1839 Office of Medical Assistance Programs; payment for nursing facility services, exceptional grant payments

DEPARTMENT OF PUBLIC WELFARE

Office of Medical Assistance Programs; Payment for Nursing Facility Services, Exceptional Grant Payments

[29 Pa.B. 5657]

   The purpose of this announcement is to provide advance notice under 42 CFR 447.205 that the Department of Public Welfare (Department) intends to make changes in its methods and standards for payment of Medical Assistance (MA) nursing facility services to authorize additional payments for certain medically necessary durable medical equipment (DME).

   Currently, the Department pays MA nursing facility providers on a per diem rate basis for services provided to MA residents. These nursing facility per diem rates include a capital component that provides a fair rental payment for the use of the facilities' allowable moveable equipment. In addition to the per diem payment rates, the Department makes exceptional payments in limited instances to nursing facilities that provide services to high technology-dependent residents. Effective January 1, 1996, these exceptional payments are limited to the rental of equipment and the supplies necessary to care for the high technology-dependent residents. Nursing facility per diem payments are made under and subject to the terms and conditions specified in the Commonwealth's approved State Plan and applicable Department regulations. Exceptional payments are made under and subject to the terms and conditions specified in the Commonwealth's approved State Plan and exceptional payment grant agreements with individual nursing facilities for services provided to specific residents.

   The Department intends to amend the Commonwealth's approved State Plan and to issue implementing policy changes to expand its exceptional payment provisions to allow additional grants to general and county nursing facilities, other than special rehabilitation facilities and hospital based nursing facilities, for the purchase or rental of medically necessary exceptional DME. In determining whether exceptional DME is medically necessary, the Department will consider, among other things, whether the DME is required in order for the resident to attain or maintain his or her highest practicable physical, mental and psychosocial well-being and whether there are any alternatives which are less costly or which are already reimbursed through the nursing facility's per diem rate that could meet the resident's needs.

   Exceptional DME qualifying for these additional grants must be prescribed by a physician and is limited to: (1) air fluidized beds; (2) powered air flotation beds meeting certain specifications; (3) augmentative communication devices; (4) vacuum-assisted closure devices; (5) parenteral nutrition pumps; (6) specially adapted DME (that is, DME that is uniquely constructed or substantially adapted or modified in accordance with the written orders of a physician for the particular use of one resident, making its contemporaneous use by another resident unsuitable), including specially adapted manual and motorized wheelchairs; (7) ventilators and related supplies; and (8) other extraordinary DME designated by the Department which is ordered by a physician for a resident whose medical needs are so extensive and complex that those needs cannot be adequately met with standard DME.

   Equipment that is furnished generally, routinely or uniformly to nursing facility residents, is furnished for the convenience of the facility or the resident, or is furnished infrequently but does not substantially exceed the cost of equipment that is furnished routinely or uniformly to residents is not exceptional DME.

   Nursing facilities will be required to submit requests for exceptional payments in accordance with instructions issued and on forms designated by the Department. Exceptional DME that is approved for purchase or rental by the Department will be reimbursed on the basis of an individual exceptional payment grant agreement executed by the Department and the facility for each individual resident. Only those additional costs identified in the agreement will be allowed.

   The primary purpose of this proposed change is to enable the Department to recognize the extraordinary costs associated with small subsets of the nursing facility population whose medical needs are so extensive and complex that they cannot be adequately met without highly customized or specialized DME and to target payments to facilities that provide care and services to those residents. This proposed change is part of the Department's continuing efforts to assure that MA nursing facility residents receive care and services in accordance with applicable law, including the Nursing Home Reform Law, 42 U.S.C.A. § 1396r, and Title II of the Americans with Disabilities Act, 42 U.S.C.A. §§ 12131--12134.

   As a result of this proposed policy change, the Department estimates that annual aggregate expenditures for Medical Assistance nursing facility services for FY 1999-2000 will increase by $13.800 million ($6.375 million in State funds).

   A copy of this notice is available for review through the Bulletin Board System (BBS) at [phone], at the local County Assistance Offices throughout the Commonwealth, or by contacting Tom Jayson in the Long Term Care Policy Section at [phone]. The Department invites interested persons to submit written comments about the Statement of Policy to the Department within 30 days. Comments should be addressed to: Department of Public Welfare, Office of Medical Assistance Programs, Attention: Policy Section, P. O. Box 8025, Harrisburg, PA 17105.

   This proposed change in payment methods and standards was discussed at the Long Term Care Subcommittee meeting of the Medical Assistance Advisory Committee (MAAC) on October 13, 1999; the Consumer Subcommittee meeting of the MAAC on October 27, 1999; and the MAAC meeting on October 28, 1999. These meetings were open to the public.

   Following review and consideration of any comments received during this public review process, the Department intends to publish Notice of Rule Change (NORC) in the Pennsylvania Bulletin announcing the final criteria for authorizing these exceptional payments and to submit a State Plan Amendment incorporating the final criteria into the Commonwealth's approved Medicaid State Plan. Payment under these proposed changes is conditioned upon the publication of the NORC and the Health Care Financing Administration's approval of the State Plan Amendment.

   Persons with a disability may use the AT&T Relay Service by calling [phone] (TDD users) or [phone] (voice users). Persons who require another alternative should contact Thomas Vracarich in the Office of Legal Counsel at [phone].

FEATHER O. HOUSTOUN,   
Secretary

   Fiscal Note:  14-NOT-222. (1) General Fund; (2) Implementing Year 1999-00 is $6.375 Million; (3) 1st Succeeding Year 2000-01 is $36.264 Million; 2nd Succeeding Year 2001-02 is $10.940 Million; 3rd Succeeding Year 2002-03 is $10.940 Million; 4th Succeeding Year 2003-04 is $10.940 Million; 5th Succeeding Year 2004-05 is $10.940 Million; (4)  1998-99 Program--$721.631 Million; 1997-98 Program--$617.252 Million; 1996-97 Program--$591.910 Million; (7)  Medical Assistance--Long Term Care; (8)  recommends adoption. Funds will be available in the Department's budget to cover the cost of this increase.

[Pa.B. Doc. No. 99-1839. Filed for public inspection October 29, 1999, 9:00 a.m.]