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Part 4      LONG TERM CARE HOSPITALS

317:30-5-60.Subacute level of care
[Issued 1-06-98]
Subacute (SA) level of care is skilled care provided by a long term care hospital to patients with medically complex needs. The patients who are treated include those with complex pulmonary problems, children requiring long-term care to improve or maintain their physical condition or prevent deterioration to children who are terminally ill, children who are experiencing severe developmental disabilities and multi-handicaps.

317:30-5-61.Eligible providers
[Issued 1-06-98]
To be eligible for reimbursement hospitals must be Medicare certified and have a current contract on file with the Oklahoma Health Care Authority. The facility must also be designated as a long term care facility by the Social Security Administration and be appropriately licensed as a Children's Specialty Hospital. Payment will be made to licensed Children's hospitals specializing in subacute nursing and rehabilitative services.

317:30-5-62.Coverage by category
[Revised 7-01-06]
(a) Adults. There is no coverage for adults.
(b) Children.Payment is made to long term care hospitals for subacute medical and rehabilitative services for persons under the age of 21 within the scope of the Authority's Medical Programs, provided the services are reasonable for the diagnosis and treatment of illness or injury, or to improve the functioning of a malformed body member.
(1) Inpatient services.
(A) All inpatient services are subject to post-payment utilization review by the Oklahoma Health Care Authority, or its designated agent. These reviews will be based on OHCA's, or its designated agent's, admission criteria on severity of illness and intensity of treatment.
(i) It is the policy and intent of the Oklahoma Health Care Authority to allow hospitals and physicians the opportunity to present any and all documentation available to support the medical necessity of an admission and/or extended stay of a Medicaid recipient. If the OHCA, or its designated agent, upon their initial review determines the admission should be denied, a notice is sent to the facility and the attending physician(s) advising them of the decision. This notice also advises that a reconsideration request may be submitted within 60 days. Additional information submitted with the reconsideration request will be reviewed by the OHCA, or its designated agent, who utilizes an independent physician advisor. If the denial decision is upheld through this review of additional information, OHCA is informed. At that point, OHCA sends a letter to the hospital and physician requesting refund of the Title XIX payment previously made on the denied admission.
(ii) If the hospital or attending physician did not request reconsideration by the OHCA, or its designated agent, the OHCA, or its designated agent, informs OHCA that there has been no request for reconsideration and as a result their initial denial decision is final. OHCA, in turn, sends a letter to the hospital and physician requesting refund of the amount of Title XIX payment previously made on the denied admission.
(iii) If an OHCA, or its designated agent, review results in denial and the denial is upheld throughout the review process and refund from the hospital and physician is required, the Medicaid recipient cannot be billed for the denied services. The reconsideration process outlined in (A) of this paragraph will end on July 1, 2006.
(B) If a hospital or physician believes that an long term care facility admission or continued stay is not medically necessary and thus not Medicaid compensable but the patient insists on treatment, the patient must be informed that he/she will be personally responsible for all charges. If a Medicaid claim is filed and paid and the service is later denied the patient is not responsible. If a Medicaid claim is not filed and paid the patient can be billed.
(2) Utilization control requirements.
(A) Certification and recertification of need for inpatient care. The certification and recertification of need for inpatient care must be in writing and must be signed and dated by the physician who has knowledge of the case that continued inpatient care is required. The certification and recertification documents for all Medicaid patients must be maintained in the patient's medical records or in a central file at the facility where the patient is or was a resident.
(i) Certification. A physician must certify for each applicant or recipient that inpatient services in a long term care hospital were needed. The certification must be made at the time of admission or, if an individual applies for assistance while in a hospital, before the Medicaid agency authorizes payment.
(ii) Recertification. A physician must recertify for each applicant or recipient that inpatient services in the long term care hospital are needed. Recertification must be made at least every 60 days after certification.
(B) Individual written plan of care.
(i) Before admission to a long term care hospital, an interdisciplinary team including the attending physician or staff physician must establish a written plan of care for each applicant or recipient. The plan of care must include:
(I) Diagnoses, symptoms, complaints, and complications indicating the need for admission,
(II) the acuity level of the individual,
(III) Objectives,
(IV) Any order for medication, treatments, restorative and rehabilitative services, activities, therapies, social services, diet and special procedures recommended for the health and safety of the patient,
(V) Plans for continuing care, including review and modification to the plan of care, and
(VI) Plans for discharge.
(ii) The attending or staff physician and other personnel involved in the recipient's care must review each plan of care at least every 90 days.
(iii) All plans of care and plan of care reviews must be clearly identified as such in the patient's medical records. All must be signed and dated by the physician and other treatment team members in the required review interval.
(iv) The plan of care must document appropriate patient and/or family participation in the development and implementation of the treatment plan.
(C) Continued stay review. The facility must complete a continued stay review at least every 90 days.
(i) The methods and criteria for the continued stay review must be contained in the facility utilization review plan.
(ii) Documentation of the continued stay review must be clearly identified as such, signed and dated by the committee chairperson, and must clearly state the continued stay dates and time period approved.

317:30-5-63.Trust funds
[Revised 09-01-17]

When a new member is admitted to a long term care hospital, the administrator will complete and send to the county office the Management of Recipient's Funds form to indicate whether or not the member has requested the administrator to handle personal funds. If the administrator agrees to handle the member's funds, the Management of Recipient's Funds form will be completed each time funds or other items of value, other than monthly income, are received.

(1) The facility may use electronic ledgers and bank statements as the source documentation for each member for whom they are holding funds or other items of value. This information must be available at all times for inspection and audit purposes. The facility must have written policies that ensure complete accounting of the member's personal funds. All member's funds which are handled by the facility must be clearly identified and maintained separately from funds belonging to the facility or to private patients. When the total sum of all funds for all members is $250.00 or more, they must be deposited by the facility in a local bank account designated as "Recipient's Trust Funds". The funds are not to be commingled with the operating funds of the facility. Each resident in an intermediate care facility for individuals with intellectual disabilities (ICF/IID) must be allowed to possess and use money in normal ways or be learning to do so.

(2) The facility is responsible for notifying the county office at any time a member's account reaches or exceeds the maximum reserve by use of the Accounting-Recipient's Personal Funds and Property form. This form is also prepared by the facility when the member dies or is transferred or discharged, and at the time of the county eligibility review of the member.

(3) The Management of Recipient's Funds form, the Accounting-Recipient's Personal Funds and Property form, and the Ledger Sheets for Recipient's Account are available online at www.okdhs.org.

(4) When the ownership or operation of the facility is discontinued or where the facility is sold and the members' trust funds are to be transferred to a successor facility, the status of all member's trust funds must be verified by the OHCA and/or the buyer must be provided with written verification by an independent public accountant of all residents' monies and properties being transferred, and a signed receipt obtained from the owner. All transfers of a member's trust funds must be acknowledged, in writing, by the transferring facility and proper receipts given by the receiving facility.

(5) Unclaimed funds or other property of deceased member's, with no known heirs, must be reported to the Oklahoma Tax Commission.

(6) It is permissible to use an individual trust fund account to defray the cost of last illness, outstanding personal debts and burial expenses of a deceased member of the OHCA; however, any remaining balance of unclaimed funds must be reported to the Oklahoma Tax Commission. The Unclaimed Property Division, Oklahoma Tax Commission, State Capitol Complex, Oklahoma City, Oklahoma, is to be notified for disposition instructions on any unclaimed funds or property. No money is to be sent to the Oklahoma Tax Commission until so instructed by the Unclaimed Property Division.

(7) Books, records, ledgers, charge slips and receipts must be on file in the facility for a period of six (6) years and available at all times in the facility for inspection and audit purposes.


317:30-5-64.Inpatient and routine services

[Issued 1-06-98]
(a) Long Term Care Hospital services includes routine items and services that must be provided directly or through appropriate arrangement by the facility when required by Medicaid residents. Charges for routine services may not be made to resident's personal funds or to resident family members, guardians or other parties who have responsibility for the resident. If reimbursement is available from Medicare or another public or private insurance or benefit program, those programs are billed by the facility. In the absence of other available reimbursement, the facility must provide routine services from the funds received from the regular Medicaid vendor payment and Medicaid resident's applied income, or spenddown amount.
(b) An ad hoc committee composed of recognized nursing facility representatives and Oklahoma Health Care Authority staff will review the listing at least annually for additions or deletions, as indicated. Routine services should be patient specific and in accordance with standard medical care. Routine Services include, but are not limited to:
(l) Regular room;
(2) Dietary Services:
(A) regular diets,
(B) special diets,
(C) salt and sugar substitutes,
(D) supplemental feedings,
(E) special dietary preparations,
(F) equipment required for preparing and dispensing tube and oral feedings, and
(G) special feeding devices (furnished or arranged for);
(3) Medically related social services to attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident, nursing care, and activities programs (costs for a private duty nurse or sitter are not allowed);
(4) Personal services - personal laundry services for residents (does not include dry cleaning);
(5) Personal hygiene items (personal care items required to be provided does not include electrical appliances such as shavers and hair dryers, or individual personal batteries) include:
(A) shampoo, comb and brush;
(B) bath soap;
(C) disinfecting soaps or specialized cleansing agents when indicated to treat or prevent special skin problems or to fight infection;
(D) razor and/or shaving cream;
(E) nail hygiene services; and
(F) sanitary napkins, douche supplies, perineal irrigation equipment, solutions and disposable douches;
(6) Routine oral hygiene items including:
(A) toothbrushes,
(B) toothpaste,
(C) dental floss,
(D) lemon glycerin swabs or equivalent products,
(7) Necessary items furnished routinely as needed to all patients, e.g., water pitcher, cup and tray, towels, wash cloths, hospital gowns, emesis basin, bedpan, and urinal.
(8) The facility will furnish as needed items such as alcohol, applicators, cotton balls, tongue depressors. Also, first aid supplies including small bandages, ointments and preparations for minor cuts and abrasions, enema supplies, including disposable enemas, gauze, 4 x 4's ABD pads, surgical and micropore tape, telfa gauze, ace bandages, etc.
(9) Over the counter drugs (non-legend) not covered by the prescription drug program (PRN or routine). In general, long term care hospitals are not required to provide any particular brand of non-legend drugs, only those items necessary to ensure appropriate care.
(A) If the physician orders a brand specific non-legend drug with no generic equivalent, the facility must provide the drug at no cost to the patient. If the physician orders a brand specific non-legend drug that has a generic equivalent, the facility may choose a generic equivalent, upon approval of the ordering physician;
(B) If the physician does not order a specific type or brand of non-legend drug, the facility may choose the type or brand;
(C) If the recipient, family, or other responsible party (excluding long term care hospital) prefers a specific type or brand of non-legend drug rather than the ones furnished by the facility, the recipient, family or responsible party may be charged the difference between the cost of the brand the resident requests and the cost of the brand generally provided by the facility. (Facilities are not required to provide an unlimited variety of brands of these items and services. It is the required assessment of resident needs, not resident preferences, that will dictate the variety of products facilities need to provide);
(D) Before purchasing or charging for the preferred items, the facility must secure written authorization from the recipient, family member, or responsible party indicating his or her desired preference, the date and signature of the person requesting the preferred item. The signature may not be that of an employee of the facility. The authorization is valid until rescinded by the maker of the instrument;
(10) The facility will furnish or obtain any necessary equipment to meet the needs of the patient upon physician order. Examples include: trapeze bars and overhead frames, foot and arm boards, bed rails, cradles, wheelchairs, foot stools, adjustable crutches, canes, walkers, bedside commode chairs, hot water bottles or heating pad, ice bags, sand bags, traction equipment, I.V. stands, etc.;
(11) Physician prescribed lotions, ointments, powders, medications and special dressings for the prevention and treatment of decubitus ulcers, skin tears and related conditions, when medications are not covered under the Vendor Drug Program or other third party payor;
(12) Supplies required for dispensing medications, including needles, syringes including insulin syringes, tubing for IVs, paper cups, medicine containers, etc.;
(13) Equipment and supplies required for simple tests and examinations, including scales, sphygmomanometers, stethoscopes, clinitest, acetest, dextrostix, pulse oximeters, blood glucose meters and test strips, etc.;
(14) Underpads and diapers, waterproof sheeting and pants, etc., as required for incontinence or other care.
(A) If the assessment and care planning process determines that it is medically necessary for the resident to use diapers as part of a plan to achieve proper management of incontinence, and if the resident has a current physician order for adult diapers, then the facility must provide the diapers without charge;
(B) If the resident or the family requests the use of disposable diapers and they are not prescribed or consistent with the facility's methods for incontinent care, the resident/family would be responsible for the expense;
(15) Oxygen for emergency use, or intermittent use as prescribed by the physician for medical necessity;
(16) Other physician ordered equipment to adequately care for the patient and in accordance with standard patient care, including infusion pumps and supplies, and nebulizers and supplies, etc.

317:30-5-65.Ancillary services

[Revised 01-01-10]
Ancillary services are those items which are not considered routine services. Ancillary services may be billed separately to the SoonerCare program, unless reimbursement is available from Medicare or other insurance or benefit programs. Coverage criteria, utilization controls and program limitations are specified in Part 17 of OAC 317:30-5. Ancillary services are limited to the following services:
(1) Services requiring prior authorization:
(A) Ventilators and supplies.
(B) Total Parenteral Nutrition (TPN), and supplies.
(C) Custom seating for wheelchairs.
(D) Enteral feeding.
(2) Services not requiring prior authorization:
(A) Permanent indwelling or male external catheters and catheter accessories.
(B) Colostomy and urostomy supplies.
(C) Tracheostomy supplies.
(D) Prescription drugs, laboratory procedures, and x-rays.

 

317:30-5-66.Reimbursement for inpatient hospital subacute services
[Revised 07-01-13]

Reimbursement for inpatient hospital subacute services is made based on cost reports submitted to the OHCA.  The cost reports will be reviewed annually to ensure that the interim rate is appropriate for the current cost/case mix of care for these facilities and to make settlement to the facility based on total allowable costs under Mecicare/Medicaid cost principles.

317:30-5-67.Cost reports
[Revised 07-01-13]

Each long term care facility is required to submit, on uniform cost reports designed by the Authority, an annual cost report for the fiscal year just completed.  The fiscal year is July 1 through June 30.  The reports must be submitted to the Authority on or before the first day of September.

(1) When there is a change of operation or ownership, the selling or closing ownership is required to file a cost report for that portion of the fiscal year it was in operation.  The successor ownership is correspondingly required to file a cost report for that portion of the fiscal year it was in operation.

(2) Cost report forms and instructions are mailed annually to each facility before the first of July.  The completed forms are to be returned to the Authority, Attention: Reimbursement and Audit.

(3) Normally, all ordinary and necessary expenses incurred in the conduct of an economical and efficiently operated business are recognized as allowable.

(4) All reports are subject to on-site audits and are deemed public records.

(A) Only "allowable costs" may be included in the cost reports, (costs should be net of any offsets of credits).  Allowable costs include all items of Medicaid-covered expense which pediatric long term care hospitals incur in the provision of routine services.  "Routine services" include, but are not limited to:

(i) regular room,

(ii) dietary and nursing services,

(iii) minor medical and surgical supplies,

(iv) over-the-counter medications,

(v) transportation, and

(vi) the use and maintenance of equipment and facilities essential to the provision of routine care.

(B) Allowable costs must be considered reasonable, necessary and proper, and shall include only those costs that are considered allowable for Medicare purposes and that are consistent with federal Medicaid requirements.  (The guidelines for allowable costs in the Medicare program are set forth in the Medicare Provider Reimbursement Manual ("PRM"), HCFA-Pub. 15.)

(C) Ancillary items reimbursed outside the long term care hospital rate should not be included in the cost report and are not allowable costs.
(D) A supplemental addendum to the cost report, including all inpatient and outpatient charges by payor source, will be included with the annual cost report.

317:30-5-68.Rate Appeals [REVOKED]
[Revoked 7-01-98]

Disclaimer. The OHCA rules found on this Web site are unofficial. The official rules are published by the Oklahoma Secretary of State Office of Administrative Rules as Title 317 of the Oklahoma Administrative Code. To order an official copy of these rules, contact the Office of Administrative Rules at (405) 521-4911.