13 CSR 70-10.017 - Nursing Facility Invasive Ventilator Program
(1) The Invasive Ventilator Program is
limited to-
(A) Nursing facilities licensed by
the Department of Health and Senior Services (DHSS) and certified for
participation in the MO HealthNet program and enrolled in the MO HealthNet
Invasive Ventilator Program; and
(B) Services provided to adult MO HealthNet
participants who are dependent on an invasive ventilator as a means of life
support. An invasive ventilator generates breath delivered to the participant
through an artificial airway positioned in the participant's trachea.
(2) Reimbursement for Invasive
Ventilator Care. Providers approved for participation in the Invasive
Ventilator Program will receive payment in the form of a per diem add-on to
their reimbursement rate established in accordance with
13 CSR
70-10.015. The per diem add-on amount will be one
hundred fifty dollars ($150.00) will be paid for MO HealthNet participants who
are dependent on a ventilator full time as a means of life support.
(3) Provider Requirements for Participation
in the Invasive Ventilator Program.
(A)
Nursing facilities seeking to participate in the Invasive Ventilator Program
must submit the following information to Missouri Medicaid Audit and Compliance
(MMAC), Provider Enrollment Unit:
1. A
completed Invasive Ventilator Program Provider application; and
2. Any other information or documentation
requested by MMAC to assist in determining enrollment
status.
(B) MMAC may
enter into agreements with facilities for the participation in the MO HealthNet
Invasive Ventilator Program through the provider enrollment process only if the
provider agrees to the following terms:
1.
The provider must maintain and provide documentation demonstrating-
A. Medicaid (Title XIX)
Certification;
B. The provider has
the capacity and capability to provide invasive ventilator medical care as
documented by DHSS, MO HealthNet Division (MHD), and MMAC records;
C. Adherence to regulatory requirements
established by DHSS, MHD, and MMAC;
D. The medical condition of the participant
to verify they meet the criteria for participation in this program;
and
E. The provider has the
following written agreements:
(I) A written
agreement with an enrolled MO HealthNet Durable Medical Equipment (DME)
provider which must include a service contract for invasive ventilator
equipment. DME providers will bill MO HealthNet for the necessary
ventilator;
(II) A written
agreement with a local emergency transportation provider;
(III) A written agreement with a local
hospital capable of providing the necessary care for invasive
ventilator-dependent participants, when appropriate;
(IV) Presence of written emergency procedures
including but not limited to the following:
(a) Procedures to care for and transport
invasive ventilator-dependent participants in the event of an emergency
evacuation;
(b) Procedures to care
for invasive ventilator-dependent participants in the event of power failure;
and
(c) Procedures to care for
invasive ventilator-dependent participants in the event of equipment
failure;
2. Individuals qualifying for participation
in the Invasive Ventilator Program must be placed in contiguous rooms;
and
3. In addition to the covered
items and services included in the reimbursement rate set forth in
13 CSR
70-10.015 -
A. The
nursing facility must purchase one (1) Ambu bag per invasive ventilator
dependent participant and place it in a designated location readily accessible
at the bedside to ensure access in the event of an emergency;
B. The provider must ensure the necessary
equipment to accommodate the needs of the invasive ventilator-dependent
participants is provided by the DME provider. The equipment and supplies
covered under the MO HealthNet DME program will be payable directly to the DME
provider;
C. Proper invasive
ventilator and tracheostomy supplies and equipment are provided to the
participant;
D. Each invasive
ventilator is equipped with an alarm on both the pressure valve and the volume
valve; and
E. Each invasive
ventilator is equipped with internal batteries to provide a short term back-up
system in case of a total loss of power, and the battery must be checked as
recommended by the manufacturer.
(C) Termination of Participation in Invasive
Ventilator Program.
1. Providers desiring to
discontinue providing invasive ventilator services shall notify MMAC Provider
Enrollment Unit in writing, at least sixty (60) days prior to the date of
termination. Payment for invasive ventilator participants already residing in
facilities who wish to discontinue providing invasive ventilator services will
remain at the previous invasive ventilator rate as long as the participant
meets the invasive ventilator criteria and as long as all related criteria are
met by the provider or the participant is discharged.
(4) Participant Eligibility for
Participation in Invasive Ventilator Program.
(A) Pre-certification must be obtained
through MO HealthNet in order to receive payment under the Invasive Ventilator
Program. The pre-certification must be initiated by an authorized medical
assistance provider who has evaluated the medical needs of the individual.
Authorized providers include physicians, advanced practice nurses, respiratory
therapists, hospitals, and nursing facilities.
1. The pre-certification application will be
available by contacting the Clinical Services Unit/Invasive Ventilator
Program.
2. The pre-certification
period will be approved for the duration of the physician's prescription for
invasive ventilation. If the invasive ventilator is used for weaning purposes,
a precertification must be completed every ninety (90) days to ensure
individuals still meet the requirements for participation in this program. An
approved pre-certification request does not guarantee payment. The provider
must verify participant eligibility on the date of service using the
Interactive Voice Response (IVR) System at (573) 635-8908 or by logging onto
the MO HealthNet Internet Web portal at www.emomed.com.
(B) Accessibility to Records. The provider
must make accessible to MHD, MMAC, and/or DHSS all provider, participant, and
other records necessary to determine that the needs of the participant are
being met and to determine the appropriateness of invasive ventilator
services.
(C) In the event that it
is determined through the precertification process that the participant is no
longer in need of or receiving invasive ventilator services, MHD shall
discontinue the add-on per diem authorized by this regulation for the
participant and reduce the rate of payment to the provider to the provider's
standard MO HealthNet per diem rate established under
13 CSR
70-10.015.
(5) Cost Reporting Requirements.
(A) Providers will be required to separately
identify the invasive ventilator-dependent patient days regardless of payer
source that relate to dates of service within the cost reporting time period by
completing a supplemental schedule as provided by MHD.
(B) Due to the complex record-keeping
requirements needed to identify the specific cost of this program, MHD will
remove the cost as a revenue offset determined as follows. The days from each
category identified above will be multiplied by the related Invasive Ventilator
add-on amount and offset against the expenses. This will ensure the additional
cost of caring for these participants will be removed from the allowable cost
in determining the prospective reimbursement rate. The offset will be allocated
among the cost components as follows: Patient Care-sixty percent (60%),
Ancillary-thirty percent (30%), and Administrative-five percent (5%). The
remaining five percent (5%) will not be offset because the capital costs are
easily identified and will be removed as non-allowable.
Notes
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