PAYMENT- A Medicaid eligible individual
qualifies for the Ventilator Assisted Program reimbursement rate if the:
(a) Individual meets the criteria described
in section (2) of this rule; and
(b) The Nursing facility providing the
ventilator services maintains an active endorsement pursuant to OAR chapter
411, division 90.
individual qualifies for reimbursement at the Ventilator Assisted Program rate
if the individual:
(a) Is chronically
dependent on an invasive mechanical ventilator to sustain life;
(b) Requires the ongoing use of a CPAP or
Bi-Pap to sustain life; or
receiving necessary support and services during the transition from mechanical
ventilation to a lower level of service.
Ventilator dependent per diem rates shall
cover all services in the bundled rate (OAR 411-070-0085
) as well as all
services, equipment, supplies and costs related to ventilator services. This
includes services necessary to accommodate the needs of a person who qualifies
for the Ventilator Assisted Program Medicaid reimbursement pursuant to this
rule. The following services and supplies are not included in the Ventilator
Assisted Program rate:
provided to residents by outside providers, excluding respiratory therapy and
speech therapy required by OAR 411-090-0180
Medical services by physicians or other
practitioners excluding the services required by OAR 411-086-0200
Ventilator Assisted Program Medical services required by OAR
services, laboratory services, and podiatry services, excluding Ventilator
Assisted Program laboratory services related to 411-090-0180.
(d) Transportation for residents to and from
medical services in vehicles that are not owned or leased by the facility or by
any person who holds an ownership interest in the facility.
(e) Biologicals (e.g., immunization
devices to promote individual's communication and quality of life.
endorsed in accordance with OAR 411-090-0120
for participation in the
Ventilator Assisted Program shall receive payment in the form of 235% of the
basic nursing facility rate established in accordance with OAR
ASSISTED PROGRAM PAYMENT PROHIBITED. APD may not provide Ventilator Assisted
Program payments to a facility:
(a) With a
waiver that allows a reduction of required licensed nurse staffing or certified
(b) For an
Individual whose needs require non-acute continuous positive airway pressure
(CPAP) or bi-level positive airway pressure (Bi-PAP).
(c) If the facility is billing the complex
medical rate for the same individual for the same dates of service.
(6) PRIOR AUTHORIZATION. A nursing
facility must obtain prior authorization from the Department prior to admitting
an individual into a Ventilator Assisted Program Unit on a form designated by
The endorsed nursing facility must maintain sufficient documentation as
described in OAR 411-090-0150
OVERPAYMENT FOR VENTILATOR ASSISTED PROGRAM MEDICAID PAYMENTS. The Department
may collect monies that were overpaid to a facility for any period the
Department determines the resident's condition or service needs did not meet
the criteria for an eligible individual or determines the facility did not
maintain the required documentation per OAR 411-090-0150
. The Department shall
issue an order to the facility that includes the determination described in
this paragraph and the facts supporting the determination as well as the amount
of overpayment the Department seeks to recoup.
(a) If a provider disagrees with the order of
the Department regarding overpayment pursuant to section (8) of this rule, the
provider may either request from APD an informal administrative review of the
decision or appeal the order as described in this paragraph.
If the provider requests an informal
administrative review, the provider must submit its request for review in
writing within 30 days of receipt of the notice.
(A) The provider must submit documentation,
as requested by APD, to substantiate its position.
(B) APD shall notify the provider in writing
of its informal decision within 45 days of APD's receipt of the provider's
request for review.
informal decision shall be an order in other than a contested case and subject
to review pursuant to ORS chapter 183.
(c) A provider who disagrees with the order
issued pursuant to section (8) of this rule may appeal the order pursuant to a
contested case proceeding. The provider must submit an appeal in writing within
60 days of receipt of the notice.
Or. Admin. R.
9-2019, adopt filed 01/31/2019, effective
2/1/2019; APD 8-2020, temporary
amend filed 03/20/2020, effective 03/20/2020 through 09/15/2020;
36-2020, amend filed 09/02/2020, effective
Statutory/Other Authority: ORS
Statutes/Other Implemented: ORS