-HCFA the Medicare and Medicaid Agency Medicaid Long Term Care Services Nursing Facility Services for Individuals Age 21 and Older Medicaid Payments for Nursing Facility Services Hospice Services Rehabilitation Services Personal Care Services Physical Therapy, Occupational Therapy, and Services for Individuals with Speech, Hearing and Language Disorders Institutions for Mental Diseases Targeted Case Management Services Home and Community-Based Services Waivers Home Health Services _________________________________________________________________ (Last updated March 14, 1997) -HCFA the Medicare and Medicaid Agency ---------- Nursing Facility Services for Individuals Age 21 and Older · Nursing facility services for individuals age 21 and older is a mandatory Medicaid benefit. · Nursing facilities are institutions which primarily provide: * skilled nursing care and related services for residents who require medical or nursing care; * rehabilitation services for the rehabilitation of injured, disabled or sick persons; or * on a regular basis, health-related care and services to individuals who because of their mental or physical condition require care and services, above the level of room and board, which can be made available to them only through institutional facilities. · A nursing facility that participates in Medicaid must provide, or arrange for, the full range of services for residents who need them, from those services above the level of room and board which can be made available only through institutional facilities, up to and including skill nursing care. Nursing facilities are required to meet a number of requirements relating to provision of services, residents' rights and administration. · In general, to the extent needed to fulfill all plans of care, a nursing facility must provide, or arrange for the provision of: * nursing and related services and specialized rehabilitative services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident; * medically-related social services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident; * pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing and administering of all drugs and biologicals) to meet the needs of each resident; * dietary services that assure that the meals meet the daily nutritional and special dietary needs of each resident; * an on-going program, directed by a qualified professional, of activities designed to meet the interests and the physical, mental, and psychosocial well-being of each resident; * routine dental services (to the extent covered under the State plan) and emergency dental services to meet the needs of each resident; and * treatment and services required by mentally ill and mentally retarded residents not otherwise provided or arranged for (or required to be provided or arranged for) by the State. · Resident rights. Each nursing facility resident has a right to a dignified existence, self-determination and communication with and access to persons and services inside and outside the facility. A facility must protect the rights of each resident. The resident has the right to exercise his or her rights as a resident of the facility and as a citizen or resident of the United States. * The resident has the right to be free of interference, coercion, discrimination, and reprisal from the facility in exercising his/her rights. * In the case of a resident who has been adjudged incompetent by a court, the rights of the resident are exercised by a person appointed to act on the person's behalf. * In the case of a resident who has not been adjudged incompetent by the court, any legal-surrogate designated in accordance with State law may exercise the resident's rights to the extent provided by State law. * The facility must inform the resident both orally and in writing, in a language that the resident understands, of his/her rights and all rules and regulations concerning resident conduct and responsibilities during his/her stay in the facility. This notice must be made prior to or upon admission and during the person's stay. Receipt of the information must be acknowledged in writing. * The resident has the right to access all records pertaining to himself or herself, including current clinical records within 24 hours (excluding weekend and holidays). At the cost of the community standard, the individual has a right to a copy of the records or any portion of the records. * The resident has the right to be fully informed, in language that he/she can understand, of his/her total health status. * The resident has the right to refuse treatment; to refuse to participate in experimental research; and to formulate an advance directive. * The facility must inform each Medicaid resident, in writing: The items and services that are included in the facility payment for which the resident may not be charged. Those other items and services that the facility offers, for which the resident may be charged, and the cost for those services.The resident must be informed when changes are made to the items, services, and costs. * The facility must furnish a written description of legal rights. * The facility must inform each resident of the name, specialty, and way of contacting the physician responsible for his/her care. * The facility must prominently display, in the facility, written information and provide applicants for admission, oral and written information about how to apply for and use Medicare and Medicaid benefits, and how to receive refunds for previous payments covered by such benefits. * A facility must immediately inform the resident; consult with the resident's physician; and, if known, notify the resident's legal representative or an interested family member when there is: - an accident involving the resident which results in injury and has the potential for requiring physician intervention; - a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications; - a need to change treatment significantly; or - a decision to transfer or discharge the resident from the facility. The resident has the right to manage his or her financial affairs, and the facility may not require residents to deposit their personal funds with the facility. If a resident does deposit funds with the facility, regulations specify how those moneys will be treated and protected. · Services included in the Medicare and Medicaid payment. During the course of a covered Medicare or Medicaid stay, facilities may not charge a resident for the following categories of items and services: * Nursing services. * Dietary services. * An activities program. * Room/bed maintenance services. * Routine personal hygiene items and services, as required, to meet the needs of residents, including, but not limited to: hair hygiene supplies, comb., brush, bath soap, disinfecting soaps or specialized cleansing agents, when indicated to treat special skin problems or to fight infection, razor, shaving cream, toothbrush, toothpaste, denture adhesive, denture cleaner, dental floss, moisturizing lotion, tissues, cotton balls, cotton swabs, deodorant, incontinence care and supplies, sanitary napkins, and related supplies, towels, washcloths, hospital gowns, over the counter drugs, hair and nail hygiene services, bathing, and basic personal laundry. * Medically-related social services. · Items and services that may be charged to residents' funds. General categories and examples of items and services that the facility may charge to residents' funds if they are requested by a resident, if the facility informs the resident that there will be a charge and if payment is not made by Medicaid or Medicare: * Telephone * Television/radio for personal use. * Personal comfort items, including smoking materials, notions and novelties, and confections. * Cosmetic and grooming items and services in excess of those for which payment is made under Medicaid or Medicare. * Personal clothing. * Personal reading materials. * Gifts purchased on behalf of a resident. * Flowers and plants. Social events and entertainment offered that are not part of the activities program. * Noncovered special care services, such as privately hired nurses or aides. * Private room, except when therapeutically required (for example, isolation for infection control). * Specially prepared or alternative food requested instead of the food generally prepared by the facility. The facility must not charge a resident (or his/her representative) for any item or service not requested by the resident. Contact: Jan Earle (410) 786-3326 or jearle@hcfa.gov ---------- Hospice Services Coverage The hospice service benefit is an optional benefit which States may choose to make available under the Medicaid program. The purpose of the hospice benefit is to provide for the palliation or management of the terminal illness and related conditions. Under Federal guidelines, the hospice benefit is available to individuals who have been certified by a physician to be terminally ill. An individual is considered to be terminally ill if he/she has a medical prognosis that his or her life expectancy is 6 months or less. Individuals who meet these requirements can elect the Medicaid hospice benefit. In order to receive payment under Medicaid, a hospice must meet the Medicare conditions of participation applicable to hospices and have a valid provider agreement. The provision of care is generally in the home to avoid an institutional setting and to improve the individual's quality of life until he or she dies. However, individuals eligible for Medicaid may reside in a nursing facility (NF) and receive hospice care in that setting. In order to be covered, a plan of care must be established before services are provided. The following are covered hospice services: nursing care; medical social services; physicians' services; counseling services; home health aide; medical appliances and supplies, including drugs and biologicals; and physical and occupational therapy. In general, the services must be related to the palliation or management of the patient's terminal illness, symptom control, or to enable the individual to maintain activities of daily living and basic functional skills. Additionally, there are other services that may be provided under the hospice benefit, subject to special coverage requirements. Continuous home care may be provided in a period of crisis. This consists of primarily nursing care to achieve palliation or management of acute medical symptoms. A minimum of 8 hours of care must be provided during a 24-hour day. Also, short-term, inpatient care is covered, as long as it is provided in a participating hospice unit or a participating hospital, or NF that additionally meets hospice standards. Services provided in an inpatient setting must conform to the written plan of care. General inpatient care may be required for procedures necessary for pain control or acute or chronic symptom management, which cannot be provided in other settings. Respite care is short-term, inpatient care provided to the individual only when necessary to relieve the family members or other persons caring for the individual at home. It may only be provided on an occasional basis and may not be reimbursed for more than 5 days at a time. Respite care may not be provided when the hospice patient is a nursing home resident. The Omnibus Budget Reconciliation Act of 1990 (OBRA 90) modified the Medicaid statute relating to hospice services. Prior to OBRA 90, when a Medicaid eligible individual elected the Medicaid hospice benefit, he or she waived the right to Medicaid payment for services other than those described earlier. As modified, the law would allow an individual to receive payment for Medicaid services related to the treatment of the terminal condition and other medical services that would be equivalent to or duplicative of hospice care, so long as the services would not be covered under the Medicare hospice program. This means that Medicaid can cover certain services which Medicare does not cover. Reimbursement Medicaid reimbursement for hospice care will be made at one of four predetermined rates for each day in which an individual is under the care of the hospice. The four rates are prospective rates; there are no retroactive adjustments, other than an optional application of a "cap" on overall payments and the limitation on payments for inpatient care, if applicable. The rate paid for any particular day would vary, depending on the level of care furnished to the individual. The four levels of care are classified as routine home care, continuous home care, inpatient respite care, or general inpatient care. Payment rates are adjusted for regional differences in wages. Payments to a hospice for inpatient care must be limited according to the number of days of inpatient care furnished under Medicaid. During the 12-month period beginning November 1 of each year and ending October 31, the aggregate number of inpatient days (both for general inpatient care and inpatient respite care) may not exceed 20 percent of the aggregate total number of days of hospice care provided to all Medicaid recipients during that period. The State may exclude recipients with AIDS in making this calculation. Any excess reimbursement must be refunded by the hospice. Additionally, if a Medicaid hospice patient resides in a NF, the State must pay an amount equal to at least 95 percent of the NF rate to the hospice to pay for the room and board services provided by the NF. Contacts: Tom Shenk (410) 786-3295 or tshenk@hcfa.gov Terry Pratt (410) 786-5831 or tpratt@hcfa.gov Melissa Harris (410) 786-3397 or mharris@hcfa.gov ---------- Rehabilitation Services Rehabilitation services are an optional Medicaid benefit that must be recommended by a physician or other licensed practitioner of the healing arts, within the scope of practice under State law, for the maximum reduction of a physical or mental disability and to restore the individual to the best possible functional level. The services may be provided in any setting and generally include mental health services such as individual and group therapies and psychosocial services. In addition, States also provide services aimed at improving physical functional abilities, including physical, occupational and speech therapies. Contacts: Linda Peltz (410) 786-3399 or lpeltz@hcfa.gov. ---------- Personal Care Services Personal care services are an optional Medicaid benefit provided to individuals who are not inpatients or residents of a hospital, nursing facility, intermediate care facility for the mentally retarded, or institution for mental disease. Personal care services must be: (1) authorized for an individual by a physician in accordance with a plan of treatment or (at the State's option) otherwise authorized for the individual in accordance with a service plan approved by the State; (2) provided by a qualified individual who is not a member of the individual's family; and (3) furnished in a home or other location. These services are provided to assist with an individual's activities of daily living, such as, assistance with eating, bathing, dressing, personal hygiene, bladder and bowel requirements, and taking medications. Contacts: Linda Peltz (410) 786-3399 or lpeltz@hcfa.gov. ---------- Physical Therapy, Occupational Therapy, and Services for Individuals with Speech, Hearing and Language Disorders All of these services are optional Medicaid services States may choose to provide. Physical therapy services are prescribed by a physician or other licensed practitioner of the healing arts within the scope of his or her practice under State law and provided to a recipient by or under the direction of a qualified physical therapist. Included are any necessary supplies and equipment. Occupational therapy services are prescribed by a physician or other licensed practitioner of the healing arts within the scope of his or her practice under State law and provided to a recipient by or under the direction of a qualified occupational therapist. Included are any necessary supplies and equipment. Services for individuals with speech, hearing, and language disorders means diagnostic, screening, preventive, or corrective services provided by or under the direction of a speech pathologist or audiologist, for which a patient is referred by a physician or other licensed practitioner of the healing arts within the scope of his or her practice under State law. Included are any necessary supplies and equipment. Qualifications for providers of physical therapy, occupational therapy and services for individuals with speech, hearing, and language disorders,are specified in Federal regulations. Contacts: Linda Peltz (410) 786-3399 or lpeltz@hcfa.gov. ---------- Institutions for Mental Diseases States may provide optional coverage for individuals 65 years of age or older who are in hospitals or nursing facilities that are institutions for mental diseases (IMDs). States may also provide optional coverage for individuals under age 21 in psychiatric facilities with JCAHO accreditation. However, the Medicaid program does not provide for coverage of medical assistance for services provided to any individual who is under age 65 and who is a patient in an IMD unless the payment is for inpatient psychiatric services for individuals under age 21. This exclusion was designed to assure that States, rather than the Federal government, continue to have principal responsibility for funding inpatient psychiatric services. Under this broad exclusion, no Medicaid payment can be made for services provided either in or outside the facility for IMD patients in this age group. Contacts: Winona Hocutt (410) 786-3329 or whocutt@hcfa.gov Mary Kay Mullen (410) 786-5480 or mmullen@hcfa.gov Linda Peltz (410) 786-3399 or lpeltz@hcfa.gov ---------- Targeted Case Management Services States may provide optional targeted case management services to recipients under its Medicaid State plan. The statute defines targeted case management services as "services which assist an individual eligible under the plan in gaining access to needed medical, social, educational and other services." This section enables States to reach out beyond the bounds of the Medicaid program to coordinate a broad range of activities and services necessary to the optimal functioning of a Medicaid client. States desiring to provide these case management services may do so by amending their State plans. Given the targeted nature of the program, States must submit a separate plan amendment for each target group. Contact: Pat Helphenstine (410) 786-5900 or phelphenstine@hcfa.gov ---------- Home and Community-Based Services Waivers Medicaid's optional home and community-based services waiver program affords States the flexibility to develop and implement creative alternatives to institutionalizing Medicaid-eligible individuals. States may request waivers of certain Federal rules which impede the development of Medicaid-financed community-based treatment alternatives. The program recognizes that many individuals at risk of institutionalization can be cared for in their homes and communities, preserving their independence and ties to family and friends, at a cost no higher than that of institutional care. The Social Security Act specifically lists seven services which may be provided; case management, homemaker services, home health aid services, personal care services, adult day health, habilitation and respite care. Other services, such as transportation, in-home support services, meal services, special communication services, minor home modifications, and adult day care, may be provided, subject to HCFA approval. States have the flexibility to design each waiver program, and select the mix of waiver services to best meet the needs of the population they wish to serve. Waiver services may be provided statewide or may be limited to specific geographic subdivisions. Waiver services may be provided to the elderly and disabled, the physically disabled, the developmentally disabled or mentally retarded and the mentally ill. Waivers may also be targeted to individuals with a specific illness or condition, such as technology-dependent children or individuals with AIDS. Under the waiver program, States can make home and community-based services available to individuals who would otherwise qualify for Medicaid only if they were in an institutional setting. To receive approval to implement a waiver, a State Medicaid agency must assure HCFA that, on average, it will not cost more to provide home and community-based services than providing institutional care would cost. The Medicaid agency also must provide and document certain other assurances, including that there are safeguards to protect the health and welfare of recipients. Contact: Mary Jean Duckett (410) 786-3294 or mduckett@hcfa.gov ---------- Home Health Services Home health services are a mandatory benefit for individuals who are entitled to nursing facility services under the State's Medicaid plan. Services must be provided at a recipient's place of residence, and must be ordered by a physician as part of a plan of care that the physician reviews every sixty days. Home health services must include nursing services, as defined in the State's Nurse Practice Act, that are provided on a part-time or intermittent basis by a home health agency, home health aide services provided by a home health agency, and medical supplies, equipment, and appliances suitable for use in the home. Physical therapy, occupational therapy, speech pathology, and audiology services are optional services that States may choose to provide. To participate in the Medicaid program, a home health agency must meet the conditions of participation for Medicare. Contacts: Laura Gange (410) 786-3395 or lgange@hcfa.gov Bill Coons (410) 786-5921 or wcoons@hcfa.gov Rick Fenton (410) 786-5920 or rfenton@hcfa.gov ---------- MEDICAID PAYMENTS FOR NURSING FACILITY SERVICES Background In 1965, Congress enacted the Medicare and Medicaid programs making health care available to a large number of people who previously did not have health care coverage. Prior to 1980, Medicaid and Medicare reimbursed nursing facilities (NFs) on a retrospective reasonable cost basis. In 1980, the Boren Amendment was passed changing the reimbursement method for NF services. Under the Boren Amendment, a State plan for medical assistance must provide for payment of NF services through the use of rates which the State finds, and makes assurances satisfactory to the Secretary, are reasonable and adequate to meet the costs which must be incurred by efficiently and economically operated providers in order to provide care and services in conformity with applicable State and Federal laws, regulations and quality and safety standards. The statutory authority for this provision is found at section 1902(a)(13)(A) of the Social Security Act and the implementing regulations are at 42 CFR 447.253. State Responsibilities Based on the Boren requirements, the Health Care Financing Administration's approval of a State plan amendment for NF services is based on the acceptability of a State's assurances, findings and related rate information concerning the rates paid under its plan. States have flexibility to develop Medicaid reimbursement methodologies that conform to the Federal laws and regulations. Consequently, there is no requirement that States develop and use a single payment methodology for all facilities providing NF services. However, the State must provide the following assurances to support their payment system(s): - Rates are reasonable and adequate - Rates will not exceed the Medicare upper payment limit - Providers have appeal rights - Providers are required to file uniform cost reports - Periodic audits are done of participating providers' financial and statistical records - Public notice of the change was done prior to the effective date of the change - Rates paid are in accordance with the approved State plan - Rates paid will not increase as a result of a sale or transfer of the facility - The payment rates takes into account the costs of complying with the requirements contained in 42 CFR 483 Subpart B - The payment rates provide for an appropriate reduction to take into account the lower costs (if any) for nursing care when provided under a waiver of the requirement to provide nursing care 24 hours a day - The data and methodology used to set the payment rate is available to the public. In addition, the State must also provide us with: - An estimate of the NF rate and the impact of the change on provider participation, type of care and access to services. Payment Summary NF payments are generally made using one of three payment systems; i.e., cost based, per diem and case mix. There is a greater use of prospective payment systems (per diem or case mix) than cost based systems for NF services. It is important to note that although the payment systems can be categorized in general terms, the specific methodology varies from State to State. Moreover, payment systems within a State may also vary between providers and provider types. For more information about State specific NF payment systems, contact the State Medicaid Agency. You can find the address and phone number of the State Agencies by clicking here. Contacts: Laura Gange (410) 786-3395 or lgange@hcfa.gov. Melissa Harris (410) 786-3397 or mharris1@hcfa.gov. Terry Pratt (410) 786-5831 or tpratt@hcfa.gov. Pete Rinehart (410) 786-4450 or prinehart@hcfa.gov. Gwen Talvert (410) 786-5928 or gtalvert@hcfa.gov. ---------- End of Document