Overview of Payment Structure

Payment for Medicaid Waiver Assisted Living, as it applies to the DHHS Home and Community-Based Services Medicaid Waiver for Aged Persons and Adults with Disabilities, consists of two main components. The first is Room and Board and the second is Medicaid Waiver Assisted Living Services.

Medicaid Waiver Assisted Living Rates Medicaid Waiver Assisted Living Rates, also referred to as “Per Day Equivalents,” are calculated to cover the total of all Medicaid Waiver Assisted Living costs/payments. Rates are applied as “"Standard vs. Health Care Trust Fund,” “Urban vs. Rural” and “Single vs. Multiple Occupancy.” Standard Rates for 1999 are illustrated in the Assisted Living Rates Chart (Appendix H). “Health Care Trust Fund” rates are computed at 95% of the corresponding Standard Rate (Per Day Equivalent).

Only the Services portion is billed on the Long Term Care Facility Turnaround Billing Document and paid under the DHHS Home and Community-Based Services Medicaid Waiver for Aged Persons and Adults with Disabilities.

Payment for Room and Board Medicaid does not pay for Room and Board. Each resident is financially responsible for his/her own Room and Board and should be contacted directly for payment. Residents may pay Room and Board with funds they receive from any of several sources such as Social Security benefits, Supplemental Security Income (SSI), a retirement/pension or a DHHS grant (Aid to the Aged, Blind and Disabled/AABD or State Supplemental).

As of this Handbook's printing, residents pay $440 per month for the Room and Board component.

Prorate each resident's payment for Room and Board in the month the resident is initially authorized for Medicaid Waiver Assisted Living by dividing $440 by the number of days in the applicable month and multiplying that by the number of days the client is an authorized Medicaid Waiver resident of the assisted living facility.

For example, let's say that “Jane” is an eligible Waiver resident from the 19th through the end of February in 1999. You should divide $440 by the 28 days in February. You'd get a daily rate of $15.71 which you'd then multiply by 10 (19th-28th) and charge “Jane” $157.10. This means that the amount to be charged for ten days of Room and Board in February will be different than that charged for ten days in other months since the number of days per month varies.

Prorating the Room and Board amount also applies for months when residents are discharged.

The Room and Board portion may be collected at the beginning, ending or during each month or according to whatever agreement is reached between the resident, his/her family and the facility.

Payment for Medicaid Waiver Assisted Living Services The balance of the monthly Medicaid Waiver Assisted Living amount is for Waiver Services. The Services portion (Level of Care amount minus $440) is used to calculate the Per Day Equivalent for each Level of Care.

Payment to the facility for the Medicaid Waiver Assisted Living Services portion must be prior authorized by the Services Coordinator. Waiver providers will receive a Medicaid payment directly from DHHS. In addition to Room and Board, the resident may have funds s/he must obligate before DHHS will assume financial responsibility for the Services component.

Each resident may have a monthly “spenddown” obligation. This “spenddown” or “Share of Cost” is called the Paid from Others Sources (POS) Amount and will be preprinted on the Long Term Care (LTC) Facility Turnaround Billing Document received by your facility near the end of each month. Please work closely with the resident, his/her family and local DHHS Medicaid Eligibility workers to arrange for collection of the POS Amount.

In summary:

• Payment of each claim is dependent on the authorized Per Day Equivalent and the Prior Authorization record, regardless of changes made by facilities to their Long Term Care Facility Turnaround Billing Documents.
• DHHS needs to receive each Long Term Care Facility Turnaround Billing Document within 90 days after the last day of the month for which the document was generated. If more than 90 days have passed, facility staff must attach justification to the documents in order for the claims to be considered for payment.
• The facility also has 90 days from the date of an Explanation of Medical Claims Activity/MC-7 (Appendix I) to request reconsideration or adjustment of a claim that has been denied, reduced, not paid or paid incorrectly. This can be done in writing or by calling the Nebraska Medicaid Provider Inquiry Line toll free at 1-877-255-3092. If calling from Lincoln, dial 471-9128. You will then receive several prompts in order to reach an DHHS Nursing Home/Assisted Living representative. The Medicaid Provider Inquiry Line is available Monday, Wednesday, and Friday, 9:00 a.m. to noon and 1:00 p.m. to 4:00 p.m. (Central Time).

If no payment or response is received within 30 days from the date the request is submitted to DHHS, call the Medicaid Provider Inquiry Line and an DHHS Nursing Home/Assisted Living representative will help you.