crisis management and intervention for an established client as allowed by federal law.

002.06 TELEHEALTH CONSULTATION. Any contact between a client and a health care practitioner relating to the health care diagnosis or treatment of such client through telehealth. For the purposes of telehealth services, a consultation includes any service delivered through telehealth.

002.07 TELEMEDICINE. The use of two-way, real-time interactive audiovisual technology by a health care practitioner at a distant site to deliver services to a client at an originating site.

002.08 TELEMONITORING. The remote monitoring of a client’s vital signs, biometric data, or subjective data by a monitoring device which transmits such data electronically to a health care practitioner for analysis and storage in order to make treatment recommendations. This requires the use of a device that is defined by the federal Food and Drug Administration as a medical device.

003. SERVICE REQUIREMENTS.

003.01 GENERAL SERVICE REQUIREMENTS.All services provided via telehealth must be medically necessary, clinically appropriate, and in compliance with any applicable requirements within Title 471 of the Nebraska Administrative Code (NAC).

003.01(A) SERVICE CODE DEFINITIONS.All services provided via telehealth must meet the applicable service code definitions for coverage.

003.01(B) FEE SCHEDULE.Payment for services provided via telehealth is made according to the Nebraska Medicaid Practitioner Fee Schedule. Payment for services provided via telehealth is only available for those services specifically indicated as telehealth eligible services in the fee schedule.

003.02 EXCLUDED SERVICES.Services requiring hands-on care or in-person contact between the client and provider are not covered if provided via telehealth.

003.03 SERVICE LIMITATIONS.Services maintain the same limitations whether provided in-person or via telehealth, unless otherwise stated within this chapter.

003.04 TELECOMMUNICATIONS TECHNOLOGY REQUIREMENTS. For services provided via telehealth to be covered, the telecommunications technology utilized must meet the following requirements:

(A) The technology must provide a secure audiovisual connection between distant and originating sites enough to ensure service parity with in-person delivery;

(B) The technology must be Health Insurance Portability and Accountability Act of 1996 (HIPAA) compliant; and

(C) The technology must be sufficient to allow the provider to appropriately complete the service billed to Nebraska Medicaid while adequately maintaining the safety of the client.

003.05 TELEMONITORING REQUIREMENTS. Nebraska Medicaid will reimburse for telemonitoring when all of the following requirements are met:

(A) The services are from the originating site;

(B) The client is cognitively capable to operate the equipment or has a willing and able person to assist in the transmission of electronic data;

(C) The originating site has space for all program equipment and full transmission capability;

(D) The provider must maintain a client’s medical record containing data supporting the medical necessity of the service, all transmissions and subsequent review received from the client, and how the data transmitted from the client is being utilized in the continuous development and implementation of the client’s plan of care; and

(E) The service is otherwise reimbursable by Nebraska Medicaid.

003.06 AUDIO-ONLY BEHAVIORAL HEALTH SERVICES. For audio-only services to be covered, they must be individual behavioral health services or crisis management and intervention, clients must have established relationships with their providers, and audio-only services must be clinically appropriate.

003.06(A) BEHAVIORAL HEALTH SERVICES FOR CHILDREN. For each client who is a child who is receiving behavioral health services via telehealth, the following protections must be in place:

(i) An appropriately trained staff member or employee familiar with the child’s

treatment plan or familiar with the child must be immediately available in person to the child receiving a telehealth behavioral consultation in order to attend to any urgent situation or emergency that may occur during provision of such service. This requirement may be waived by the child’s parent or legal guardian. The medical record must document the waiver; and

(ii) In cases in which there is a threat that the child may harm himself or herself or

others, before an initial telehealth consultation the health practitioner must work with the child and his or her parent or guardian to develop a safety plan. Such plan must document actions the child, the health care practitioner, and the parent or guardian will take in the event of an emergency or urgent situation occurring during or after the telehealth consultation. Such plan may include having a staff member or employee familiar with the child’s treatment plan immediately available in person to the child if such measures are deemed necessary by the team developing the safety plan.

003.07 OUT-OF-STATE SERVICES. Services provided via telehealth to clients out-of-state are covered if the services meet the regulatory requirements for payment for services provided outside Nebraska.

004. PROVIDER REQUIREMENTS.

004.01 APPLICABLE LAWS. Providers delivering services via telehealth must follow all applicable state and federal laws and regulations governing their practice and the services they provide.

004.02 GENERAL PROVIDER REQUIREMENTS. Providers of services delivered via telehealth must comply with all applicable provider participation requirements under 471 NAC Chapters 2 and 3. In the event that provider participation requirements in 471 NAC Chapters 2 or 3 conflict with requirements outlined in this chapter, the requirements herein shall govern:

(A) Providers must ensure that services can be safely and effectively delivered using telehealth;

(B) Providers must consider a beneficiary’s behavioral, physical, and cognitive abilities to participate in services provided using telehealth;

(C) The beneficiary’s safety must be carefully considered for the complexity of the services provided;

(D) In situations where a caregiver or facilitator is necessary to assist with the delivery of services via telehealth their ability to assist and safety must also be considered;

(E) Beneficiaries are not required to seek services through telehealth and must be allowed to access in-person services, if the beneficiary requests; and

(F) Providers must ensure that beneficiary privacy and confidentiality is protected to the best of their ability.

004.03 TECHNOLOGY PROFICIENCY AND RESPONSIBILITY. To deliver services via telehealth, providers must be proficient in the use of applicable telehealth technologies. Providers are responsible for ensuring that the telecommunications technology requirements within this chapter are met when delivering services via telehealth.

004.04 INFORMED CONSENT. Before an initial telehealth consultation, the provider must provide the client the following written information, which must be acknowledged by the client in writing or via email:

(i) Alternative options are available, including in-person services. These alternatives are specifically listed on the client’s informed consent statement. The client must be aware of their right to refuse the telehealth consultation;

(ii) All existing laws and protections for services received in-person also apply to telehealth, including:

(1) Confidentiality of information;

(2) Access to medical records and information resulting from the telehealth consultation; and

(3) Dissemination of client identifiable information, which cannot occur without written consent;

(iii) The need for the client to utilize a private location as their originating site to preserve confidentiality;

(iv) Whether the telehealth consultation will be or will not be recorded;

(v) The identification of all the parties who will be present at each telehealth consultation, and a statement indicating that the client has the right to exclude anyone from either the originating or the distant site; and

(vi) The written consent form becomes a part of the client’s medical record, and a copy must be provided to the client or the client’s authorized representative.

004.04(A) VERBAL CONSENT. Clients may provide verbal rather than written consent during initial telehealth consultations. The client must confirm that they understand the information contained in the written consent form. A signed statement must be collected from the client within ten days of the service being provided and added to the client’s medical record.

004.04(B) LEGALLY AUTHORIZED REPRESENTATIVE. If the client is unable to provide consent, then it must be obtained verbally or in writing from the client’s legally authorized representative.

004.04(C) EXCEPTION FOR EMERGENCY SITUATIONS. Informed consent is not required if, because of a medical emergency, a client or their authorized representative are unable to provide written or verbal consent prior to the delivery of a service via telehealth.

004.05 PROVIDER REQUIREMENTS FOR OUT-OF-STATE SERVICES. For services delivered via telehealth to Nebraska Medicaid clients when the provider or the client, or both, is located outside of Nebraska, providers must be enrolled with Nebraska Medicaid and appropriately licensed.

005. ORIGINATING AND DISTANT SITE REQUIREMENTS.

005.01 ORIGINATING SITES. Originating sites must provide a place where the client’s right to receive confidential and private services is protected.

005.01(A) GEOGRAPHIC RESTRICTIONS. There are no geographic restrictions dictating where an originating site may be located.

005.01(B) TECHNOLOGICAL COMPATABILITY. Originating sites must be compatible with the telecommunications technology necessary for services to be provided via telehealth.

005.02 DISTANT SITES HEALTH CARE FACILITIES. To receive reimbursement, health care facilities must have quality of care protocols and patient confidentiality guidelines consistent with the requirements under this chapter.

006. DOCUMENTATION REQUIREMENTS.

006.01 MEDICAL RECORD. The medical record for telehealth services must follow all applicable statutes and regulations on documentation. The use of telehealth technology must be documented in the same medical record, and must include the following telehealth information:

(A) Documentation of which site initiated the call;

(B) Documentation of the telecommunication technology utilized;

(C) The time the service began and ended;

(D) Assurance that services provided via telehealth meet applicable service definitions;

and

(E) Documentation of informed consent.

007. BILLING.

007.01 FEE SCHEDULE INDICATORS. Services allowed to be delivered via telehealth are distinguished on the Nebraska Medicaid Fee Schedule using the coding indicated therein.

007.02 MINIMUM STANDARD. Services provided via telehealth must be reimbursed at the equivalent rate for the comparable in-person service and without regard to the distance between the originating and distant sites.

007.03 ORIGINATING SITE FEE. The originating site fee is paid to the health care facility hosting the client for telehealth services at a rate set forth in the Nebraska Medicaid Fee Schedule or under arrangement with the managed care organization (MCO).

007.04 TELEMONITORING PER DIEM RATE. Telemonitoring is paid at a daily per diem rate set by Nebraska Medicaid and includes the following:

(i) Provider review and interpretation of client data;

(ii) Equipment and all supplies, accessories, and services necessary for proper functioning and effective use of the equipment;

(iii) Medically necessary visits to the home by a provider; and

(iv) Training on the use of equipment and completion of necessary medical records.

007.04(A) FIXED PAYMENT. No additional or separate payment beyond the fixed payment is allowable.

007.05 OUT-OF-STATE TELEHEALTH SERVICES. Out-of-state telehealth services are covered when the Nebraska client is located at an originating site in another state, whether or not the provider’s distant site is located in or out of Nebraska, if the telehealth services are appropriately provided in accordance with this chapter and otherwise meet any applicable requirements within Title 471 of the Nebraska Administrative Code (NAC).

History

• Effective 2025-01-20