OAR 411-070-0092: Ventilator Assisted Program - Medicaid Payment

(1) 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. (2) An 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 (c) Is receiving necessary support and services during the transition from mechanical ventilation to a lower level of service. (3) 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: (a) Therapy services provided to residents by outside providers, excluding respiratory therapy and speech therapy required by OAR 411-090-0180. (b) Medical services by physicians or other practitioners excluding the services required by OAR 411-086-0200 and the Ventilator Assisted Program Medical services required by OAR 411-090-0180. (c) Radiology 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 vaccines). (f) Hyperalimentation. (g) Prescription pharmaceuticals. (h) Electronic devices to promote individual's communication and quality of life. (4) ENDORSEMENT- Providers 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 411-070-0442. (5) VENTILATOR 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 nurse staffing. (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 Department. (7) DOCUMENTATION- The endorsed nursing facility must maintain sufficient documentation as described in OAR 411-090-0150. (8) 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. (9) ADMINISTRATIVE REVIEW. (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. (b) 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. (C) APD’s 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.