10-144-101 Me. Code R. § III-97-F-2400
Allowable costs shall include salaries and wages for direct service staff and services, as defined in Chapter II, Section 97, as listed below:
Registered nurses
Licensed practical nurses
Licensed social workers
Personal care services staff
Other qualified medical and remedial staff
Other qualified mental health staff
Clinical consultant services
All staff must meet qualification requirements specified in Chapter II, Section 97.
It is the responsibility of the PNMI to provide and coordinate all covered services performed by direct care staff listed in this Section to assure that members receive the full range of services necessary to meet members' needs without duplication of services. See MaineCare Benefits Manual (MBM), Chapter II, Section 97, Sections 97.04 and 97.05 regarding covered services and non-duplication of services.
The personal care services component is determined by inflating the most recent audited costs for these services to the facility's fiscal year ending after July 1, 2002. This becomes the PNMI's facility-specific personal care cap. The personal care cap is deducted from the facility's routine costs as of July 1, 2002. The actual allowable personal care services costs will be settled at audit up to this facility-specific cap.
Allowable costs include, in addition to salaries and wages, the taxes and benefit costs described in Chapter III.
The Department shall approve staffing based on the services necessary to carry out individualized service plans at an accepted standard of care. In the case of services that were created as a result of a competitive bidding (request for proposal) process, the provider must deliver the services accepted and approved by the Department during that process. The Department will use the description of the PNMI services, and any additional information from onsite review or surveys of the facility, including payroll information, as the basis for reviewing/approving staff.
Staffing approvals may, at the discretion of the Department, be accompanied by requirements with regard to admission, discharge and service provision, non-discrimination, reasonable accommodation, dispute resolution procedures, quality improvement practices, access to departmental consultants, training, and other areas as may be required to provide members with a person centered service plan.
All approvals are subject to audit. Those staffing hours not utilized for the purpose approved by the Department will be disallowed at audit, either in whole or in part.
Consultation services referred to in this Appendix may be considered as part of the allowable per diem cost, with the prior approval of the Department, in accordance with the following:
Department-approved training is an allowable cost.
Medical supplies are an allowable cost.
If the Department requires a provider to maintain an accredited status with a recognized accreditation organization, then the costs related to accreditation are allowable.
As of July 1, 2004, allowable costs shall include a State-mandated service tax. The State-mandated service tax is a tax on the value of PNMI services pursuant to 36 M.R.S. §2552.
A program allowance, expressed as a percentage of the allowable costs in Sections 2400 through 2410 will be allowed in lieu of indirect and/or PNMI related cost. The program allowance, as set forth in Chapter III, Section 97, is a percentage specific to this Appendix and is applicable to all facilities covered under this Appendix. The program allowance will be 35%.
Temporary High Intensity Staffing Services are reimbursed on a direct care price. This direct care price is not subject to audit. The Temporary High Intensity Staffing Services remittances received will be removed from the total Direct Service Staff costs in determining the allowable cost for the PNMI rehabilitation and personal care direct service staff costs.
Pending CMS approval, effective retroactive to November 1, 2017, eligible facilities, as defined in Principle 1030, which experience unforeseen and uncontrollable events during a year that result in unforeseen or uncontrollable increases in expenses, as defined herein, may request an adjustment to a prospective rate in the form of an extraordinary circumstance allowance (ECA).
Unforeseen means that a provider did not have sufficient notice of the change to make changes to their operations that would have avoided the cost of the event.
Uncontrollable means that the event occurred as a result of forces unrelated to the discretionary management authority exercised by the provider's organization. Business decisions are not considered uncontrollable.
ECA may include, but not limited to:
* Events of a catastrophic nature (fire, flood, etc.);
* Unforeseen increase in minimum wage, Social Security, or employee retirement contribution expenses in lieu of Social Security expenses;
* Changes in number of licensed beds;
* Changes in licensure or accreditation requirements.
If the Department concludes that an ECA existed, and the increased costs are considered reasonable and necessary, and an adjustment will be made by the Department in the form of a supplemental allowance.
The Department will determine from the nature of the ECA whether it would have a continuing impact and therefore whether the allowance should be included in the computation of the base rate for the succeeding year. Reimbursement to a residential care facility for additional costs arising from ECA must be paid via a supplemental payment that is added to the per diem reimbursement rate until the Department adjusts the direct care and personal care services rates, as applicable, to fairly reimburse a facility for these costs.
A request for ECA must be made in writing and addressed to:
Department of Health and Human Services
Director of Rate-setting
11 State House Station
Augusta, ME 04333
The written request must include:
The Department may require additional documentation to review and process the ECA request. A facility requesting an ECA shall provide all documents requested by the Department. The Department shall deny any ECA requests from facilities who refuse to supply requested documentation.
Pending CMS approval, effective retroactive to November 1, 2017, costs incurred by a residential care facility to comply with changes in federal or state laws, regulations, and rules or local ordinances and not otherwise specified in rules adopted by the Department are considered reasonable and necessary cost. Reimbursement for these additional regulatory costs will be paid via a supplemental payment that is added to the per diem reimbursement rate until the Department adjusts the direct care and personal care services rates, as applicable to fairly and properly reimburse a facility for these costs.
Requests for adjustments must be made in writing and addressed to:
Department of Health and Human Services
Director of Rate-Setting
11 State House Station 5
Augusta, ME 04333
The Department may deny or modify the adjustment request based on documentation provided for review. The Department will provide written notification of adjustment request determination.
10-144 C.M.R. ch. 101, § III-97-F-2400